C.

Legal Issues Law and mental health have been linked for many years: Even in ancient Rome : -should the individual have a guardian? Could the individual enter into a contract? -person with a mental disability could not form a marriage contract, if the law made him ward [dependent], the person did not have any legal rights Middle Age - mental illness posses by demons - kings will hold custody of property of the mentally ill profits were applied to the maintenance of the individuals and their household American colony [17th cent] - lack of facilities meant that families had to care for mentally ill people, if no family: wanderers - no distinction between a homeless person and mentally ill person Massachusetts: - passed a law to manage people who had mental illnesses and were dangerous: be detained but there were no procedures for commitment of a person with mental illness Commitment: a term referring to the various ways that an individual enters a mental health treatment Important Concept related to location and tenure of mental health Concept of Least Restrictive Alternatives: Providing mental health treatment in the least restrictive environment, using least restrictive treatment. Three most common types I. Voluntary - Nurses are the most familiar with clients who access treatment voluntarily by consenting to be admitted and treated - Treats clients whose clinical conditions vary widely in their psychiatric severity on a voluntary basis However: if seeks discharge and is an immediate danger to themselves or others placed on an emergency commitment status pending further evaluation and treatment II. Emergency Commitment

Severe mental illness affects clients cognitive functions refuses treatment for a variety of reasons: - psychosis, paranoia, delusions, hallucinations rejects treatment: fear of being harmed - mood disturbances who are depressed and suicidal refuses: hopelessness and wish to die - results to immediate risks of self-harm or harm-to-others - unable to provide food, clothing and shelters for himself EC for a shorter period and generally has more restrictive criteria for admissions - must be seen by physician, psychologist, social worker, Note: taking away an individuals freedom through a commitment procedure is a serious matter The US Supreme Court has established the standards of clear and convincing evidence as the standard of proof that must be met for commitment. III. Civil or Judicial Commitment: this is for longer time Legal basis for extended detention of an individual for treatment lies in the: parens patriae - power Parens patriae power of the: 1. State to protect and care of the individuals with disabilities and the 2. Police power of the state to protect the community from persons who are threat For judicial: client be given time to prepare a defense state why hospitalization is not necessary * Client has the right for his attorney to cross-examine physician regarding the necessity of confinement * California [effective 1-1-2003]: passed a law for mandatory outpatient treatment Purpose: to break the cyclical pattern of clients, who upon discharged from an inpatient treatment unit, discontinued medication, detoriorate, exhibit dangerous behavior,and subsequently requires re-admission to the acute psychiatric setting

Psychiatric Advance Directives [PADs] * legal documents utilized when a patient is unable to participate in the decision making process * allows a competent person to describe warning signs of declining mental health and consent or refuse a treatment method

* allows competent person to agree on commitment in a psychiatric care facility for a determined period of time and to appoint a surrogate [substitute] decision maker * PADs implementation: - reduces hospital length of stay - impacts on burden on mental health legal system - significantly decreases involuntary commitments

Confidentiality: * Health Insurance Portability and Accountability Act [HIPAA] 1999: - regulates the protection and privacy of health information * HIPPAA Privacy Rule: for all health care provider who sends bills or are paid for health care Privacy Rules defines: - any individual identifiable health information than an organization keeps, files, uses - or shares in an oral, electronic or written form * Violation of privacy: civil and criminal penalties for fines or prison sentences - mental health records, to includes psychotherapy and drug and alcohol treatment Nursing Implications * Upon admission: ask to signs a release of information documents, the information usually are: - information that will be released - person or parties that information will be shared with such as health care providers and insurance providers - purpose of releasing the information - period or time the information will be released * the release of information even for the best intended purpose and even with subpoena from HIPPAA is risky,: must consult employers attorneys Privilege Communication Enacted by statute [decree/bill] to designate professionals such as physician, nurses, psychologist] * privilege belongs to the client and he only can assert [declare] or waive [ignore] this privilege

