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6. legal, ethical and psychosocial issues dr. r.jeyadeepa
- 1. Legal, Ethical and Psychosocialissues in critical care By Prof. R.Jeyadeepa M.Sc (N), MBA, PGDHM, Ph.D Vice Principal Karuna College of Nursing Vilayodi, Chittur, Palakkad
- 2. Objectives • At theend of the session nurses – Identify legal issues – Explain the measures to overcome the legal issues – Describe ethical issues – Judge ethical dilemmas in decision making – Identify psycho social issues in critical care – Include psycho social aspects in planning nursing care
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- 5. Legal issues • Informedconsent • Medico legal cases • Documentation • Restrains • Life sustaining treatment • Organ donation • Will • Insurance coverage • Transfer to higher institution
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- 10. Who is responsible? •Person who is performing the procedure is responsible • Nurses are witness • If signed it indicates client gave it voluntarily, signature authentic and client appears competent
- 11. Legally authorized/ acceptable representative •Children • Mentally challenged • Mentally ill • Unconscious
- 12. Needed for 1. ICUADMISSON 2. SUSTAINING/ WITHDRAWING TREATMENT 3. INTERVENTION 4. AUTOPSY 5. ORGAN DONAITON & TRANSPLANT
- 13. Elements of informedconsent • Language • Risk and discomfort • Understandable • Short sentences, simple words • One concept in one sentence • No medical terms • Avoid style change
- 14. INVALID CONSENT • Intoxicatedperson • Person of unsound mind • Person below twelve years of age • Consent of an intoxicated person • Oral consent is valid if taken in front of a witness
- 15. MLC • Accidents • Burns •Assaults • Alleged suicide or homicide • Poisoning • RTA • Rape • Drowning
- 16. • Enter asMLC • Record MLC number in case file • Inform police and document • MLC form to be filled
- 17. Documentation • All treatmentplans must be documented and communicated
- 18. What to bedocumented? • Clear transfer notes • Vital signs • Medication orders and care plans • Records on rounds and meetings • Clinical alerts • Any abnormality or deterioration in patients’ condition
- 19. What to bedocumented? • Document all evidences to justify the diagnosis • Clear records for all investigation reports received and handed over • All investigation findings to be recorded in the case sheet • Patients and relatives refusal to treatment must be recorded
- 20. RESTRAINS Moral responsibility to ensure patient dignity,autonomy and protection from harm
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- 22. Types of restrains •Physical • Medical • Behavioural • Secular • Chemical • Easy remove
- 23. Procedure • Safety ofthe patient, staff and others is primary • Comprehensive, individual physical assessment • Never use for staff convenience • It is not a routine part of care • Specific physician order is mandatory • Clear documents & assessment once in 2 hours
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- 25. Restrains protocol reducedthe incidence of skin bruising, edema and paleness
- 26. LIFE SUSTAINING TREATMENT • Skilfulcommunication and careful observation • Principle of autonomy, beneficence, non malaffence to be balanced
- 27. Steps in decisionmaking • Explain the nature of the ailment, treatment option and prognosis • Seek opinion from experts • Consult with other team members • Call for hospital bio ethics committee • Give adequate time to patient and family • Substitute physician if family is not convinced • Discuss the details of payment
- 28. Advance directives • Livingwill • Durable power of attorney • Terminal care document
- 29. Legal provision • Rightto refuse treatment act • Withdrawal and withholding of life sustaining treatment act • Right to palliative care act
- 30. ORGAN DONATION • Regulatedby Transplantation of human organ and tissues 2014 – Authority to remove organ or tissue – Panel for brain death certification – Duties of RMP – Regulations – Donar and receipient forms Prevents Organ trading
- 31. LIVING WILL • Suicide •Euthanasia • Assisted suicide • Abetment of suicide • Stopping life support treatment RIGHT TO DIE WITH DIGNITY KERALA IS THE ONLY STATE HAS PALLIATIVE CARE POLICY IN PUBLIC HEALTH
- 32. • Living willand euthanasia • DNR orders • Withholding or withdrawing treatment • Paternalism violates patients autonomy • Final decision should reflect patients’ wish
- 33. INSURANCE COVERAGE • Difficultbecause no uniform structure • No “one size fits all” • To be regulated to minimize out of pocket payment
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- 35. WHAT IS MEDICAL ETHICS? •Medical ethics refers – chiefly to the rules of etiquette adopted by the health care professionals to regulate professional conduct with each other, – but also towards their individual patients – and towards society, – and includes considerations of the motives behind that conduct.
- 36. ETHICAL PRINCIPLES • Beneficence:This refers to the tradition of acting always in the patients’ best interest to maximise benefits and minimise harm. • Non-malfeasance: This principle ensures that treatment or research ought not to produce harm – Negligence – Misconduct
- 37. ETHICAL PRINCIPLES • Justice:This refers to the need to treat all people equally and fairly • Society uses a variety of factors as a criteria for distributive justice, including the following: – to each person an equal share – to each person according to need – to each person according to effort – to each person according to contribution – to each person according to merit – to each person according to free-market exchanges • We should strive to provide some decent minimum level of health care for all citizens, regardless of ability to pay
- 38. CONFLICTING PRINCIPLES? • Nothierarchical • Autonomy can conflict with beneficence • In India many people do not know how to deal with autonomy – Wishes of relatives also important • Autonomy/beneficence can conflict with justice • Need to balance beneficence with non-malfeasance
- 39. ETHICS • Complex systemmakes the decision making a tough task • Staff burnout • Individual differences on the value system
- 40. • End oflife care decisions • Surrogate decision making • Physician parenting
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- 42. • Justice – Allocatingresources – Distribution of services
- 43. The Multi Layered Approach PatientPreferences Medical Goals Foundational Principles, Type of Ethical Problem Contextual features: legal, social, family, economic societal Quality of life issues
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- 45. Factors • Separation fromfamily • Deprivation of information • Intrusion to human dignity and privacy • Repulsive physical environment • Lack of sleep • Immobility • Feeling of powerlessness, frailty and vulnerability • Inability to communicate
- 46. The focus ismainly on bringing the vitals to normal Psychosocial needs are neglected
- 47. Interventions • Understand theculture • Good in communication • Be a supportive person • Spread positive energy around • Arrange for a counselling • Create a conducive environment • Policy on visiting hours
- 48. For the nurses •Know the laws regulating nursing practice • Aware of hospital policies and procedures • Take care of your physical and mental health • Love your work • Develop clinical judgement skills
- 49. Points to remember •Patient safety is the primary task • Respect the patients’ autonomy
- 50. Understand the common issuesrelated to legal, ethical and psychosocial aspects. Protect yourself, the patient and the family