Leg Ability

LEG ABILITY

INTRODUCTION: As the roles and duties of nurses have expanded in the current health care system, so too has their legal accountability. In the past, many nurses worked under the supervision of a physician, few carried liability insurance, and even if a nurse's actions were the direct cause of harm to a client, primary liability for the nursing action fell on the employing agency or physician. Currently, nurses independently assess and diagnose clients and plan, implement, and evaluate nursing care. Full legal responsibility and accountability for these nursing actions rest with the nurse. Nurses who wish to avoid legal conflicts must develop trusting nurse-client relationships, and identify potential liabilities in their practice and develop prevention strategies. ^ Legal Concepts: Definition of I AW: A law is a standard or rule of conduct established and enforced by the government of a society/ Laws are intended chiefly to protect the rights of the public. Public law is a law in which regulates the relationships between individuals and the government and also, describes the powers of the government in authority. Civil law; regulates the relationships among people. Civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry.

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LEGABILITY

Sources of Laws: Three sources of law are civil law, administrative law, and criminal law. t-

Civil law generally governs actions by one individual against

another. Criminal law involves actions by the government against an individual for violations of criminal actions. Administrative law involves actions by administrative agencies against individuals or organizations. Note: malpractice cases are generally the kind of civil law that involve nurses, for example the client or family members sues the nurse or the nurse's employer for malpractice because of a claim of client injury caused by nursing care.

Professional and legal Regulation of nursing practice: Standards developed and implemented by the nursing profession itself are not mandatory but may be used as guidelines by Professional nursing organizations continually reassess the functions, standards and qualifications of their members. The organizations are guided by their own assessment of society's need for nursing and by the public's expectations of nursing. Examples of voluntary standards include the American nurses Association (ANA) and Canadian nurses Association (CAN) standards of practice/(will be discussed latter in this lecture) including professional standards for the accreditation of education programs and service organization and standards for the certification of individual nurses in all areas of practice. Legal standards are developed to determine minimum standards for the education of nurses, to set requirements for licensure for

LEGABILITY

registration and to decide when a nurse's license may be suspended or revoked. Credentialing: Credentialing refers to ways in which professional competence is ensured and maintained. Three processes are used for Credentialing in nursing; The first is accreditation, which is the process by which an educational program is evaluated and then recognized as having met certain predetermined standards of education. The second is licensure, which is the process which determines that a candidate meets certain minimum requirements to practice in the profession of his or her choice and grants a license to do so. The third is certification, which is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition. • Accreditation: Constitutions provide governments with the responsibility of securing the public welfare and have used this principle to provide certain controls on occupational and professional groups. One function of these laws is to see that schools preparing practitioners maintain certain minimum standards of education. Nursing is one group operating under these laws that aim to promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. In the United Stales, state-approved, or accredited, educational programs in nursing include practical or vocational, associate degree, diploma, baccalaureate, and graduate programs in nursing.

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• Licensure and Registration: Licensure is a specialized form of credentialing that has a legal basis in laws. A license is a legal document that permits a person to offer to the public His [or her] skills and knowledge in a particular way, where such practice would otherwise be unlawful without this license. Licensure and registration are mandatory in Canada, Both must be

rene

ration Revocation

wed

Nurse Examiners in the United States (or the registering body in

perio Canada) may revoke or suspend a nurse's license or registration for dicall drug or alcohol abuse (currently the most frequent reason). Other y.

reasons for revocation or suspension of a license or registration include fraud, deceptive practices, criminal acts, negligence, and L iphysical or mental impairments, even those resulting from aging c e • Certification: n Many U.S, professional organizations offer nursing s ucertification, including two primary organizations, (1) the American r eAssociation of Critical-Care Nurses, which represents the specialty with the largest number of certified nurses, and (2) ANA, which began o rcertifying nurses in 1974. RCrimes and Torts: e A crime is a wrong against a person or his or her property. g i A tort is also a wrong committed by a person against another s t person or his or her property.

