LEGAL & ETHICAL issues in Nursing Nursing Etiquette concerned with moral principle governing the conduct of nurses towards patients, physicians, colleagues, the nursing profession and public Ethics part of philosophy that deals with systematic approaches to questions of morality a term for the study of how we make judgments regarding right and wrong a system of MORAL PRINCIPLES or moral standards governing conduct Moral human conduct in the application of ethics Concerned with JUDGMENT PRINCIPLES of right and wrong in relation to human actions and character Determinants of the Morality of Human Act •The OBJECT •The END •The CIRCUMSTANCES Ethical Principles Ethical Principles: INVIOLABILITY OF LIFE All human life, from the moment of conception and through all subsequent stages, is SACRED! No one can violate or destroy life! 8 ETHICAL DILEMMAS 1. 2. 3. 4. 5. 6. 7. 8. ARTIFICIAL INSEMINATION IN VITRO FERTILIZATION HUMAN CLONING CONTRACEPTION ABORTION EUTHANASIA PHYSICIAN ASSISTED SUICIDE HUMAN TRANSPLANTATION 9 Argument favoring Euthanasia: compassion for the patient and shortening the period of suffering of the patient
Argument disapproving Euthanasia: it is intrinsically wrong since it rejects life. 10 STEWARDSHIP Man has DOMINION over God’s creation: himself (life and health), creatures and environment One should reasonably, responsibly and respectfully benefit from them for service NOT domination TOTALITY Parts are integral, destined to be part of and subordinate to a whole SOLIDARITY One to be with others; to have a unity of interest, responsibility or goal. Based on the common good, love of neighbor, preferential for the most proximate and most need SUBSIDIARITY
Every creature should be entrusted with the functions he is capable of performing. It relates to human dignity and recognize persons as free and responsible agents able to care and make decisions for them AUTONOMY – Self Governance/Self Rule – Having the freedom to make choices 4 Basic Elements of Autonomy 1. Respect for Autonomous Person 2. Ability to determine personal goals 3. Capacity to decide 4. Has Freedom to Act CONFIDENTIALITY Requires non-disclosure of private or secret information Confidentiality of Information ? Privileged communication ? Based on trust Revealed when: a.
The patient permits such revelation. b. Medico-legal cases/legal proceedings c. Communicable disease /public safety may be jeopardized. d. Continuity of care JUSTICE – refers to the obligation to be fair to other people. Types: 1. distributive justice- fair distribution of responsibilities 2. criminal justice- penalty proportionate to crime 3. rectificatory justice- just compensation in civil law Distributive Justice To each equally. To each according to need. To each according to merit. To each according to person’s right. To each according to individual effort.
To each as you would have done by. To each according to the greatest good to a greater number Double Effect Principle When an act has both good and bad effects, it is permissible if: 1) The direct freely chosen effect is morally good and the indirect foreseen but not desired may be harmful, 2) The action/object must not be evil, 3) The foreseen beneficial effect must be greater or equal to the foreseen evil effect 4) The beneficial effect must follow directly from the action or at least as immediate as the harmful effect BENEFICENCE- means to do good and not to do harm.
