Professional Documents
Culture Documents
4
Ethical and Legal Guidelines
for Nursing Practice
Ginny Wacker Guido and Annita Watson
THIS CHAPTER highlights the continuing influence that ethical and legal concepts have on the professional practice of nursing. Professional accountability and responsibility continue to
gather additional prominence, especially as nurses become more
autonomous and practice settings expand from acute care facilities to community, ambulatory, and long-term settings and as
consumers of health care become more knowledgeable about
their rights and options for care.
It is not sufficient, though, to know and understand ethical
and legal concepts. Nurses must blend these important aspects
with competent, skilled nursing diagnoses and interventions. To
perform this high-quality nursing care, nurses must also understand the concepts of critical thinking and clinical judgment, for
without these latter concepts one is not able to fully appreciate
the application of legal and ethical concepts in professional
practice settings. Thus, this chapter first explores ethics and legal concepts and issues that impact professional nursing practice and concludes with a section on critical thinking and clinical
judgment. Knowing about and using these concepts and issues
moves nursing from merely a hands-on skills performance
role to that of a truly professional practice.
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Ethical Theories
Many different ethical theories have evolved to justify existing
moral principles. These theories are considered normative because they describe the norms or standards of behavior and
value that are ultimately applied to daily life. Normative ethics
concerns human actions and the outcomes of those actions.
Most normative approaches to ethics fall under the three broad
theoretical categories discussed next.
Deontological Theories
Deontological (from the Greek deon, or duty) theories derive
norms and rules from the duties human beings owe to one another by virtue of commitments made and roles assumed. Generally, deontologists hold that a sense of duty consists of rational
respect for the fulfilling of ones obligations to other human beings, rather than looking at the rewards of ones actions. The
greatest strength of this theory is its emphasis on the dignity of
human beings. Deontological theory looks not to the end or
consequences of an action, but to the intention of the action. It
is ones good intentions, the intentions to do a moral duty that
ultimately determine the praiseworthiness of the action.
Duty-based, rights-based, and intuitionist ethical reasoning
derive their framework from deontological theory. Deontological ethics have sometimes been subdivided into situation or
love ethics, wherein the decision making takes into account
the unique characteristics of each individual, the caring relationship between the person and the caregiver, and the most humanistic course of action given the circumstances (Butts & Rich,
2005). Examples of this theory in action in the health care setting abound when making these types of decisions:
Decisions about forgoing life-sustaining treatment that may
conflict with religious beliefs
Decisions not to pursue aggressive treatment while waiting to
see what outcome God wants or trusting that conservative
treatment will work if God so intends
Decisions to bow to a higher order, given by divine command, such as in the case of Jehovahs Witnesses, who do not
ingest blood and, therefore, refuse blood transfusions even if
they will lose their lives or the lives of their children (DeWolfBosek & Savage, 2007).
Teleological Theories
Teleological (from the Greek telos, for end) theories derive
norms or rules for conduct from the consequences of actions.
Right consists of actions that have good consequences, and
wrong consists of actions that have bad consequences. Teleologists disagree, though, about how to determine the goodness or
badness of the consequences of actions. Teleological theories
support decisions that favor the common good. An alternate
way of viewing this theory is that the usefulness of an action is
determined by the amount of happiness it brings. An example of
a decision using this approach is that of allowing individual
family members to make the difficult choices for their loved
ones rather than mandating that all patients in persistent vegetative states must be given parenteral nutrition.
This theory frequently is referred to as utilitarianism; what
makes an action right or wrong is its utility, and useful actions
bring the greatest amount of happiness and satisfaction into existence (Butts & Rich, 2005). Teleological theories are used to
support utilitarianism. Utilitarian ethics can be subdivided into
rule and act utilitarianism. Rule utilitarianism seeks the greatest
happiness for all; it appeals to public agreement as a basis for objective judgment about the nature of happiness. Act utilitarianism tries to determine in a particular situation which course of
action will bring about the greatest happiness, or the least harm
and suffering, to a single person. As such, act utilitarianism
makes happiness subjective, basing decisions on what is the best
for the greatest number of people (Guido, 2006; Marquis & Huston, 2006).
Principlism
A third ethical theory has slowly been evolving over the past 25
years and, although not yet given the full status of a theory, it does
assist nurses and health care providers who are struggling with
difficult ethical issues. Called principlism, this emerging theory
incorporates existing ethical principles and attempts to resolve
conflicts by applying one or more of those ethical principles
(Beauchamp & Childress, 2001). Ethical principles actually control ethical decision making much more than do ethical theories,
since principles encompass the basic premises from which rules
are developed. Principles are moral norms that nurses demand
and strive to implement daily in clinical settings. In the case of
principlism, four principles form the basis for decision making:
respect for autonomy, nonmaleficence, beneficence, and justice.
Each of the principles can be used individually, although it is
much more common to encounter two or more ethical principles
used in concert or to see two or more principles coming into conflict in a specific patient situation.
