Legal/Ethical issues in nursing

  1. 0 Hi everyone! I am currently a nursing student taking an ethics course for anyone going into a health or human resource field. I am currently working on a paper about how some of the issues we disscused in class are handled in the nursing field. I have interviewed some nurses (who didn't seem to want to talk about it too much...) and done some reading...but if anyone could add any comments to these questions that would be great!

    1. How is confidentiality (of their medical file,etc.) explained/presented to your patients? Are there any limits to their cofidentiality?


    2. What do you have priviledge in knowing about a patient?

    3. What would you do if your nursind records/charts were supoenoaed?

    4. How are the right's of minors treated differently?

    5. What ethical dilemas do you face in your everyday nursing practice?


    Thanks to anyone who shares their ideas/experiences!!
  2. Enjoy this?

    Join thousands and get our weekly Nursing Insights newsletter with the hottest, discussions, articles, and toons.


  3. Visit  Tigger100S} profile page

    About Tigger100S

    From 'PA'; Joined Apr '02; Posts: 46.

    12 Comments so far...

  4. Visit  whipping girl in 07} profile page
    1
    I don't really know the answer to your question, but I'm going to try to respond to keep it near the top, as this is something we as nurses need to think about.

    1. As a nurse I usually don't address confidentiality with the patient. When they are admitted, they get an explanation of confidentiality on the form they sign. However, I do watch my charts closely on the unit. We have had patients who have family members who are doctors who seem to think they have access to the patient's chart. More than once these doctors have had to be stopped and redirected ("Dr. So-and-so, you are violating your mom's confidentiality by reading her chart, since you are not involved with her care.") I've also seen "nosy" family members try to read the nurse's notes of the patient (or worse, of other patients!) I keep the charts closed if they are on the desk, unless I'm reading it, and I keep the nurses notes at the desk instead of at the bedside if it is visiting hours.

    2. I have access to their entire medical record if I am involved in their care. The chart, nurses notes, dr's orders, lab results, h&p, xray/procedure report, surgery report, progress notes, etc. If I am not involved in the patient's care, I do not have access to their chart. However, if we are "troubleshooting" a patient's problems at 3am, contemplating calling the dr, and trying to decide which dr to call, other nurses who are not actively caring for the patient will review the chart/history, to figure out what to do.

    3. I would hope I charted everything that happened. I would review them so I would have an idea what I was testifying about. Remember, if it wasn't charted, it wasn't done.

    4. I believe the rights of minors are similar except we share information with the parents instead of the patient sharing the information. At some point, the minor is old enough to share with the parent and the HCP has to keep information confidential, but I'm not sure I know what age that is. I'm glad I don't work in peds.

    5. The biggest ethical dilemma I face is coding patients who will have no quality of life after they are revived. I'm talking about people who are terminally ill or with multiple chronic medical problems who have deteriorated to the point of not being able to do anything for themselves, and may not even have much brain function left. I have been an RN for less than a year and I have seen patients literally rot away on the ventilator, being kept alive on 100% O2 and not breathing above the vent at all. The heart keeps beating because we are giving O2 and breathing for the patient. Don't get me wrong, I believe in life support, and I will do anything in the ACLS protocol to save a patient who is not DNR. But there are too many patients who should be DNR who aren't. Sometimes patients come into the hospital with an advanced directive that gets ignored, or they give health care power of attorney to a family member who ignores the patient's wishes. The doctors are worried about the family members suing them if they don't do everything possible for the patient. Sometimes it is just time for the patient to die, but we keep doing everything to keep the patient alive when there is no hope for a recovery. I have seen some miracles, but I see more prolonged deaths with the patient suffering. If you talk to the family members six months later, after the patient has died, they always say that they wish they hadn't let Daddy suffer and linger so long, that they feel bad that Mama didn't get to die at home, which is what she wanted. Our technology is too far ahead of our bioethics. We can save you, but we can't guarantee you'll actually get to live. We can drain your life savings and leave your family with a huge bill, but we can't give you any quality of life for that last couple of weeks we keep you alive.
    RN Power Ohio likes this.
  5. Visit  frankie} profile page
    0
    Hi Tigger,
    I am frankie - your questions are interesting - Confidentiality is quite a concern for patients and nurses and hospitals and just about any medical facility.