NON- MALEFICENCE- one ought not to inflict evil or harm. 22 FIDELITY- refers to the obligation to be faithful to the agreements, commitments and responsibilities that one has made to oneself and others VERACITY- refers to telling the truth or not intentionally deceiving or misleading patients 23 RESPECT- treat all human beings as persons with rights SHARING AND ALLOCATION OF RESOURCESwho will receive particular scarce resources. 24 NURSING ETHICS ? All principles of right conduct in the practice of nursing ? Appraisal of rightness or wrongness of an act BIO–ETHICS Specific domain of ethics
• Systemic study of human behavior in the field of life science and health care in the light of moral values and principles Code of Nursing Ethics
• respect for human dignity
• safeguards the client’s right to privacy
• safeguard client and public
• assumes responsibility and accountability for own actions and judgments
• maintains competence in nursing
• uses informed judgment, competence and qualifications in accepting responsibilities and delegating nursing activities
• Contributes to the development of the profession’s body of knowledge implement and improve standards of care
• establish and maintain conditions of employment conducive to high-quality nursing care
• protect the public from misinformation and misrepresentation and to maintain the integrity of nursing
• In collaboration with other allied health team members, meet the health care needs of the public Patient’s Bill of Rights The patient has the right to: 1) considerate and respectful care. 2) relevant, current, and understandable information concerning diagnosis, treatment, and prognosis. ) make decisions regarding his plan of care; in case of refusal, he is entitled to other appropriate care and service or to be transferred to another hospital. 4) Have advance directive (such as living will) concerning treatment or designating a surrogate decision maker. 5) Every consideration of his privacy such as in case discussion, consultation and treatment. 6) Confidentiality of communication and records 7) Review his records concerning his medical care and have these explained to him except when restricted by law. ) 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. 9) Be informed of business relationship among hospital, educational institution, health care providers that may influence the patient’s treatment and care. 10) Consent or decline to participate in experimental research affecting his care. 11) Reasonable continuity of care when appropriate and be informed of other care options when hospital care is no longer appropriate 12) Be informed of hospital policies and practices that relate to patient care.
Nurse’s Bill of Rights Nurse’s have the right to: 1) Practice in a manner that fulfills their obligation to the society and to those who receive nursing care. 2) Practice in environments that allow them to act in accordance with professional standards and legally authorized scope of nursing. 3) Work environment that supports and facilitates ethical practice 4) Freely and openly advocate for themselves and their patients without fear of retribution. 5. Fair compensation for their work consistent with their knowledge, experience, and professional responsibilities. 6.
Work environment that is safe for themselves and their patients. 7. Negotiate conditions of employment, in all practice settings. LEGAL ASPECTS OF NURSING Nursing Jurisprudence the philosophy of law, or the science which treats the principles of positive law and legal relations Comprises all laws, rules, doctrines and principles, legal opinions and decisions of competent authority regarding governance and regulations of the practice of nursing. Functions of the Law in Nursing 1. Provides a framework for establishing what nursing actions in the care of patients are legal. . Delineates the nurse’s responsibilities from those of other health practitioners 3. Helps to establish the boundaries of independent nursing action 4. Assists in maintaining a standard of nursing practice by making nurses accountable under the law. Philippine Nursing Law Philippine Nursing Act of 2002 R. A. 9173 (October 21, 2002/ November 20, 2002) regulates Philippine nursing practice at present. The law provides about nursing registration, nursing examination, nursing education, nursing practice, and health human resource production, utilization and development.
It is made up of 19 articles and 41 sections. Prohibitions in Practice of Nursing (Section 35) PENALTY: Fine: a. b. c. d. e. f. g. Php50,000- Php100,000 and/or Imprisonment 1- 6 years practice nursing without certificate or special permit use the certificate of others as his own use an invalid certificate give false evidence during registration falsely pose or advertise as a registered nurse illegally append BSN/RN to his/her name abet or assist the illegal practice of a person who is not lawfully qualified to practice nursing
NEGLIGENCE Commission or omission of an act, pursuant to a duty, that a reasonably prudent person in the same or similar circumstance would or would not do, and acting or the non-acting of which is the proximate cause of injury to another person or his property Elements of Professional Negligence
• Breach of duty
• Direct relationship between failure to meet standard of care and injury can be proved Res Ipsa Loquitor “the thing speaks for itself” 3 conditions: 1.
Accident which ordinarily doesn’t occur in the absence of someone’s negligence 2. Must be caused by an agency or within the exclusive control of the defendant 3. Must not have been due to voluntary action or contribution on the part of the plaintiff Specific Examples of Negligence
• Failure to report observations to attending physicians.