Ethical theories are important because they form the essential base of knowledge from which to proceed. Without ethical
theories, decisions revolve around personal emotions. Because
most health care providers do not ascribe to either deontology
or teleology exclusively, principlism is growing in popularity
among health care professionals in todays society.
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Ethical Principles
There are eight ethical principles that nurses encounter when
making decisions in clinical settings. Chart 41 outlines these
principles and gives a short definition for each principle.
Autonomy
The principle of autonomy addresses personal freedom and the
right to choose what will happen to ones own person. The legal
doctrine of informed consent is a direct reflection of this principle. Autonomy involves health care deliverers respect for patients rights even if the health care deliverer does not agree with
the decisions made. For example, autonomy issues often arise
when parents of young children refuse immunizations. Most
health care deliverers would advocate for their need in preventing possible complications should the child later be exposed to
what could have been a preventable disease.
Beneficence
The principle of beneficence states that the actions a person
takes should promote good. In caring for patients, good can be
defined in many ways, including allowing a person to die without advanced life support and in the company of loved ones.
Good may prompt the nurse to encourage the patient to undergo extensive, painful treatment procedures especially if these
procedures will increase both the quality and quantity of life.
Good also may extend to the patients family by prompting family members to leave a patients bedside so that they can get some
needed rest.
Nonmaleficence
The corollary of beneficence, the principle of nonmaleficence,
states that a person should do no harm. Many nurses find it difficult to follow this principle when performing treatments and
procedures that bring discomfort and pain to patients. Health
care providers often use the concept of a detrimental-benefit
analysis when the issue of nonmaleficence is raised. Using this
analysis, the focus of the projected treatment or procedure is on
the consequences of the benefits to the patient and not on the
harm that occurs at the time of the intervention. For example,
the nurse may use this analysis when medicating a postoperative
patient. Even though the injection causes some level of discom-
CHART 41
Ethical Principles
Principle
Definition
Autonomy
Veracity
Veracity concerns truth telling and incorporates the concept
that individuals should always tell the truth. This principle also
compels that the truth be told completely. Nurses and other
health care providers exemplify this principle when they give all
of the facts of a situation truthfully and then assist patients and
their loved ones to make appropriate decisions. For example, patients must be told of all options in terms that they can understand and then be allowed to make their own decisions.
The principle of veracity compels health care members to
fully inform patients about all aspects of care, both the desirable
effects as well as the more negative effects. Without the entire
truth, patients cannot make informed choices. This also is true
of nursing management. For instance, a manager who believes
deception is morally acceptable if it is done with the objective of
beneficence may tell all rejected job applicants that they were
highly considered, whether they had been or not. Another management example is that of the nurse manager who, in the event
of a low patient census (i.e., a slow period on a unit), relays all of
the options to staff and lets them make their own decisions
about floating to other units, taking vacation time, or taking a
day without pay, contingent on agency policy.
Justice
Justice concerns the issue that persons should be treated equally
and fairly. This principle usually arises in times of short supplies
or when there is competition for resources or benefits. This
principle most often is considered when patient census is high
and two patients are equally qualified to be cared for in a specific
unit, such as an intensive care or cardiac care unit, or when there
is an organ available for transplantation and two patients are
equally appropriate candidates for the organ transplant.
Justice also demands that the same quality of care be given to
all patients, regardless of their ethnicity, socio-economic status,
or lifestyle. Thus, the health care team must be vigilant concerning decisions that are made about why one candidate would be
the more appropriate recipient of an available transplant organ
and how the care of the second potential recipient will be delivered. Acceptable reasons for selecting one candidate over a second potential recipient could be compliance with recommended
therapies and the supportive role of family members.
Beneficence
Paternalism
Nonmaleficence
Veracity
Truth-telling
Justice
Paternalism
Fidelity
The principle of paternalism sometimes referred to as parentialism, allows one to make decisions for another and often has been
viewed as a negative or undesirable principle. Used appropriately,
however, paternalism assists persons to make decisions when
they do not have sufficient data or expertise to make a decision.
Staff members frequently use some degree of paternalism when
they assist patients and their family members to decide if surgical procedures should be undertaken or if medical management
is a better option. Paternalism becomes undesirable when the entire decision is taken from the patient or family member.
Fidelity
Fidelity means keeping ones promises or commitments. Staff
members know not to make promises to patients that they may
not be able to keep, such as assuring the patient that no code will
be performed before consulting with the patients physician for
such an order or that the patient will be able to return home at
a specific time frame. Fidelity also prevents health care deliverers from promising that the patient will be given sufficient pain
medication after a surgical procedure so that the patient is totally pain free. Rather, nurses reinforce that such freedom from
pain is a goal that the health care team will work to achieve.
Hamric (2002) suggests that it is helpful to view the nurse in
the middle phenomenon from a fidelity perspective. Although
nurses have multiple fidelity duties to the patient, physician organization, profession, and self that at times may conflict with
one another, the American Nurses Association (ANA) Code of
Ethics is clear than one duty dominates over all others, namely,
the nurses commitment to the patient.