    I do not explain confidentiality to patients, that is, unless a question is posed. This is a patient right. A patient should NEVER have to ask for confidentiality. There are limits to confidentiality, in a sense, like reporting suicidal ideation to a physicial, informing a radiology technician of a persons know pregnancy, things like that - but I do not view this as breaking confidentiality. A reasonable individual would know these things are required to be shared on a need to know basis.

    In caring for a patient, I require the pertinent info R/T care I am delivering. I cannot address the holistic patient if I do not know pertinent facts. It depends on what I am doing - venipuncture probably would not require much info, where as a hospice care plan would be indepth patient and family info.

    If nursing records and charts are required for legal proceedings, I would have to comply with the law. Same for deposition.

    Minor rights are not different from any other patient right. Legalities r/e consent, authorization, informed consent, etc...require a legal guardian, however, only pertinent info need be relayed.

    Everyday ethical delimas are everywhere. The most common are being asked/required to do something you feel is not in the best interest of the patient. It may not be in the worst patient interest, and it may not really harm the patient, but you have to do such and so - usually to not make waves. It becomes a pick your battles carefully. I think most nurses weigh this issue early on in their carrer. The other ethical problem that irks me is physicians who are not OK MDs. Especially when the patient is compromised. This is always a tricky issue. We all work through it. I have left jobs before due to ethical issues, like being told what my charting should say, despite what is really the case. This happens alot in homecare.

    This is an issue we could all wax on about for a long time; I guess the important thing is I see myself as a patient advocate - always have/always will.

    frankie
  6. Visit  frankie} profile page
    0
    not many of you posting here - what do you think?
  7. Visit  DelGR} profile page
    0
    http://www.hhs.gov/ocr/combinedregtext.pdf
    I hope this helps some regarding patient privacy issues. It is the US Dept. of Health and Human Services site regarding the latest about HIPPA that is suppose to take effect next April.
  8. Visit  Tigger100S} profile page
    0
    Konni and Frankie,
    Thank you both so much for your lenghty and detailed responces! I really appreciate it when my questions on this board are taken seriously and friendly nurses like you guys help out us students!

    Konni- I agree with you on the bioethics...sometimes the quality of someone's life is more important than the length. Hope I put that correctly...
    The nurse's I have already interview for my project also expressed pretty strong (negative) feelings towards "nosy" family members trying to look at patient's charts!

    Frankie-
    Thanks for trying to get people's attention to this post! Also thank you for the examples of times when confidentiality should be breached (pregnancy, suicide), that helped clear things up for me!

    Thanks again to you both, with your permission I would love to incorporate some of your thoughts into my paper.

    You guys sound like great nurses and role models for students like me!

    One last question for anyone-- what is the difference between being called to testify about a patient/patient's notes, and having your notes/charts subpoenaed?

    Thanks!!
  9. Visit  jode} profile page
    1
    Hi. Having your notes/charts subpoenaed means your notes get reviewed by the court, lawyer or whoever subpeonaed them. If a chart gets subpeonaed, you may not even be made aware of it if your notes are not relative to the issue. If YOU get subpoenaed, then YOU get to answer undr oath about what you have wriitten and or written about and/or the events that surround the issue at hand. An I making sense?...:-) I have been in court for criminal cases and it can be very stressful....but good nurses notes carried me through every time. Hope that helps some...
    RN Power Ohio likes this.
  10. Visit  Danielle4} profile page
    0
    This is the same thing we are studying in my class. It is interesting to read your answers.

    I am told confidentiality is taken so lighly at the hosptials and patients sign away on forms they have no idea what they are and they are not informed consent at all.

    How do you declare a person dead? In my class we learned the "higher brain" declaration of dead and the "whole brain" declaration of dead. Basically one is that the patient is still alive even if they are breathing by a breathing machine and others believe if only their brain stem is working- ie breathing and they are not a person anymore then they are dead.
    how long do you say people should be on life support for? a week? month? year? If they are in a persistant vegitative State and they are never going to regain consciousness isn't that the same as being "Dead?"