• Failure to exercise the degree of diligence which the circumstances of the particular case demands.
• Mistaken identity.
• Wrong medicine, wrong concentration, wrong route, wrong dose. Defects in the equipment such as stretchers and wheelchairs may lead to falls thus injuring the patients.
• Errors due to family assistance.
• Administration of medicine without a doctor’s prescription. Legal Defense in Negligence
• Provision of standard of care in giving service and that they have documented the care they given in a concise and accurate manner.
• Exercise sound judgment
• “assumption of risk” MALPRACTICE Stepping beyond one’s authority with serious consequences Reducing The Risk of Malpractice Litigation
• Maintain Good Communication Be courteous, show respect, and take time to listen – Do not belittle patients or make value judgment – Involve patients in decision making – Assess clients level of understanding – Explain so client understand – Clarify and verify Reducing The Risk of Malpractice Litigation
• Maintain Expertise in Practice – Keep up to date in both knowledge and skills – Do not attempt any task or give any meds that is unfamiliar – Practice within the professional scope of practice – Be familiar with standards of care – Be attentive of client’s changing status – Pay close attention to details – Document objectively, thoroughly and in a timely fashion
Reducing The Risk of Malpractice Litigation
• Maintain autonomy and empowerment – Challenge questionable physician order – Seek attention for patient with changing needs – Challenge bureaucratic structures that threaten patient’s welfare – Avoid institutional settings that produce systematic threats to patient welfare Respondeat Superior
• Let the superior answer for the acts of the subordinate
• Master and servant are answerable; servant is responsible
• Actions performed by the employee within the scope of his employment. Force Majeure “irresistible/ superior force”
• Accident which human prudence can neither foresee or prevent
• “Act of God” Liability of Nurses
• Work of Nursing Aides
• Work of Nursing Students Delegation A process of transferring selected Nursing tasks to an individual who is competent. Any nursing intervention that requires independent special nursing knowledge, skill or judgment CANNOT be delegated. Tasks that involve the assessment, planning and evaluation phases of the nursing process cannot be delegated. Delegation involves:
• Responsibility: an obligation to accomplish a task Accountability: acceptance of responsibility for the outcome of a duty
• Authority: right to act or empower Principles of delegation
• A nurse can only delegate those tasks for which that nurse is responsible, according to the specific state’s nurse practice act The delegator remains accountable for the task Along with responsibility for a task, the nurse who delegates must also transfer the authority necessary to complete the task The delegator knows well the task to be delegated Delegation is a contractual agreement that is entered into voluntarily
• Telephone Orders
• Only in an extreme emergency and when no other resident or intern is available.
• Nurse should read back the order to the physician.
• Signed by the physician within 24 hours.
• Nurse should sign the name of physician per her own and note the time the order was received. CONSENT CONSENT
• Free and rational act that presupposes knowledge of the thing to which consent is being given by a person who is legally capable to give consent.
• Authorization, by a patient or a person authorized by law to give the consent on the patient’s behalf.
Informed Consent a) The diagnosis and explanation of the condition. b) A fair explanation of the procedures to be done and used and the consequences. c) A description of alternative treatments or procedures. d) A description of the benefits to be expected. e) Material rights if any. f) The prognosis. Things to Remember:
• Patient is the one who gives the consent.
• Person who is authorized to give the consent in behalf of the patient.
• Parents of minors.
• Minors are allowed if emancipated or married.
• Parents or legal guardians for mentally ill patients. Emergency situation entails implied consent.