CHART 42
ily and the staff caring for him may feel that he needs closer supervision and desire that the patient be relocated to an assisted living center (beneficence). Resolving such issues is the goal of
understanding ethical dilemmas and ethical decision making.
Ethical Dilemma
When such disagreements occur, an ethical dilemma emerges.
Ethical dilemmas by definition involve two or more unfavorable alternatives to a given situation. For example, in the preceding scenario, the elderly gentleman may be at risk for injury
when living by himself at his home, but his ability to be independent will be hampered by living at an assisted living center.
One means of addressing such situations is to use ethical decisionmaking models. Ethical decision making involves asking the following questions:
1.
2.
3.
4.
The letters of the acronym remind users of the steps of the model
Acronym Request
Example
Issues are identified and defined, taking into consideration the value systems and
principles of all major players in the dilemma.
Options are fully examined, including those that are less realistic.
Issues and options are reviewed and basic ethical principles are applied to each of
the identified options. A decision is made concerning the plan of action that will be
taken.
Requires implementation by all members of the health care team and family
members.
Process of reviewing and reexamining whether desired outcomes were attained and
whether new options need to be implemented.
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move through any models various steps, they may find that they
need to return to a previous step and redefine the issue or that a
major players values were not taken into consideration when
making the final decision. Sufficient time must be allowed for
making decisions so that all players in the dilemma reach a conclusion that they can support.
Accountability and responsibility for making ethical decisions varies depending on the dilemma encountered. For the
ethical decisions that must be addressed on a daily basis, such as
helping family members understand the full extent of their
loved ones prognosis or assisting a patient with understanding
why a nurse cannot give more pain medication when the patient
continues to have pain, the nurses working directly with the patients are generally responsible for these ethical dilemmas. For
issues that involve the entire health care team, such as assisting
family members to determine if a feeding tube should be placed
for nutritional support in an elderly patient who is terminal, the
hospital ethics committee is generally responsible for making
such decisions.
It is not uncommon in the practice of nursing to encounter
situations in which a patient and family members must make
decisions about lifesaving measures: Should they or should
they not be used? The resulting conflict may compromise how
nurses choose to provide care to the patient/family and how that care is
rendered, keeping in mind that the nurse has an ethical duty to provide the
minimum standard of care. It is essential that nurses know what resources
are available to them in the agency where they work to help them solve this
dilemma and meet the normal standard of care for the given situation.
Ethics Committees
With the increasing complexity of ethical issues in health care,
ethics committees have been created to assist in making ethical decisions in clinical settings. Ethical committees can:
1. Provide structure and guidelines for potential problems.
2. Serve as an open forum for discussion and debate.
3. Function as a patient advocate by placing the patient at the
core of the committees deliberations.
Committee Structures
Ethics committees generally follow one of three distinct structures, though in some institutions these structures are blended.
The autonomy model facilitates decision making for the competent patient. The patient benefit model uses substituted judgment (what the person would have done if she were capable of
making a decision) and facilitates decision making for the incompetent patient. The social justice model considers broad social issues that may arise within the institution; in this model,
many ethics committees hold ethical grand rounds.
Ethical grand rounds usually are conducted on a monthly basis and allow staff members to begin to be more involved in ethical decision making by presenting cases that involve a variety of
ethical issues. The purpose of ethical grand rounds is to assist
health care providers with future ethical decision making by
making them more knowledgeable about ethical principles and
the MORAL model. For example, presenting the case of the elderly gentleman who desires to remain in his own home rather
than move to an assisted living center helps nurses to fully ex-
amine both sides of the issue. The nurses are then able to more
quickly and competently address this same type of issue in the
future. Such case presentations also allow nurses to become
more fully versed on both sides of controversies and better understand their own ethical values and principles.
Sources of Law
The most basic source of law is constitutional law, which is a system of fundamental laws or principles for the governance of a
nation, society, or other aggregate of individuals. Statutory laws
are those rules and regulations enacted by the legislative branch
of the government. Nurses are usually familiar with this source
of law because the nurse practice act is an example of statutory
law. Administrative laws are enacted through the decisions and
rules of administrative agencies, which are specific governing
bodies charged with implementing selected legislation. When
statutory laws are enacted, administrative agencies are given the
authority to implement the specific intentions of the statutes,
creating rules and regulations that enforce the statutory law.
Boards of nursing are examples of administrative law agencies.
Finally, judicial laws are created by courts of law, interpreting legal issues that are in dispute.
All laws, regardless of origin, are subject to change. Constitutional laws may be amended; statutory laws may be amended,
repealed, or expanded; administrative agencies may be dissolved, expanded, or redefined; and judicial laws may be modified or completely altered by subsequent court decisions.
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Criminal Law
Criminal law, sometimes called public law, refers to laws that affect the state in its political capacity and that affect society as a
Elements of Malpractice
To understand how the law applies each element of malpractice
to specific court cases, we use the following scenario: A nurse
employed by a state medical center has been assigned to care for
Mr. Gee, a patient admitted for a right hip replacement. Mr. Gee
is 89 years old, weighs 255 pounds, is in relatively good health,
and is competent mentally. He is to have surgery tomorrow and
requires assistance in ambulating to and from the bathroom.