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LEGABILITY

Types of Torts: • Intentional Torts: It includes: > Assault and Battery: Assault is a threat, or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out and includes every willful, angry, and violent touching of another person's body or clothes or anything attached to or held by that other person- Forcibly removing a client's clothing, administering an injection after the client has refused it, and shoving a client into a chair are all examples of battery. Informed Consent Every person is granted freedom from bodily contact by another person unless consent has been granted. In hospitals and other health care settings, a signed informed consent form is needed on admission (for routine treatment); for each specialized diagnostic procedure or medical or surgical treatment. The consent must be written, be signed by the client or person legally responsible for the client, and be for the procedure performed/A signed consent is not needed in an emergency if there is an immediate threat to life or health, experts agree that it is an emergency, and the client is unable to consent and the legally authorized person cannot be reached. Although some value informed consent as a protection against lawsuits, the central values underlying informed consent include the promotion of a client's well-being and respect for the client's selfdetermination.

LEGABILITY

Elements

of

informed

consent:

include

{disclosure,

comprehension, competence, and voluntariness}. Obtaining an informed consent is the responsibility of the person who will execute the diagnostic or treatment procedure or conduct the research study. The nurse's role is to confirm that a signed consent is in the client's chart and to respond to any questions the client has about the consent In some instances, the nurse may be responsible for having the client sign the consent form after the physician has explained to the client the procedure, its risks and benefits, and alternative treatments. The documentation of the consent process through the use of a printed consent form should not be confused with the actual explanation given to the client and the informed consent itself. When documenting consent, the nurse should assess if the client understands what he or she is signing and report to the physician any problems. Nurses often find themselves in a position where they question the client's understanding of the proposed procedure and its risks, or the client's ability to voluntarily consent to the procedure. Impediments include effects of anxiety, pain, medication, depression.

Checklist to Ensure informed Cones: • Disclosure: 1. Patient has been informed of current medical status and course of treatment. 2. Patient has been informed of the risks and benefits of various treatment alternatives. 3. Patient has been told that no outcomes can be guaranteed.

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4. Patient has been given a professional opinion as to the best alternative. • Comprehension: 1.

The nurse has been innovative in transmitting information to aid understanding.

2.

Interior impediments to comprehension (eg, anxiety, pain, and medication) have been assessed.

3. Exterior impediments to comprehension (eg, transcultural barriers, terminology, and speed of presentation) have been assessed. • Competence: 1. The nurse has assessed competence in terms of the abilities of the client, considering age, education, and emotional stability. 2. The nurse has assessed the requirements of the task. 3. The nurse has assessed the possible effects of the client's decision. 4. The client possesses a set of values and goals that make possible reasonably consistent choices. 5. The client is able to communicate and understand the information presented. 6. The client has the ability to reason and deliberate. L^- • Voluntariness: 1. The nurse had determined that the client has not been forced to consent.

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LEGABILITY

2. The nurse has been careful to avoid coercive influences by herself/himself or others. 3.

The nurse has been careful to avoid subtle manipulation of the client by herself/himself or others. ^ Consequences of not obtaining a valid consent include Charges

of battery against the nurse, doctor, and hospital (the hospital has a duty to protect clients and is responsible for its employees' actions). A client's refusal to sign a consent should be documented and the client should be informed of the possible consequences of the refusal. The client should sign a release form indicating his or her refusal to consent and releasing the nurse, physician, and hospital from responsibility for outcomes of this act. > Defamation: Defamation of character is an intentional tort in which one party makes derogatory remarks about another, diminishing the other party's reputation. Slander is an untruthful, oral statement about a person that subjects that person to ridicule or contempt. Libel is written defamation. Defamation of character is grounds for an award of civil damages. Damages are awarded on the basis of the degree of harm done to the plaintiff. Nurses who make false statements about their clients or co-workers run the risk of being sued for slander or libel, a person charged with slander or libel may not be liable if it can be proved that his statement was made not to injure another (eg, proof of consent, truth, or fair comment). > Invasion of Privacy This law protects citizens by giving them the right of privacy

LEGABIL1TY

practice may be prosecuted under nurse practice acts. Also, misrepresenting the outcome of a procedure or treatment may constitute fraud.