• Patient has the right to refuse. MEDICAL RECORDS ? Legal protection for the hospital, doctor, and nurse ? “If it was not charted, it was not observed or done. ” ? Nurses are expected to fully, accurately, legibly, and promptly document their observations. ? Subpoena duces tecum ? When a nurse or clinical instructor countersigns the charting of a nursing student, he/she attests that he/she has personal knowledge of information and that such is accurate and authentic. CRIME ?An act committed or omitted in violation of the law. Elements: a)Criminal act b)Evil/criminal intent TORTS ?A legal wrong, committed against a person or property. 1. Assault and Battery 2. False Imprisonment or Illegal Detention 3. Invasion of Right to Privacy and Breach of Confidentiality 4. Defamation Criminal Actions a. Misdemeanor
• • General name for a criminal offense which does not amount to felony Punishment is usually a fine or imprisonment less than 1 year. b. Felony
• • Public offense Liable to be sentenced to death or penitentiary imprisonment. Deceit (dolo) ? deliberate intent Fault (culpa)? rongful acts result from imprudence , negligence, or lack of skill or foresight Classes of Felonies Degree of the Acts of Execution Attempted …offender commences the commission of the act and does not perform all the acts or execution by reason of some cause or accident other than his own spontaneous desistance Frustrated Consummated …offender performs all …when all the elements acts or execution of felony necessary for its execution but never produce it and accomplishment are because of causes present independent of the will of the perpetrator Degree of Punishment Grave Less Grave Light capital punishment (death) or penalties which any of their periods are afflictive (imprisonment ranging from 6 yrs to 1 day to life improsnment or a fine not exceeding P6000. 00) …penalties which in …penalty of arresto their maximum period menor (imprisonment are correctional for 1 day to 30 days or a (imprisonment ranging fine not exceeding from 1 month and 1 day P200. 00 or both to 30 days or a fine not exceeding P6000. 00 but not less than P200. 00) CRIMINAL NEGLIGENCE a. Reckless Imprudence
• Person does an act or fails to do it voluntarily but without malice, from which material damage results immediately.
Person did not use precaution and the damage was not immediate or the impending danger was not evident b. Simple Imprudence
• CRIMINAL INTENT
• State of mind of a person at the time the criminal act is committed
• Knowledge that the act was unlawful Requisites:
• There must be FREEDOM
• There must be INTELLIGENCE Requisites of Criminal Intent Freedom Intelligence Freedom is absent in the 1. An imbecile or insane (unless following circumstances: acting during lucid of 1. Under compulsion of an interval). irresistible force. 2. Under nine years old. 2. Under the impulse of 3.
Over nine under fifteen uncontrollable fear or an equal (unless he had acted with or greater injury. discernment). Persons Criminally Liable Principals •Those who take direct part in the execution of the act (principal by direct participation) •Those who directly force or induce others to commit it (principal by inducement) •Those who cooperate in the commission of the offense by another act without which it would not have been accomplished (principal by cooperation) Accomplices •The person who have a common criminal purpose with the criminal. •Have the intention to help and knowledge about the crime.
Accessories •Have the knowledge but did not participate in the act. a. By profiting themselves. b. By concealing or destroying body of the crime, or instrument thereof, in order to prevent its discovery. c. By harboring, concealing or assisting in escape of the principal. Circumstances Affecting Criminal Liability JUSTIFYING ? Does not commit crime in the eye of the law a. In defense of his person or rights b. In defense of the rights of his family c. In order to avoid an evil or injury d. In the fulfillment of a duty e. In obedience to an order by some superior for some lawful purposes
EXEMPTING ? There is crime committed but there is no criminal on account of absence of freewill and voluntariness to act. a. An imbecile or insane (unless acted on lucid interval) b. Under 9 yrs c. Over 9 and under 15 (unless acted on discernment) d. While performing a lawful act with due care, cause an injury by mere accident without fault or intention of causing it e. Act under the compulsion of an irresistible force f. Acts under impulse of uncontrollable fear of an equal injury g. Who fails to perform an act required by law, when prevented by some lawful or insuperable cause. MITIGATING ? which lessen the penalty a. b. c. d. e. f. g. h. Under 18 or over 70 yrs old No intention to commit so grave There was sufficient provocation Acted on impulse so powerful to have produced obfuscation Voluntarily surrendered Deaf or dumb, blind or suffering from defect. Illness that diminish will power Immediate vindication of grave offense to the one committing the felony, his/her spouse, ascendants, descendants, legitimate, natural or adopted brothers or sisters, or relative by affinity within the first degree Lack of education is not Mitigating in: 1. Rape 2. Forcible abduction 3. Arson 4. Treason 5.