    I thought minors could not make decisions till they were 18 as they do not understand so they would not have complete autonomy. Their parents would make the decisions.

    Why is it that the advanced directive is always ignored? If that is what the patient wanted it should be more important. I read somewhere that only 30% of advanced directives are even carried out. If they do resusitate couldn't the victim sue? If the family does if the doctor doesn't resusitate isn't that a bad situation either way? That would be a tough decision to make.
    If they do not follow the advanced directives why bother having one?

    Tigger100S, I hope you did well on your paper!

    -Danielle
  11. Visit  kathyhinsh} profile page
    0
    hi, i this has helped me 2, as i'm writing an asignment at present & need 2 include legal/ethical issues applied 2 my patient.
  12. Visit  RN Power Ohio} profile page
    0
    As a legal nurse consultant there are 2 nursing failures I see most often:

    1. Failure to continue to go up the chain of command for assistance i.e. patient not getting adequate treatment in a crisis or pending crisis by a physician.

    2. Failure to refuse unsafe assignments. Though there are no guidelines (except CA) as to what is safe and unsafe, I see it as a contributing factor once we become aware of the staffing. Naturally, there is not much we can say about it without staffing standards but having been there I know it was the reason for the incident. (Remember there is a difference between courtroom law and BON standards).

    It is called Failure to Rescue.

    All students should read the article titled same by Linda Aiken. I cannot attach in this post but if you want a copy I will email it to - just PM me.
  13. Visit  RN Power Ohio} profile page
    0
    The biggest ethical dilemma (IMO) facing nurses in their everyday practice is the conflict of interest that exists for the RN.

    It is the duty of the RN to act in the best interest of the patient and NOT the employer. Therefore, we must often object to unsafe assignments or float positions for which we are not qualified for.

    Duty requires that we refuse these assignments even if it means the boss threatens to fire or discipline. Unfortunately, I think that many nurses forget this duty. However, there are many, many who do not and speak up for their patient.
  14. Visit  patwil73} profile page
    0
    Quote from Tigger100S
    Hi everyone! I am currently a nursing student taking an ethics course for anyone going into a health or human resource field. I am currently working on a paper about how some of the issues we disscused in class are handled in the nursing field. I have interviewed some nurses (who didn't seem to want to talk about it too much...) and done some reading...but if anyone could add any comments to these questions that would be great!
    I will do my best!

    Quote from Tigger100S
    1. How is confidentiality (of their medical file,etc.) explained/presented to your patients? Are there any limits to their cofidentiality?
    When a patient is admitted to or hospital one of the questions we ask is whether they want to be a confidential patient or not. If they elect to be a confidential patient we give absolutely no information out to callers or visitors unless they know the password established by the visitor - we don't even say if they are a patient here.

    Now if they don't elect to be a confidential patient, then if someone calls and asks for them we can say they are in the hospital and if they are doing "ok". Anything else we need specific permission from the patient.

    I approach it with the patient this way: "Do you wish to be a confidential patient and keep all mention that you are here from anyone who might call or visit unless you have pre-approved them?" They will then ask what it entails and if they should so I ask "Is there anyone who might want to call that you don't want to talk to? and Is there anyone who might visit that you don't want to see?" If the answer to both is negative they usually don't need to be confidential.

    Now as to there chart. At our facility patients actually have the right to read their chart if they want. They can't make copies, but can go over it. We try to have someone in the room to explain what different things mean (usually a doctor), but they can read it without if they wish.

    We don't often explain that others won't be viewing the chart unless the patient asks.


    Quote from Tigger100S
    2. What do you have priviledge in knowing about a patient?
    I can look up any of their records as long as it pertains to the care I am providing. Anything that has been documented before is ok as long as is relevant to their care now. So I might look up old stress tests for my CP patient, but would not peruse their OB charts from last years delivery.

    Quote from Tigger100S
    3. What would you do if your nursind records/charts were supoenoaed?
    Flee to Canada! Just kidding, actually not much. I doubt I would even know unless I was called to testify or the hospital grapevine was working OT that week.