While caring for Mr. Gee, the nurse fails to obtain the assistance
of a second person when walking Mr. Gee to the bathroom, and
he falls. Mr. Gee sustains a broken left hip and a mild concussion.
He will be hospitalized for several additional days because he
must now undergo bilateral hip replacement and physical therapy. Additionally, he will spend 2 days in the neurological stepdown unit because of the concussion.
Duty Owed the Patient
The first element of malpractice is duty owed the patient and involves both the existence of the duty and the nature of the duty.
That a nurse owes a duty of care to a patient is usually not hard
to establish. Often this is established merely by showing the valid
employment of the nurse within the institution. The more difficult part is the nature of the duty, which involves standards of
care that represent the minimum requirements that define acceptable practice (internal standards). In the preceding scenario,
CHART 43
Elements of Malpractice and Examples of Nursing Actions That May Result in Malpractice
Element
Explanation
Foreseeability of harm
Injury
Damages
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CHART 44
of care than that shown by the defendant hospital and staff. Each
of these two sides to the dispute help determine the standard of
care through the testimony of expert witnesses. Expert witnesses
give testimony in court to determine the applicable and acceptable standard of care on a case-by-case basis and to assist the
judge and jury in understanding nursing standards of care. In the
scenario involving Mr. Gee, the injured partys expert witness
would quote the institutions policy manual, and the nurses expert witness would note any viable exceptions to the stated policy.
An example case that remains the standard for the distinction
in standards of care is Sabol v. Richmond Heights General Hospital (1996). In Sabol, a patient was admitted to a general acute
care hospital for treatment after attempting suicide by drug
overdose. While in the acute care facility, the patient became increasingly paranoid and delusional. A nurse sat with the patient
and tried to calm him. Restraints were not applied because the
staff feared this would compound the situation by raising his
level of paranoia and agitation. The patient got out of bed,
knocked down the nurse who was in his room, fought his way
past two nurses in the hallway, ran off the unit, and jumped from
Intentional Torts
Nurses also may be found liable for intentional torts, which are
generally defined as actions that violate another persons rights.
In such actions, the nurses actions must intend to interfere with
the patient or property, the nurse must intend to bring about the
consequences of the act, and the act must be a substantial factor
in bringing about the consequences or outcomes. Note that, unlike negligence and malpractice, no actual harm is necessary for
this tort; it is the violation of another persons rights that creates
the cause of action. The more commonly seen intentional torts in
Quasi-Intentional Torts
Tort law also recognizes quasi-intentional torts. The difference
between quasi-intentional and intentional torts is that there is
no intent to injure or cause distress to another person; there is,
however, an intentional (volitional) action that causes injury or
distress. Two quasi-intentional torts are recognized in health
care settings: defamation of character and invasion of privacy,
which includes the subset of breach of confidentiality.
Defamation of Character
Defamation of character, also known as libel and slander, is
harming anothers reputation by diminishing the esteem, respect,
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Invasion of Privacy
Invasion of privacy is a violation of a persons right to protection against unreasonable and unwarranted interference with
his personal life. To show that invasion of privacy has occurred,
the person must show that the nurse intruded on the patients
privacy, the intrusion would be objectionable to a prudent and
reasonable person, the intrusion concerns private or unpublished facts or pictures of a private nature, and that public disclosure of private facts was made. Examples of invasion of
privacy include the taking of photographs without the patients
permission, disclosure of medical facts to persons not entitled to
those facts, and publishing information that misrepresents the
patients condition.
Breach of Confidentiality
Breach of confidentiality, a part of invasion of privacy, concerns facts that are presented in the medical record. The majority of the cases concerning breach of confidentiality concern
privileged conversations that are included in the patients medical record and the faxing or electronic conveyance of medical
records. Health care professionals are cautioned to have procedures in place that allow for the disclosure of confidential data;
the patients written authorization to reveal selected information prevents a cause of action concerning invasion of privacy
and breach of confidentiality.
Consent
Generally, the health care providers right to treat a patient, barring true emergency conditions or unanticipated occurrences, is
based on a contractual relationship that arises through the mutual consent of parties to the relationship. This relationship is
formed when the health care provider performing the therapy
or treatment provides the patient with needed information and
the patient voluntarily consents to the therapy or treatment.
This fulfills the provisions of contracts: (1) agreements made
between two or more persons or entities for the performance of
an action; (2) mutual understanding of the terms and meanings
of the contract; (3) compensation in the terms of something of
value; and (4) fulfillment of a lawful purpose (Guido, 2006). This
concept is discussed under the previous section on contract law
and in Chapter 6
.
Consent is the voluntary authorization by a patient or the patients legal representative to do something to the patient. It is
based on the mutual consent of all parties involved, and the key
to true and valid consent is patient comprehension. Consent
may be given orally or in writing. Unless state law mandates
written consent, the law views oral and written consent as
tion of and compliance with HIPAA standards seriously. Unintentional violations may result in fines of up to $25,000 for each
incident. Intentional violations can result in imprisonment of
up to 10 years and fines of $250,000 (HIPAAdvisory, 2006).