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Unintentional Torts:

> Negligence and Malpractice: Negligence is defined as performing an act that a reasonably prudent person under similar circumstances would not do, or conversely, failing to perform an act that a reasonably prudent person under similar circumstances would do. Malpractice is the term generally used to describe negligence of professional personnel. Elements of Liability: Liability means legal responsibility to pay damage. It consists of four elements that must be established to prove that malpractice or negligence has occurred are {duty, breach of duty, causation, and damages.} Duty refers to an obligation to use due care and is defined by the standard of care appropriate for the nurse-client relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, refers to the failure to meet the standard of care (breach) - this failure actually causes the injury. Damages are the actual harm or injury resulting to the client. Examples of these four elements are presented in the following Table.

LEGABILITY

Examples of Elements of Liability Element

Example

Duty

Hospital staff nurses are responsible for: • Accurate assessment, of clients assigned to their care • Alerting responsible health care professionals to changes in a client's condition. •

of

Competent execution of safely measures for clients. Breach

• Failure to note and report that an elderly client assessed as duty alert on admission is exhibiting periods of confusion. • Failure to execute and document use of appropriate safety measures (eg, upper and lower bedside rails, use of restraints if necessary, assisted ambulation). Causation

•

Failure to use appropriate safety measures; this failure causes the client to fall while attempting to get out of bed, resulting in a fractured left hip. Damages

Fractured left hip,

pain and suffering, lengthened hospital stay, and need for rehabilitation. Standards of Care: To determine negligence, each nurse is responsible for following the standards of care for his or her particular area of practice/For example, the labor and delivery nurse must understand how standards for nursing practice differ from those for medical obstetric practice (nurse practice act); be familiar with specific standards for obstetric nursing (eg. Standards of the Nurses' Association of the American College of Obstetricians and Gynecologists); and execute the nursing responsibilities detailed in the hospital's policies and procedures and in the job description, if hospital policy dictates an assessment of each woman in the early stages or labor every 30 minutes, the nurse must

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LEGABILITY

adhere to this standard unless the nurse documents a reason for doing otherwise. The following table lists areas of potential liability associated with each of the ANA standards of clinical nursing practice. Although any nurse can make an error, nursing errors can result in serious outcomes for the client, as is in the examples.

Standards of Care

Areas of Potential Liability for Nurses Areas of Potential Liability

Examples

Standard I; Assessment The nurse collects client health data:

Incomplete data base obtained - Child too weak to be weighed on (occurs frequently when client is admission or chart contains no too ill at admission to respond to record of client's weight; or dosage questions). of postoperative antibiotic therapy (which should be calculated on - Significant omissions or errors child's weight) too small to prevent in recording data base infection; abscess develops - Failure to note in the client's - No record of client's allergies on plan of care (and to execute) the chart, medication administered that need for more frequent nursing led to anaphylactic shock assessments - Failure to recognize and to - Previously alert client was report significant changes in the exhibiting periods of confusion. -

client's condition

- Mother's labor is failing to progress, nurses unaware of signs of fetal distress; obstetrician not informed; irreversible cerebral damage to fetus

- Healthy client making slower than usual post-anesthesia recovery; signs of developing cerebrovascular accident (slurred speech, difficulty moving extremities, falling to one side) present and unnoted Standard II: Diagnosis The nurse - Failure to identify priority analyzes the nursing diagnosis critical to the assessment data client's care in determining - Nursing diagnosis incorrectly diagnoses. developed and "labels" the client

- Nowhere in the client's plan of care was it noted that the client had a history of choking on food ("impaired swallowing") and that close supervision was indicated during meals; client aspirated and

LEGABILITY

negatively.

died - Homosexual male client without AIDS admitted for gallbladder surgery questions the few interactions he has with staff, nursing diagnosis on cardex reads "High Risk for Violence. Directed at Others (AIDS), related to homosexuality."

