Ethics In Mental Health Nursing

Mental Health Nursing Practice: A Mental Health Nursing Response to Ethical Dilemmas 1

2

Essential … For people using health services For the health professional For healthcare organisations For communities

3

Basic rights Fundamental Legislation

4

Fundamental Legislation NZ Bill of Rights 1990 „

„

Freedom of thought, belief, expression, association, movement Right to refuse to undergo medical treatment

Human Rights Act 1993 „

To protect Human Rights & Prohibits discrimination

5

For mental health services? Absolutely essential that all clinicians have a good understanding of ethical principles because…..

6

Mental Health Act Takes away many of a persons basic Human Rights Enforcement of treatment

7

Misunderstanding about the scope of the MHA Definition of being “Mentally Disordered” ..an abnormal state of mind…characterised by delusions, or by disorders of mood or perception or volition or cognition, of such a degree that it – „

„

Poses a serious danger to the health and safety of that person or of others; or Seriously diminishes the capacity of that person to take care of himself or herself; 8

9

Common mental health issues Many people who have experienced a mental illness or are mentally unwell are capable of making important decisions – life and death decisions At times a person may decide to end their life by suicide

10

Risky behaviours Some people self harm (cut themselves) as their way of coping - they have no intention of killing themselves People take risks with their lives all the time – base jumping, mountain climbing? People knowingly damage their health – smoking, diet Are they considered to be suicidal or to be self harming? Do we have legislation that stops people from, „ Competing in their chosen sports? „ Pursuing their lifestyle choices? 11

Perspectives Moralists – an overriding duty to protect life and prevent suicide Libertarians - own your own body therefore have the right to choose death. No obligation to prevent suicide. Relativists - consider the rightness or wrongness, consider context, culture, and consequences. 12

13

Ethical principles Respect for Autonomy Nonmaleficence Beneficence Justice

14

Mr B 49 yr old man, dysphasia, hemiplegia Forensic psychiatric history and brain injury Current client of Mental Health Service Fear of needles and invasive procedures Difficulty ascertaining his level of understanding Presenting with abdominal pain, dehydration – there is a need for diagnostic testing 15

Ethical dilemma Gaining informed consent for medical treatment in the face of communication barriers and needle phobia. Principle of Respect for Autonomy. This principle is the basis for the practice of "informed consent“. Principles of beneficence and nonmaleficence 16

Competence to consent Specific capacities must be assessed „ „ „ „

Communication of choice Understanding of information provided Appreciation of options available Rational decision making

Mental illness does not equal incompetence – this must be assessed. 17

Contextual considerations Mr B may have been competent to make other decisions He still has right to refuse treatment Consider - Are interventions in the best interests of Mr B or being done to satisfy medical diagnoses? Balance of benefit and discomfort is subjective so continuing communication with Mr B was vital 18

Mr B outcome Terminal Cancer - Primary and secondary sites Medical and nursing staff worked with Mr B - time consuming but satisfying Palliative care consistent with Mr B’s wishes Mr B died within two weeks of admission

19

Mrs C 45 year old woman Married with adult family Diabetes and other health problems No attempt at self care of diabetes Frequent hospitalisations to prevent death due to diabetes

20

Mrs C Has had contact with mental health services for assessment purposes but no diagnosable mental illness Doesn’t want to live with diabetes All general services referring back to mental health “she must be mentally ill” Where to from here?

21

Ethical issue Autonomy – again Assessed as competent to make informed decisions Does she have the right to neglect her care and die???? Do you take a moralist, libertarian or relativist perspective?

22

Mrs C outcome Moralist perspective dominates - life saving input as required Mental health team input on request and occasional admission to MH wards after hours Significant use of resources to maintain life Principle of Justice? 23

Admitting to overcrowded wards

24

Ethical issues Principles of beneficence, justice and nonmaleficence Equity of access, doing no harm and doing what’s best. Individual vs group - What is ‘best’ for the individual may not be the ‘best’ for a group How does the nurse decide? Does the nurse decide? 25

Nursing autonomy Control over ‘nursing practice’ only Don’t control the patient Don’t control other members of the MDT Don’t ultimately determine the policy and resource decisions ‘Meat in sandwich’ or ‘buffer’ between patient and others = Moral distress

26

In closing - Minimizing the opportunities for moral distress Ask the questions Be aware of the different perspectives including the wider contextual and cultural issues Contribute in an informed way to ethical discussions Contribute to policy/positioning documents Reflect and discuss with colleagues 27