Only covered entities come under the HIPAA regulations and
such covered entities include health care plans that employ
greater than 50 participants and who transmit health care information in an electronic format (45 Code of Federal Regulations,
Sections 160.102 and 160.103, 1996).
One of the most important reasons for this act was the concept that patients retained a right to their medical information.
Before HIPAA was enacted, information could be shared with
other entities; now, patients have the right to either allow the disclosure or deny the disclosure. To ensure that medical information is protected, the act defines protected health information
(PHI), which includes 18 possible identifiers that relate to the
past, present, or future physical or mental health of the person.
PHI includes the following: names of the individual or initials;
addresses, including street, e-mail, and Internet addresses; dates,
including birth dates and dates of services received; telephone
and fax numbers; Social Security or other personal identification
numbers; medical record numbers; health plan identification
numbers; license or certificate numbers; medical device identifiers; biometric identifiers such as fingerprints or photographic
images; or any other unique identifying characteristic or code (45
Code of Federal Regulations, Section 160.103, 1996).
The HIPAA standards limit how information will be used or
shared, mandate safeguards for the protection of health information, and shift control of health information from providers
to the patient. Covered health care facilities must provide patients with a document entitled Notice of Privacy Practices,
which explains how the PHI will be used or shared with other
entities. The document also alerts patients to the process for
complaints if they determine that their information rights were
violated. Chart 45 provides a concise overview of the components of the HIPAA.
CHART 45
Overview of HIPAA
Provision
Requirements
Electronic data
interchange
Security
Privacy
CHART 46
Information Necessary
for Informed Consent
equally valid. As a precaution, health care providers should recognize that oral consent is much more difficult to prove should
consent or lack of consent become a legal issue. As a convenience
and to prevent such court issues, most health care institutions
require written consent, primarily for invasive procedures, surgical interventions, and selected medication regimes.
Consent becomes an important issue from a legal perspective
in that the patient may sue for a battery (unconsented touching)
if she does not consent to the procedure or treatment and the
health care provider goes ahead with the procedure or treatment. This means that the patient may bring a lawsuit and be
awarded damages even if the patient was helped by the procedure or treatment. The more current trend, though, is to argue
consent under a negligence or malpractice cause of action because generally the patient has given consent for the procedure,
an adverse outcome has occurred, and the issue of consent is argued secondary to the adverse outcome (harm) that occurred.
The right to consent and the right to refuse consent are based
on a long-recognized, common law right of persons to be free
from harmful or offensive touching of their bodies. Consent is
not contingent on a request for information or clarification by
the patient, but must be actively given by health care providers.
Consent may be obtained in a variety of ways. Perhaps the easiest means of obtaining informed consent is when the consent is
expressed. Expressed consent is consent given by direct words, either written or oral. For example, after the nurse informs the patient that she is going to start an intravenous infusion, the patient
says, Okay, but could you put the needle in my left hand, as I am
right-handed? As a rule, expressed consent is the type most often
sought and received by health care providers, particularly nurses.
Informed Consent
Consent, technically, is an easy yes or no: Yes, I will allow the surgery or No, I want to try medications first, then maybe I will allow the surgery. The law concerning consent in health care
situations is based on informed consent. The doctrine of
informed consent has developed from negligence law as the
courts began to realize that although consent may have been
given, not enough information was imparted to form the foundation of an informed decision. Informed consent mandates to the
physician or independent health care provider the separate legal
duty to disclose needed material facts in terms that the patient can
reasonably understand so that the patient can make an informed
choice. There should also be a description of the available alternatives to the proposed treatment and the risks and dangers involved
in each alternative. Failure to disclose the needed facts in understandable terms does not negate the consent, but it does place potential liability on the practitioner for malpractice. To be
informed, the patient must receive, in terms he can understand
and comprehend, specific information (American Medical Association, 2007), as shown in Chart 46.
Nurses may become involved in the process of obtaining informed consent in one of several ways. When one realizes that
consent must be obtained for all procedures and treatments, not
just medical procedures, one realizes the vast impact of this doctrine. This does not mean that nurses have to obtain written consent each time they give an injection or turn a patient. Most
nursing interventions rely on oral expressed consent or implied
consent that may be readily inferred through the patients actions.
What the doctrine of informed consent means is that nurses
must continually communicate with patients. What it also
means is that the patients refusal to allow a certain procedure
must be respected. If the patient is unable to communicate, permission may be derived from the patients admission to the hospital or obtained from the patients legal representative.
A second way to enhance understanding is to allow time between the actual giving of information and when the patient
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must make a decision. Such time intervals allow patients to consider what has been suggested, to put into words their questions
and concerns, and then make the final decision and sign the informed consent forms.