* allows certain information given to the professionals to remain secret during any litigation [court case, legal actions] - exclude the mandatory reporting of child, elder, impaired adult - domestic violence - communicable diseases relating to public safety - information that will prevent felony /crime such as murder Duty to Warn and Protection: Tarasoff Case: Indian student misinterpret a New Years kiss as a serious romantic gestures [Tatiana Tarasoff] After several months: - Tarasoft dated other guy and told him she did not view their relationship as a serious one - He become subsequently depressed and sought mental health counselling and communicates with the therapist that he will harm her upon her arrival [South America] - Ran out of the therapist office and arrested by police and released Tarasoff returns - He went to her home and fatally wounded her with a knife Family of Tarassof - File a case against the school Supreme Court - Justices rule out protective privilege ends when the public perils begins Duty to warn: - Established the responsibility of a treating mental health professional to notify an intended, identifiable victim Rights of Client - individuals when enter a mental health facility, they usually retain the rights : unless clearly restricted by using due process to certify that an individual lacks the capacity or competence Retain their rights to: * vote, manage financial matters ,enters into a contractual relationship, and asserts constitutional rights, to seek advice of an attorney

Other basic rights: * send and received unopened mail, wears own clothes, receive visitors, keep and use personal possessions, access to telephone * to be informed regarding potential risks and benefits reasonable alternatives before giving consent for any specific: Therapy, surgery, treatment, including medications * nurses: need to disclose serious side effects that will uncomfortable and irreversible to the client * client are able to give informed consent unless there has been a judicial ruling to the contrary In documented emergency or endangered situation: Nurses are able to administer medications and treatment without the clients consent * many states requires all client receives a written summary of their rights in their own language on admissions * treatment facilities are expected to know the dominant language of the clients that they serve and make provisions to have clients rights available in those languages Seclusions and Restraints Since the Middle Ages, mental health facilities have been using S/R to control behaviors New rules states: Health care professional were to use S/R only when less restrictive alternatives to ensure client safety had failed: such talking [ e.g. - Lloyd Latigay, Samuel Marquez, Mario Tinonga] * Coercion or force, discipline, punishment, or staff convenience were unacceptable reasons for placing a person in S/R However: A. 1 hour rule, it requires: - a face-to-face evaluation by a licensed independent practitioner within 1 hour of initiation or restraints used for behavioral management, additional is: B. Clients family and legal representatives be notified when restraints are used Right to Treatment Budget shortfall - layoff: few employees clients can not receive proper treatment U.S. Supreme Court: ruled that healthcare professionals cannot keep an individual in a mental hospital

without treatment if he or she is non- dangerous and capable of defining and carrying out a plan of self-carte in the community Right to Refuse Treatment Giving of psychotrophic medications cause side effects such as akithesia and tardive diskenesia [wormlike movement of the tongue] NOTE: If there were no agreement about the appropriate medications to be given Patient has the rights to refuse medications *During emergency situations, if there is potential danger, clients can be forcibly medicated Nursing Implications: - nurses must be aware of state laws, policies and procedures in administering medications whether involuntary or involuntary - frequent nursing assessment for side effects and careful documentation of clients complaints related to side effects are essential for readjustment or discontinuance. Nurses should carefully analyze and questions the reasons for the refusal of medications - is it because of clients denial of the illness or symptomatology, side effects, displeasure with the treatment staff - client and family medication education by nurses, physician and pharmacist and a reassuring therapeutic relationship will greatly adhere in medications adherence Electroconvulsive Therapy Views as traumatic procedures. However- can be effective treatment for a lifethreatening depression. Client needs to give informed consent for the procedures, which includes being knowledgeable about the risks and benefits. potential side effects is memory loss that is temporary but is sometimes irreversible Q: who can give informed consent - if incompetent client can not give informed consent, then a relative of the client is sufficient * client has rights to refuse ECT unless there is clear and convincing evidence that it is necessary The state must have compelling evidence: - that ECT is necessary and would be effective and - that the other forms of treatment have not been beneficial or not available The Americans with Disabilities Acts