In crimes against chastity like seduction and acts of lasciviousness; and 6. Those acts committed in a merciless or heinous manner AGGRAVATING ? …which increases the penalty a. Public position b. In contempt of public authority c. Committed with insult or in disregard of the respect of the offended party on account of his/her rank, age, or sex or that it is committed in the dwelling of the offended party, if the latter has not given provocation d. With abuse or confidence or obvious ungratefulness e. in a place of worship f. Conflagration, shipwreck, earthquake, epidemic or other calamity or misfortune g.
Price, reward, or promise h. Committed by means of fire, poison, explosion, i. With evident premeditation or after unlawful entry j. Craft, fraud, or disguise is employed k. Causing other wrongs not necessary for its commission ? ALTERNATIVE ? Those which must be taken into consideration as aggravating or mitigating according to the nature effects of the crime and other conditions attending its commission ? Alternative circumstance of relationship should be taken into consideration Points to Observe in Order to Avoid Criminal Liability a. Be very familiar with the nursing law. b. Beware of the laws affecting nursing practice. . At the start of employment, get a copy of your job description, the agency’s rules, regulations and policies. d. Upgrade your skills and competence. e. Accept only such responsibility that is within the scope of your employment and your job description. f. Do not delegate your responsibility to others. g. Determine whether your subordinates are competent in the work you are assigning them. h. Develop good interpersonal relationships with your coworkers, whether they be your supervisors, peers or subordinates. i. Consult your superiors for problems that may be too big for you to handle. . Verify orders that are not clear to you or those that seem to be erroneous. k. The doctors should be informed about the patient’s condition. l. Keep in mind the value and necessity of keeping accurate and adequate records. m. Patients are entitled to an informed consent. Moral Turpitude An act of baseness, vileness or depravity in social or private duties which a man owes to hi fellow man or society in general, an act contrary to the accepted and customary rule of right and duty between men Murder ? Unlawful killing a human being WITH INTENT to kill. ? A very serious crime
Ex. Criminal Abortion Euthanasia Homicide ? Killing of a human being WITHOUT CRIMAL INTENT by a person other than his father, mother or child or any of his ascendants or descendants, or his spouse Abortion ? Expulsion of the product of conceptus before the age of viability ? In the law, any person who, with the intention pr prematurely ending a pregnancy, willfully and unlawfully does any act to cause the same is guilty of procuring abortion ? Art. II Sec. 15 of Phil. Constitution protects the life of the unborn Infanticide ? Killing of a child less than three (3) days of age ?
Mother who committed this crime shall be imprisoned for two (2) years, four (4) months and one (1) day to six (6) years Parricide ? Crime committed by one who kills his/her father, mother or child whether legitimate or illegitimate, or any of his ascedants or descedants or his spouse. ? Convicted with this crime, shall be imposed a penalty of life imprisonment (Reclusion Perpetua) to death Robbery ? Crime against a person or property ? The taking of personal property of another person from him or in his presence Common Legal Terms R. Ns should know Affidavit – is a written statement made under oath efore a notary public or other person duly authorized Civil Law – concerned with legal rights and duties of private persons Criminal Law – deals with conduct that is considered to be offensive to a society as a whole Day in Court – the right of a person to appear in court and be heard concerning his complaint/defense Defendant – the person being accused of wrongdoing; therefore needs to defend himself Deposition – an oral interrogation answering all manner of questions relating to the transaction at issue, given under oath and taken in writing before a judicial officer or attorney