Implied Consent
Implied consent is consent that may be inferred by the patients
conduct or that may legally be presumed in emergency situations. Many patients hold out their arm and roll up their sleeve
when the nurse approaches with a stethoscope and blood pressure cuff. This is an example of implied consent because a reasonable person would infer by the patients action that she is
consenting to the procedure. Or the patient extends his left
shoulder for an injection after the nurse explains why the medication is being given. Nurses most often obtain implied consent
for minor procedures and routine care.
Implied consent may be presumed to exist in true emergency
situations and is known as the emergency doctrine. For such
consent, the patient must not be able to make his wishes known,
and a delay in providing care would result in the loss of life or
limb. An important element in allowing emergency consent is
that the health care provider must not have any reason to know
or believe that consent would not be given were the patient able
to deny consent. For example, a health care provider cannot wait
until a patient loses consciousness to order treatment that the
patient had previously refused, such as a blood transfusion for a
patient who is known to be a Jehovahs Witness. Implied consent
is frequently relied on during surgery or in critical care units
when an untoward event occurs and an immediate decision
must be made to prevent further injury to the patient.
Revocation of Consent
The nurse also has an important role if the patient subsequently
wishes to revoke his or her prior consent or if it becomes obvious
that the patients already signed, informed consent form does not
meet the institutions standards for informed consent. Most
nurses have been faced with the problem of what to do when it
becomes all too clear that the patient does not understand the
procedure to be performed or believes that there are no major
risks or adverse consequences inherent to the procedure. It is important to remember that the nurse and the hospital may incur
liability if there is reason to know that the standards of informed
consent have not been met. In such a case, it is the nurses responsibility to contact his immediate supervisor and the responsible
physician. Both entities need to be informed of the patients
change of mind or lack of comprehension.
consent forms. Competency at law means that (1) the court has
not declared the person to be incompetent and (2) the person is
generally able to understand the consequences of her actions.
There is a strong legal presumption of continuing competency.
Some persons are never adjudicated or judged to be incompetent by a court of law, but they become incompetent to give
informed consent based on their current medical condition.
Many states allow the patients family members to make decisions for the incompetent patient. For example, an automobile
accident may render the patient incapable of making decisions
and giving consent, and the physician will frequently ask the
family about medical matters for the unconscious patient. The
order of selection for most states usually is (1) spouse, (2) adult
children or grandchildren, (3) parents, (4) grandparents, (5)
adult brothers and sisters, and (6) adult nieces and nephews.
Most states recognize the child under 18 as a minor. Parental
or guardian consent is necessary for medical therapies unless (1)
the emergency doctrine applies, (2) the individual is an emancipated (liberated) minor or mature minor, (3) there is a court order to proceed with the therapy, or (4) the law recognizes the minor
as having the ability to consent to the therapy. Some states also follow the in loco parentis doctrine, which refers to the ability of a person or the state to stand in the place of the parents. Look to the
individual state statutory laws to see who may consent in the absence of a parent and what constitutes emancipated status because
there is no general consensus on these issues. Such laws can be accessed through the individual state governmental website. If there
is a family consent doctrine, it will generally be a grandparent, adult
brother or sister, or adult aunt or uncle.
Emancipated minors are persons under the legal age of an
adult who are no longer under their parents control and regulation and who are managing their own financial affairs.
Some states require the parent to completely surrender the
right of care and custody of the child to prevent runaways from
coming under this classification. Such emancipated minors
may validly consent for their own medical therapies. Examples
of emancipated minors are married persons, underage parents, or those in the armed service of their country. In some
states pregnant adolescents are considered emancipated for
the purposes of giving or refusing medical treatment for themselves and their fetuses. However, after the infant is born, the
adolescent mother may only make decisions for the infant or
for herself unless she is married. Some states allow college students living away from their parents to fall in the category of
emancipated minor. Individual nurses should consult agency
policies and state regulations for information regarding emancipated minors.
Mature minors also may consent to some medical care. The
concept of a mature minor is a relatively new one that is gaining legal recognition (DeWolf-Bosek & Savage, 2007; Driggs,
2002; Guido, 2006). The mature minor is a minor between the
ages of 14 and 17 who is able to understand the nature and
consequences of the proposed therapy, is making his own decisions on a daily basis, and is independent. The health care
provider is encouraged to seek parental consent along with the
consent of the mature minor in most circumstances. Such a
practice aids in limiting potential liability and encourages
family involvement. It is necessary to consult agency policy for
NursePatient Relationship
One of the most fundamental aspects of malpractice law involves
relationships. For a duty to be owed the patient, one must first establish that a nursepatient relationship exists. This may be accomplished by showing that a reliance relationship exists: One
person (the patient) is depending on another person (the nurse)
for competent, quality nursing care.
The core of any reliance relationship is trust and communication. Establishing rapport with a patient, informing patients
honestly and openly of all aspects of their care, and allowing patients to make decisions for themselves have always been credited
to nurses as one means of preventing potential liability. Nursing
is a caring profession; part of caring is maintaining communications and ensuring that trust is established and continues
throughout the interactions between the nurse and the patient.