Disabilities Acts - mental barriers that limit the ability of the individual in one or more major activities Court Rule: if a persons mental condition is stabilized, there is no disability. However: they are protected if the fact that they once had mental disability [depression] is used against them in the employment situation. Excluded : uses controlled substances for unlawful purposes, takes prescribed drugs without the supervision of a health care professionals, possess direct threat to others. However: it is important to recognize that this must be based on actual behaviour of the individual and not on the mental disability itself Employer - cannot ask a person about prior history of mental health treatment as part of an application process for employment neither questions about the prior use health insurance coverage are not permitted - can evaluate the individual as to the ability to perform the job functions Competency to Stand Trial: criteria includes the following - does the individual charged with the crime understand the criminal charges - is there an understanding of the legal process and the consequences of the charges - can the individual advice an attorney and defend the charges Fundamentally: it is the persons awareness of the legal process that the mental health professional has to evaluate. Court, judges, prosecutors could request a court ordered evaluation, asking for the persons competency to stand trial Criminal Responsibility [Insanity Defense] - insanity defense relates to the state of the mind at the time of offense [legal doctrine: mens rea]. For a person to be found guilty, the individual must be able to form intent [intention/aim/purpose] IF: because of mental illness, intent cannot be formed and the person is possibly responding to hallucinatory voices, there is no quilt involved. M Naghten Rule: an accused will not be held responsible if at the time of the commission of the act, he was labouring under such a defect of reason, from the disease of the mind, as to not know the

nature and quality of the act he was doing, or if he did know it, that he did know he was doing what was wrong Daniel M Naghten: shot and murdered the secretary to the prime minister instead of the intended victim because he has irrational belief that he was plotting against him. - found not guilty by reason of insanity. After s person is found not guilty by reasons of insanity he or she is usually hospitalized Guilty But Mentally Ill [GBMI] Individual found guilty but because of the plea that mental illness caused the person to commit the crime, the person is sent to prison and treated for mental illness Nursing Responsibilities in the Criminal Justice System Malpractice Situations that will potentially lead to a malpractice lawsuit - irreversible side effects of some medications and the trend of short-term hospitalization Negligence - Primary practice for malpractice lawsuits * the actions of the professional causes injury resulting in measurable damages Elements of a Malpractice Suit Based on Negligence I. Nurse had a legal duty or relationship to provide a standard of care. To establish in that relationship is a breach of duty Care is measured by the Reasonably Prudent Nurse Standard - What would another nurse working in a mental health facility have done in same situations? - Expert witness can testify regarding the adherence or departure from the standard of care II. Court explores whether the nurse was the causal link in the injury [damage] that occurred: 2 test to determine connections 1. but for test - the alleged damages would not have occurred but for the act of negligence 2. substantial factor test - the negligence was substantial factor in causing the damage Example: nurse gave wrong medications, or the nurse did not know about the drug interactions that led to injury III. Last element to consider by the court is:

Whether there is a proven injury because of the nurses behaviour. Most damaging and reckless behavior would involve a gross negligence: - acting with willful and conscious disregards of the rights of others Documentation: - records are excellent source of communicating with other mental health professionals/ agencies - used to validate reimbursement for care - must carefully record a clear outline of all clients symptoms to documents *Adequate legible documentation is the best means of defense against a lawsuit and the best ways to validate that adhered to their scope of practice and a safe standard of care {NIC-NOC] Important: * be specific and to document symptoms by writing in quotes what the client expresses to you, such as: I am hearing voices that say I am a bad person * recording the actual words of the client is more definite than simply noting, the client is hallucinating * record the time it happens is more adequate Client record is a sequential document: thus it does not save space for late entries, only label entries and initial them Essentially important to document: when the person has achieved the goals outlined in the treatment plan If exacerbation of the illness: - treatment plans needs to reflect the change Informed consent regarding giving of psychiatric medications side effects *do not use improper abbreviations that the agency does not authorize * accurate recording of VS especially when taking psychotropic medications * careful documentations means words and grammar are corrects * if makes error in documentations place a single line through the words without making them illegible and then initial the error Sexual Misconduct Social workers, psychiatrist and psychologist: 14% had a sexual relationship with a client