    Quote from Tigger100S
    4. How are the right's of minors treated differently?
    MInors with certain exceptions don't have the right to consent for their care, so a legal guardian must be involved. They also can't refuse a treatment although the guardian can. One interesting twist is that a 16 year old can't consent to her own care but if she is a mother she can consent for her child.

    Quote from Tigger100S
    5. What ethical dilemas do you face in your everyday nursing practice?
    1) How long do we continue to utilize life-saving measures on someone who didn't wish for them (but family does) and will not benefit from them in any way? Continuing to perform CPR on the demented, 98 y.o. COPD'er whose every waking moment was a struggle to breathe just because family can't let go is ethically difficult. Morally I believe that it wrong to not honor the wishes of the patient, but legally we have little choice.

    2) Keeping suicidal patients locked up. I might be different than a lot of people on this one, but I have a deep sense that the personal freedoms of individuals should not be compromised unless they can harm others. A person in full control over his faculties locked up because s/he decides that they don't want to continue with their life is morally wrong to me.

    3) Watching a baby die because the mother refuses a C-section. I am pro-choice and believe that for those who believe they can't raise, care, and love a baby abortion is a viable option. But once that baby is developed enough to survive on his own, I feel we have a moral obligation to do things to keep him alive and not do things we know will kill him.

    4) Deciding on a course of action when a physician fails to order treatment. Does the welfare of the patient justify moving up the chain of command here or is the issue non-urgent enough to adopt a wait and see approach.


    Quote from Tigger100S
    Thanks to anyone who shares their ideas/experiences!!
    Hope this helps

    Pat
  15. Visit  patwil73} profile page
    0
    Quote from Danielle4
    This is the same thing we are studying in my class. It is interesting to read your answers.

    I am told confidentiality is taken so lighly at the hosptials and patients sign away on forms they have no idea what they are and they are not informed consent at all.
    I actually find that people are much more educated about their illness and often ask very good questions. Where I think we tend to fail is when our language is not the patient's primary language. Because often it can be time consuming and difficult to get a translator or hear over the phone, people tend to turn to family and friends to do this. Or the patient understands some of what you say and just agrees because of the stress or culture or whatever.

    Quote from Danielle4
    How do you declare a person dead? In my class we learned the "higher brain" declaration of dead and the "whole brain" declaration of dead. Basically one is that the patient is still alive even if they are breathing by a breathing machine and others believe if only their brain stem is working- ie breathing and they are not a person anymore then they are dead.
    In our hospitals it is actually the residents who usually determine death. 1 minutes of listening for heart tones or breath - without it, they call time of death.

    Technicaly you are alive as long as you have a heart beat and breath - although with families who are wondering I often try to explain the difference between the body being alive and the person being alive.

    Quote from Danielle4
    how long do you say people should be on life support for? a week? month? year? If they are in a persistant vegitative State and they are never going to regain consciousness isn't that the same as being "Dead?"
    Depends. Is there a realistic chance of survival and quality of life afterwards? And quality of life must be as the patient defines it, not what we define it as. If the patient things living in a bed being fed through a tube is ok with them, then we must respect that.

    Quote from Danielle4
    I thought minors could not make decisions till they were 18 as they do not understand so they would not have complete autonomy. Their parents would make the decisions.
    Depends on the decision being made and whether or not they are emancipated.

    Quote from Danielle4
    Why is it that the advanced directive is always ignored? If that is what the patient wanted it should be more important. I read somewhere that only 30% of advanced directives are even carried out. If they do resusitate couldn't the victim sue? If the family does if the doctor doesn't resusitate isn't that a bad situation either way? That would be a tough decision to make.
    If they do not follow the advanced directives why bother having one?

    Tigger100S, I hope you did well on your paper!

    -Danielle
    It is not always ignored. It just often seems to turn out badly when it is. Often people don't know the advanced directive. Sometimes people argue that it was made under duress or in an altered state of mind. I do wish as a society we could come to some firm agreement on the validity of advanced directives and that they should be followed above any decision by family - but it might actually take someone who was resucitated when they didn't want to be suing for it to happen.

    Hope this helps

    Pat


Nursing Jobs in every specialty and state. Visit today and Create Job Alerts, Manage Your Resume, and Apply for Jobs.

Top