Patient Rights
Health care providers are becoming increasingly more aware
and respective of patient rights. In 1959, the National League for
Nursing wrote one of the earliest statements regarding patients
rights (National League for Nursing, 1959). In the early 1970s,
the American Hospital Association (AHA) published A Patients
Bill of Rights, enumerating 12 rights that were to be afforded all
hospitalized patients. These rights primarily concern the patients right to considerate and respectful care; informed consent
concepts, including making treatment decisions based on informed choice; considerations of privacy; the right to know who
will provide care; and the right to information about advance di-
80
UNIT 1
CHART 47
These rights can be exercised on the patients behalf by a designated surrogate or proxy decision maker if the patient lacks decision-making capacity, is legally incompetent, or is a minor.
1. The patient has the right to considerate and respectful care.
2. The patient has the right to and is encouraged to obtain from
physicians and other direct caregivers relevant, current, and
understandable information concerning diagnosis, treatment, and
prognosis.
Except in emergencies when the patient lacks decisionmaking capacity and the need for treatment is urgent, the patient is
entitled to the opportunity to discuss and request information related
to the specific procedures and/or treatments, the risks involved, the
possible length of recuperation, and the medically reasonable
alternatives and their accompanying risks and benefits.
Patients have the right to know the identity of physicians,
nurses, and others involved in their care, as well as when those
involved are students, residents, or other trainees. The patient also
has the right to know the immediate and long-term financial
implications of treatment choices, insofar as they are known.
3. The patient has the right to make decisions about the plan of care
prior to and during the course of treatment and to refuse a
recommended treatment or plan of care to the extent permitted by
law and hospital policy and to be informed of the medical
consequences of this action. In case of such refusal, the patient is
entitled to other appropriate care and services that the hospital
provides or transfer to another hospital. The hospital should notify
patients of any policy that might affect patient choice within the
institution.
4. The patient has the right to have an advance directive (such as a
living will, health care proxy, or durable power of attorney for health
care) concerning treatment or designating a surrogate decision
maker with the expectation that the hospital will honor the intent of
that directive to the extent permitted by law and hospital policy.
Health care institutions must advise patients of their rights
under state law and hospital policy to make informed medical
choices, ask if the patient has an advance directive, and include that
information in patient records. The patient has the right to timely
information about hospital policy that may limit its ability to
implement fully a legally valid advance directive.
5. The patient has the right to every consideration of privacy. Case
discussion, consultation, examination, and treatment should be
conducted so as to protect each patients privacy.
6. The patient has the right to expect that all communications and
records pertaining to his/her care will be treated as confidential by
the hospital, except in cases such as suspected abuse and public
health hazards when reporting is permitted or required by law. The
patient has the right to expect that the hospital will emphasize the
confidentiality of this information when it releases it to any other
parties entitled to review information in these records.
7. The patient has the right to review the records pertaining to his/her
medical care and to have the information explained or interpreted as
necessary, except when restricted by law.
8. The patient has the right to expect that, within its capacity and
policies, a hospital will make reasonable response to the request of
a patient for appropriate and medically indicated care and services.
The hospital must provide evaluation, service, and/or referral as
indicated by the urgency of the case. When medically appropriate
and legally permissible, or when a patient has so requested, a
patient may be transferred to another facility. The institution to
which the patient is to be transferred must first have accepted the
patient for transfer. The patient must also have the benefit of
complete information and explanation concerning the need for,
risks, benefits, and alternatives to such a transfer.
9. The patient has the right to ask and be informed of the existence of
business relationships among the hospital, educational institutions,
other health care providers, or payers that may influence the
patients treatment and care.
10. The patient has the right to consent to or decline to participate in
proposed research studies or human experimentation affecting care
and treatment or requiring direct patient involvement, and to have
those studies fully explained prior to consent. A patient who declines
to participate in research or experimentation is entitled to the most
effective care that the hospital can otherwise provide.
11. The patient has the right to expect reasonable continuity of care
when appropriate and to be informed by physicians and other
caregivers of available and realistic patient care options when
hospital care is no longer appropriate.
12. The patient has the right to be informed of hospital policies and
practices that relate to patient care, treatment, and responsibilities.
The patient has the right to be informed of available resources for
resolving disputes, grievances, and conflicts, such as ethics
committees, patient representatives, or other mechanisms available
in the institution. The patient has the right to be informed of the
hospitals charges for services and available payment methods.
Source: American Hospital Association. (1992). A patients bill of rights. Chicago, IL: Author.
Immunity
Immunity statutes have been enacted in some states that serve to
dismiss certain causes of action. A good example of a state immunity statute is the Good Samaritan statute. Because of these
laws, negligent actions against health care providers at scenes of
accidents are rare. Good Samaritan laws are enacted to allow
health care personnel and citizens who are trained in first aid to
deliver needed medical care in an emergency without unnecessary fear of incurring criminal and civil liability (Garner, 2004).
Most states require that the care be given in good faith and that
it be gratuitous. Guidelines that govern the interpretation of
Good Samaritan laws are shown in Chart 48 (p. 82).
