Legal/Ethical issues in nursing

whipping girl in 07, RN · Oct 8, 2002

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.

frankie · Oct 8, 2002

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

frankie · Oct 10, 2002

not many of you posting here - what do you think?

DelGR · Oct 10, 2002

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.

Tigger100S · Oct 10, 2002

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!!

jode · Oct 10, 2002

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...

Danielle4 · Oct 31, 2002

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

Danielle4 · Oct 31, 2002

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

kathyhinsh · Oct 5, 2008

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.

RN Power Ohio · Oct 9, 2008

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.

RN Power Ohio · Oct 9, 2008

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.