Ethical and Legal Issues in the Life of the Elderly Adult

Gero Test 1
"Nursing Jurisprudence" as defined by Board of Nurse Examiners, Advisory Committee on Laws and Regulations (April 1998):
" the system of ethical principles and legal mandates which govern the behavior of professional nursing practitioners to further the goal of promotion and protection of the health, safety, and welfare of the public."
Mandatory Nursing Jurisprudence Exam (Sec.301.252. - 256.)
Requirement of Texas Board of Nursing

For all new graduates of basic ADN and BSN programs and RN endorsees into Texas from another state or foreign country

Applicants must achieve BON "passing score" to be licensed in Texas; may retake exam; 2 failures - must meet BON ruling
are binding rules of conduct enforced by authority
is a philosophic study that examines values, choices, and actions to determine right and wrong.
strongly held personal and professional beliefs about worth and importance of human beings upon which choices are made and actions taken.
ethical principle
When a law is challenged as unjust or unfair, the challenge reflects some underlying ________.
Ethical principles for all elders
-Respect; worth; dignity
-Autonomy (self-determination)
-Informed consent or informed refusal
-Justice; fairness; rights
-Fidelity; honoring promises
-Veracity; truth-telling
-CONFIDENTIALITY (disclosure vs. non-disclosure) Cite examples for each.....
-Futility of treatment, procedures
-Physician-Patient /Nurse-Patient therapeutic relationships
-Non-abandonment by healthcare providers
-Non-discriminatory allocation of limited health care resources
Nurse - Patient Advocacy
-recognizing conflicts in values and beliefs

-mediating, negotiating, clarifying, explaining, and intervening; important to determine competency of elder's understanding

-assuring respect, equality/fairness and right of human dignity toward others without discrimination

-serving as a liaison between patient/client receiving health care and the health care system;
Role of the Nurse in Patient Advocacy
-Involves developing and implementing nursing diagnosis, exercising good patient judgment, monitoring the care given to patients by physicians and nursing peers
-Duty to report medical care or medical orders that jeopardize care of patients
-Failure to function in this "independent role" as a professional nurse is recognized as "failure to act"
Topics of Advocacy for Elders

-Protection of specific rights
-Promoting least restrictive residential alternative
-Rights of medical patients. Cite examples
-Right to have in-home supportive services
-Maintenance of government benefits. Cite examples
-In terms of "pleading for and supporting best interests of other person with respect to choice, provision, and refusal of health care"
1.Decisional capacity vs. incapacity
Ethical Issues in Care of the Elderly Person "Decisional Capacity"/Competency

-_________used by medical practitioners to distinguish from legal designation of competence vs. incompetence
-Right to decide based on ________: individual initiative, autonomy, independence, self-determination and with right to have decisions respected.
-When ________ of person is impaired, legal options protect person; done in best interest of person or what he/she would do
1. have an "ordinary" conversation
2. observe person's behavior
3. talk with family, friends or staff
Decisional Capacity versus Incapacity

To determine decisional ability of a person:

-Discuss the interactions between you and individuals whom you interviewed, assessed their functional capacity and/or their nutritional status (identify age, gender, psycho-social being)
1.Employment vs. Retirement
2.Living accommodations
Discuss potential risk factor/s in selected behaviors requiring "values laden" decision-making by, with or for elderly persons:

-___________:(Medicare A and B; Social Security;Pension funds; Medicaid)
-___________: Independent /alone or with spouse or child; assisted-living facility; LTC/nursing home; CCRC/senior residential community (rental vs. "life-care"); use of day care facility
-___________:continuing licensure vs. cessation
3.Financial management
4.Healthcare resources
5.Healthcare insurance
Discuss potential risk factor/s in selected behaviors requiring "values laden" decision-making by, with or for elderly persons
-_________: prescriptive; OTC
-_________ (adequate vs. inadequate); Dehydration
-_________: cash; credit card/s; bank account/s; investments; property ownership...Vulnerability to fraud
-_________: availability; accessibility
-_________: no coverage; Medicaid; Medicare; MCO/HMO; PPO; supplemental health insurance; LTC insurance
Decisional Incapacity/In-competency
Individuals who clearly lack capacity to decide for themselves, as manifested in "dementia" or in situations of "disorientation" or "delusions" whether transitory or irreversible
---should have a surrogate decision-maker
---even if person might be seriously incapacitated in decision-making, he/she might retain ability to designate an appropriate surrogate; allow him/her this choice to name the surrogate person
Elder Abuse/Neglect/Exploitation
Is defined by state law.
Detecting neglect/abuse
______________: whether in a home, nursing home, emergency room, in-patient hospital or clinic settings, nurses might be the first to notice or suspect mistreatment
Elder Abuse/Neglect/Exploitation
Includes, according to Eversole, et al, 6th ed:

-Physical abuse (force with body injury)
-Sexual abuse
-Emotional/psychological abuse
-Financial or material exploitation
-Neglect (passive abuse)
4.Nutritional status
Consider more specific common signs and symptoms of neglect/abuse that create issues based on ethical principles:

-________ and ________ problems
-________; Unexplained bruises, burns, skin tears
-Mobility vs. restraints (physical, drug/s)
-________; thirst and dehydration
-Urinary and/or bowel incontinence
-Over-medication or under-medication
-Infection (URI, UTI; others?)
-Poor personal hygiene; clothing appearance
-Residential appearance (interior)
-Social withdrawal; loneliness; despair; anger/hostility; fear
Prolonging life
Other Ethical Issues in Care of the Elderly: _________.

-escalating medical costs; scarce public resources
-increasing use of high technology for procedures/treatments
-rationing of health care: decisions made by society vs. medical professionals
-State law and the court system
Patient Self-Determination Act, 1991 (PSDA)
-Ensures rights of individual/client/patient to "author or execute" written and signed instructions about his/her wishes for medical treatment in the event of becoming "incapacitated" and appropriately witnessed.
-Requires health care facilities receiving Medicare funds to provide information about Advance Directives to patients on admission.
A state's statute may vary in procedures; as well as, each institutions procedures.
Advance Directives/Living Will

Are they the same or different?
Advance directive
-____________: written statement that directs health care providers concerning consent or refusal of treatment when the individual patient does not possess decision-making capacity." (Brent, N.J, 2001. Nurses and the
Living will
__________: document that establishes a written mechanism for an individual to specify wishes about withdrawing or forgoing life-sustaining treatment (treatment that only prolongs or delays the process of dying)." (Brent, N.J. 2001. Nurses and the Law. Pg. 217)
1. Oral revocation
2. Destroying the document
3. Amending document in writing
State statutes may also include how Advance Directive/Living Will can be revoked after it is executed: (preferably with witness/es):
Legislation often provides ________ from civil and criminal litigation and disciplinary actions by state licensing agencies for healthcare providers, who in good faith and consistent good medical and nursing practice, abide by a patient's Advance Directive.
Joint Commission for Accreditation of Healthcare Organization (JCAHO) standard
Advance Directives and Hospital Policies
__________ mandates that:
-each hospital provides adult patients information to initiate Advance Directives; unless patient
-has a valid document that is available to physician or on patient's chart
-If an individual does not have a valid Advance Directives and does not have decisional-making capacity may use a Healthcare Proxy (surrogate) or
decisions can be made through state "guardianship" laws
-Hospital must honor the Advance Directives within limits of the law and within the hospital's capabilities (refer to Texas law as amended 2003)
1.Ethics Committee
2.Physician's role
3.Healthcare Proxy
4.Healthcare Proxy
Hospital policy and procedures must include the process in which conflicts regarding Advance Directives will be resolved.