Defenses against nonintentional torts or negligent actions include release, contributory or comparative negligence, assumption of the risk, unavoidable accident, defense of the fact, and
immunity statutes. A release may be signed during the process
of settling a claim to prevent any and all future claims arising
from the same incident. Once signed, the release bars future
suits. In medical malpractice claims, a release is frequently a part
of the out-of-court settlement. Effectively, the plaintiff states
that the agreed-on settlement is the only compensation for the
negligent action. Contributory and comparative negligence
serve as defenses and in essence hold injured parties accountable
for their part in the injury. Such fault by the plaintiff may occur
for failure to follow prescribed treatments or if incorrect treatment is given based on the patients false information to the
physician. Similarly, the assumption of risk defense states that
plaintiffs are partially responsible for consequences if they understood the risk involved when they proceeded with the action
(Guido, 2006).
The defense of unavoidable accident comes into play when
nothing other than an accident could have caused the persons
injury. An unavoidable accident is an inevitable occurrence
that cannot be foreseen or prevented by vigilance, care, and attention and not occasioned by or contributed to in any manner by an act or omission of the party claiming the accident
was unavoidable (Dawson, 2007; Guido, 2006). The defense of
the fact is used when there is no indication, direct or otherwise, that the health care providers actions were the cause of
the patients injury or untoward outcome (e.g., the patient
who receives an injection in his right arm and then begins to
experience numbness and tingling in his left leg). There is no
connection between the two events; thus, the defense is defense
of fact.
82
UNIT 1
CHART 48
1. Make your decision quickly as to whether you will stay and help.
There is no common law duty to stop and render aid; however, once
you begin to provide care, you incur the legal duty to maintain a
standard of reasonable emergency care.
2. Ask the injured person or family members for permission to help. Do
not force your services once refused.
3. Care for the injured party where you can do so safely, in the vehicle
or at the exact site where the victim is found. Only move the injured
party if you must do so without causing further harm and as needed
to prevent further harm.
4. Apply the rules of first aid. Assess for and prevent major bleeding,
assess for the need to initiate cardiopulmonary resuscitation, cover
the injured party with a blanket or coat, and so forth.
5. Assess and reassess the person continuously for additional injuries,
and communicate findings of your assessment to the injured person
and family.
6. Have someone call or go for additional help while you stay with the
injured person.
7. Stay with the injured person until equally or more qualified help
arrives. Prevent unskilled persons from treating or moving the
injured party.
8. Provide the police or emergency medical personnel with as complete
a description as possible of the care that you have rendered so that
continuity of care exists. Give family members or police any personal
items such as dentures, eyeglasses, and the like.
9. Do not accept any compensation of any kind offered by the injured
party or family members as this may change your status into a feefor-service situation and cause you to lose your Good Samaritan
protection.
10. Should you choose not to stop and render aid, stop at the nearest
phone and report the accident to proper authorities so that the
injured party may be aided.
Source: Adapted from Guido, G. W. (2006). Legal and ethical issues in nursing (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
Clinical Impact
Improve the knowledge base of nurses concerning ethical principles so that
they can make more effective ethical decisions in clinical practice settings.
Explore why nurses are not on ethics committees and the vital need to
include nurses in this aspect of patient care.
Understand the extent of lawsuits filed against nurses, the causes of actions
in the filed lawsuits, and the legal knowledge of practicing and student
nurses to hopefully prevent further lawsuits.
Improve nurses decision-making and critical thinking skills with the goal of
improving patient outcomes.
REVIEW QUESTIONS
1. During the course of one day, a nurse will support one
patients decision to not receive a particular medication,
suggest family members of another patient go home to get
rest, promise one patient that the injection will only pinch
for a second, and will spend equal amounts of time with
each patient on her assignment. Which ethical theory is this
nurse demonstrating?
1.
2.
3.
4.
Deontology
Principlism
Rule utilitarianism
Act utilitarianism
Identify issues
Resolve
Options
Evaluate
1.
2.
3.
4.
Common
Civil
Contract
Tort
Answers for review questions appear in Appendix 5
Autonomy model
Social justice model
Fidelity model
Patient benefit model
KEY TERMS
assault p.75
autonomy p.68
battery p.75
beneficence p.68
breach of confidentiality p.76
civil law p.71
common law p.71
criminal law p.72
defamation of character p.75
deontological theories p.67
emancipated minors p.78
emergency doctrine p.78
ethical decision making p.69
ethical dilemma p.69
ethics p.66
EXPLORE
MyNursingKit is your one stop for online chapter review materials and
resources. Prepare for success with additional NCLEX-style practice
questions, interactive assignments and activities, web links, animations
and videos, and more!
Register your access code from the front of your book at
www.mynursingkit.com
negligence p.72
nonintentional torts p.71
nonmaleficence p.68
nurse practice acts p.70
paternalism p.68
principlism p.67
quasi-intentional torts p.71
regional (locality) rule p.75
respect for others p.69
scope of practice p.70
substituted judgment p.70
teleological theories p.67
tort law p.71
veracity p.68
84
UNIT 1
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