Cases for removal of nurses license had been reported All mental health professions consider such behavior unethical, and in many

states this behavior is criminal, especially within a few months of the therapeutic relationships Suicide and Homicide More common: Malpractice suits Wrongful death actions for homicidal clients injury to a third party Death from suicide * some states have ruled that individuals working in government agencies have sovereign immunity and are protected from liability in malpractice situations When conducting a nursing assessment that includes a suicidal component: use extreme caution! - when individual threatens intent of suicide with a definite plan and - demonstrate lethality and access to the means to commit suicide Intent - aim, goal, and target Lethality - causing or sufficient to cause death Means resources Nurse: must communicate this information, in a timely manner, to mental health provider. Then they must follow appropriate steps to provide safety, including involuntary commitment, or escape liability If there is Q, nurse should seek legal consultation HOWEVER: clinicians are not liable for errors of clinical judgment, they are liable only for departures from the relevant standard of care, given the clinical situation Tarassoft case: important to communicate with the mental health treatment team when a client threatens to harm someone! Ethical Issues: they connected to legal implications for nursing care Ethics: is the body of knowledge that explores the moral problems about specific issues In nursing practice: - look at the rules, principles and ethical guidelines developed to guide conduct Laws reflect the moral character of a society and are developed with an ethical basis, therefore:

* we must consider ethical principles when evaluating a dilemma or problematic situation A. Autonomy: Refers to having respect for an individuals decision or self-determination about health care issues * problems with the rights to die and in mental health: rights to least restrictive alternatives Case of Involuntary Commitment: - difficult for mental health personnel to follow the law but rather than to do what the client currently desires. - caregivers must follow clients decision, but if the client is demonstrating intent by threatening suicide with an active plan., therefore: proceeding against the wishes of the client is necessary for safety and compliance with the law this decision is ethical tern as paternalistic decision or parentalism Q: autonomy and privacy in relation to video monitoring of psychiatric clients placed in seclusion NOTE: one loses autonomy when in seclusion or restrained and to add video is threatening to client To justify use of video: - keep a records that a monitor is being used and the therapeutic reasons for such use - clients is notified of the monitoring - only staff with clinically competent can access to the monitor - staff nurse should perform visualization assessment of the client Ethical treatment means balancing the good of a safe environment with the potential of harm from a loss of privacy B. Beneficence: refers to bringing about the good Nurses - have special duty and responsibility to act in a manner that is going to benefit and to harm clients Goals: in mental health treatment to assist individuals in return to a mentally healthy way of life Moral Rule: Primum no nocere [first do no harm]

Example: giving of neuroleptic medications, considering of ECT treatment, C. Distributive Justice Comparative treatment of individuals in the allotment of benefits and burdens Principles of justice holds: a person should be treated according to what is fair, given what is due or owed Q - Who is going to get the treatment and the cost of treatment?

D. Standards of Mental Health Nursing Standard I Theory : Applies appropriate theory that is scientifically sound as a basis decision regarding nursing practice Standard II Data Collection: Continually collects data that are comprehensive, accurate and systematic Standard III Diagnosis Utilizes nursing diagnosis and or under standard classification of mental disorders to express conclusions supported by recorded assessment data and current scientific premises. Standard IV Planning Develops nursing care plan with specific goals and interventions delineating nursing actions unique to each client care Standard V Intervention Intervene as guided by the nursing care plan to implement nursing actions that promote maintain or restore physical and mental health, prevent illness and effect rehabilitation Standard VA Psychotherapeutic Intervention Uses psychotherapeutic interventions to assist clients regaining or improving their previouscoping abilities to prevent further disability Standard VB Health Teaching Assist clients, families and groups to achieve satisfying and productive patterns of living through health teaching Standard VC Activities of Daily Living