-Referral to ________ for mediation
-________ : may refuse to comply with decisions he/she believes to contrary to patient's wishes (refer to TX. law, 2003)
-________ may request patient to be transferred to physician who will honor patient's or proxy's request
-________ may seek court order to stop or to continue care, as a last resort.
1. ethics or medical committee
State of Texas Health & Safety Code: (1999; amended 2003)
-Sec. 166.046: Procedure if Not Effectuating a Directive or Treatment Decision (2003)
-(a) If an attending physician refuses to honor a patient's advance directive or a health care or treatment decision made by or on behalf of a patient, the physician's refusal shall be reviewed by an _________. The attending physician may not be a member of that committee. The patient shall be given life-sustaining treatment during the review........
1.physician setting
Tex. Health & Safety Code Sec. 166.046 (cont.)
(d) If the attending physician, the patient, or the person responsible for the health care decisions of the individual does not agree with the decision reached during the review process under Subsection (b), the physician shall make a reasonable effort to transfer the patient to (1)another ________ who is willing to comply with the directive
(2) an alternative ________ within that facility;
3) another________....(h)
Natural Death Act/Advance Directive/Living Will
Texas Laws
-Medical Power of Attorney(Durable; not a general POA)
-Directive to Physicians and Family or Surrogates
-Are individuals, agencies or corporations appointed by the court to have care, custody, and control of a legally disabled person (not medically disable; cite examples)
-Manage his/her personal and/or financial business
-Make provisions for one's physical health and safety, such as health care, food, shelter, personal hygiene (partial dependency) vs. "total dependency" person unable to meet basic needs for survival and manage his/her environment
-Consider high risk for exploitation.
American Geriatric Society Foundation
website provides educational information for healthcare providers to discuss with elders about Advance Directives
Elder's failure to cooperate with medical recommendations
-Physicians have responsibility to recommend course of treatment or other behaviors that in their best judgment would help the patient/client.
-Patient/client has right to be informed of benefits and risks associated with recommendations and accept or reject them.
-May accept recommendations, then fail to act on them ("non-compliance") and continue to seek care from physician.
Nursing interventions
Elder's failure to cooperate with medical recommendations (cont.)

_________ should include:
-serving as patient/client advocate: need for additional assessment? more teaching about condition, medications, treatments?
-assessing patient's/client's actions:
--voluntarily non-compliant or uncooperative
--involuntarily non-compliant due to complicated regimen, forgetfulness, poor explanation by M.D. and/or R.N.
--inability to pay for treatment, medications
--follow-up care with physician? RN?
3.American law
4. safety and protection
Care of the Elderly and Right to Refuse Extraordinary Treatment

-Patient has right to refuse extraordinary treatment; supported ethically by principles of ________, _______ and legally by _______. (Cite examples of treatments)
-Has right of dying (or at death) with dignity, privacy, respect
-Has right to institutional care to provide safety and protection; basic human right for elders
Care of the Elderly Person "The Right to Die"
-No standard clinical definition of "terminal"; often loosely used to refer to any patient with a "lethal/deadly" disease or condition.
-Compare and contrast "terminal" condition vs. "life-threatening" condition.
-Cite examples of each as related to elders
Refusal of life-sustaining treatment
not considered suicide by ethical standards; courts have ruled these practices as legally acceptable.
-Cite examples of potential refusals by elders
assisted suicide
administering drugs with intent to cause death, even when done at request of mentally competent older adult, is an act of __________, irregardless if done by physician or nurse.
1. American Nurses' Association Code of Ethics for Nurses (2001)
2. ANA's Position Statement
Right to Die
What is the nurse's professional responsibility?

-__________: "the nurse acts to safeguard the client; assumes responsibility and accountability for nursing judgment and action".

-__________: identifies support against physician-assisted suicide and participation in voluntary active euthanasia.
Ethical Issues in Care of Elderly Persons: Do Not Resuscitate Order
1. "Out of Hospital DNR"
whether in-patient or out- of-hospital, should be ordered by the physician and stated in specific terms.
-If patient changes his/her mind, what procedure should be followed by the patient? by the physician
-An _________ is a separate document. If signed form states DNR then paramedics/EMTs cannot initiate resuscitation. If no signed form, required to initiate CPR if out of hospital.
Do Not Intubate (DNI) and/or Resuscitate Order
-do not perform endotracheal intubation in event of cardiac arrest or respiratory failure;
-do not resuscitate by chemical/drug, electrical or manual means;
-do not contact "code team"; all other medical care will be provided unless ordered otherwise
"Comfort Measures Only" in lieu of DNI or DNR Orders
-This decision and treatment plan must be documented in detail in patient's "progress notes" by the physician.
-Further care of patient, including all current and future diagnostic studies and monitoring, is directed at providing comfort measures only.
-All therapy directed at sustaining life and bio-function will be discontinued.
Legal/Ethical Issue Pronouncement of Death by RN (Texas)
Since 1991, the Texas Nurse Practice Act, Board of Nurse Examiners for the State of Texas, has ruled that a registered nurse may pronounce the death of a patient based on his/her nursing assessment and in the absence of the physician. The RN does not sign the death certificate; patient's physician is legally responsible for that act.