Provides structures and maintains a therapeutic environment in collaboration with the client and other health care providers Standard VD Psychotherapy Utilizes advance clinical expertise in individual, group, family psychotherapy and other treatment modalities to functions as a psychotherapist and recognizes professional accountability to nursing practice Standard VI Evaluation Evaluates clients response to nursing action in order to revise the database, nursing diagnosis and nursing care plan Standard VII Peer Review Participate in peer review and other means of evaluation to assure quality of nursing care provided for the client Standard VIII Continuing Education Assumes responsibility for continuing education and professional development and contributes to the professional growth of others Standard IX Interdisciplinary Collaboration Collaborates with other health care providers in assessing, planning, implementing and evaluating programs and other mental health activities Standard X Utilization of Community Health System Participates with other member of the community in assessing, planning, implementing, and evaluating mental health services and community system that include promotion of the broad continuum pf primary, secondary and tertiary prevention of mental illness. Standard XI Research Contributes to nursing and mental health field through innovations in theory and practices and participation research

E. Community- Based Care: Nurses have a major role in community based services because of: o psychotherapeutic management skills, knowledge of psychopathology and pharmacology

o ability to adapt the use of nursing process to any setting o holistic approach help reintegrate mentally illness into community living and assist individual in linking with community resources Nurses might need to advocate and negotiate for services Medical clinics dental services financial services vocational services Transportation Housing Medicare - Medicaid legal justice system telehealth Church-related services employees assistance program consumer groups

1. Traditional Outpatient Services Person providing counseling: psychiatrist, psychologist and social worker, clinical nurse specialist Process: For chronic cases once a month visit - Medication review or counseling During counseling visits: assessment of needs for additional services is made to determine whether they need more intensive services or a different type of services Example: Dx w/ chronic undifferentiated schizo attends community support program Meets case supervisor every other weeks after receiving his Haloperidol Dec from the nursewho assess for effectiveness of the medication & side effects He also participates in his social club which offers lunch and social activities 2x/week Psychiatrist meets him every 3 months for medication evaluation

2. Partial Programs and Day Treatment Process: - Individuals who need supervision, structured activities, ongoing treatment and nursing care - Programs vary in length 4 to 8 hrs/day and 1 to 5 days a week and can occur during the day, evening and night

Might provide treatment for specific population based on: - Child, adolescent, adult or older adult Type of problem Drug addiction and mental problem Attends partial program for 2 weeks that meets 10 am 3 pm from monday to Friday Attends groups that focus on exercises, spiritual, coping with loses and self esteem issues Lunch time provides an opportunity for socialization with program members Example: Dx with severe depression discharged from hospital but unable to return to work -

3. Residential Services - are available to help individuals who needs temporary or long-term housing LOS - LOS last for 3 to 6 mos. With 24 hr supervision A. Extended Care Facilities nursing homes 24 hr supervision and medical nursing care severe developmental disabilities, dementia, acute and chronic medical illnesses

B. Group Homes might provide temporary or permanent housing for individual with chronic mental disorders Depending on the needs of residents: staff might be present for 24 hr or less or group therapy and well structured activities or provides only meals, a bed and laundry facilities

C. Halfway Houses: residents are expected to: seek employment, participate in cooking and cleaning chores attends self-help group that meets on site staff may be available on site on a daily basis offering group sessions and activities or only visits periodically to ensure medication compliance and attendance on various appointments E. Foster Boarding Homes: staff by nonprofessional but has professional supervision shelters provide room and board to homeless and services for special population: abused women and their families/addiction

D. Apartment Living: provides variety of degree of supervision and programming

F. Self - Help Groups sources of support on the continuum of care meetings are conducted by members, not professionals and takes place on a weekly basis