Standard III: Outcome The nurse identifies Identification expected outcomes No indication in nursing individualized to the care plan that nurses client. were aware of and sensitive to the client's health care priorities

Standard IV: Planning The nurse develops a plan of care that prescribes interventions to attain expected outcomes Standard V: implementation The nurse Client's record implements the contains no interventions documentation of identified in the attempts to teach plan of care. appropriate self-care measures to client and family • Nursing interventions deviate from usual standard of care (understanding, indifference on part of nurse, inexperience of nurse, faulty or inefficient equipments or resources) Standard VI: Evaluation The nurse • No evidence in plan of evaluates the care and nursing notes client's progress

Obese client with a history of impaired circulation continually refuses to ambulate after major abdominal surgery, client dies following a massive pulmonary embolism; plan of care showed no concern or attempt to compensate for client's lack of mobility

Male client discharged from shortprocedure unit on crutches; falls first day home, refracturing leg; alleges his not receiving instructions for crutchwalking caused fall; client record contains no documentation of client, education Skin breakdown on trail, elderly client worsens with eventual muscle deterioration; sepsis; nurses seem confused about treatment regimen for pressure ulcers; treatment is inconsistent

Male client newly started on insulin therapy discharged without

LEGABILITY

toward attainment of outcomes.

that nurses evaluated whether the client achieved target goals • Client discharged before goals are met and without follow-up instructions

understanding the relationship among food, exercise, kind insulin and after giving himself the insulin only once-no referral made to visiting nurse; client readmitted after 2 weeks with dangerously low blood sugar following overdose with insulin

^^Malpractice Litigation: • When a client believes that he or she has been injured through the negligence of a nurse or other health care professional

National Nurses Claims Data Base: The National Nurses Claims Data Base (NNCDB) was set up by ANA in 1967 to provide information to the profession about professional

liability

claims and

incidents

Involving

nurses,

information from the NNCDB: •

Is available to nurses who need help in defending themselves against liability suits Assists the nursing profession in negotiating with insurance companies, assuring nurses adequate and available coverage

•

Provides data for development of programs that teach nurses how to avoid malpractice

Legal Safeguards for the Nurse: /

■ Contracts: A contract may be defined as the exchange of promises between

two persons. For a contract to be legally enforceable, it must contain real consent of the parties, a valid consideration, a lawful purpose, competent parties, and the form required by law.

LEGABILITY

Practicing nurses enter into legally valid and binding contracts with both their employers and their clients. It is thus important that they understand and are able to fulfill the terms of their agreement before giving consent. -"*" Competent Practice: Competent practice remains the nurse's most important and best legal safeguard. Each nurse is responsible for making sure that educational background and clinical experience are adequate to fulfill the nursing responsibilities described in the job description. Legal safeguards include the following: • Respecting legal boundaries of practice. • Following institutional procedures and policies. •

"Owning" personal strengths and weaknesses; seeking means of growth, education, supervised experience, and discussions with colleagues.

• Evaluating

proposed

assignments;

refusing

to

accept

responsibilities for which the nurse is unprepared • Keeping current and updated. • Respecting client rights and developing rapport with clients. • Keeping careful documentation. • Working within the institution to develop and support management policies. Competent practice includes developing sensitivity to common sources of client injury, such as falls, use of restraints, and malfunctioning equipment, and then taking specific measures to prevent client injury.

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LEGABIHTY

~~f Client Education: The client's right to know and client education is the legal duty of the nurse. Standards for client education are derived from national professional standards, as well as the local standards described in hospital policies, procedure manuals, and job descriptions. Special forms for documenting the nurse's assessment of the client's learning needs and for subsequent teaching are available at some agencies. Failure to conduct or document the assessment of learning needs and teaching may later be construed as negligence. General guidelines for the nurse wishing to execute client education responsibilities competently include the, following: • Determine in your practice setting what specific aspects of client education are the responsibility of nursing. Consult your job description and be familiar with agency policies regarding client education and its documentation. • Remember that an important aim of nursing is to assist clients in managing their own care. • Discuss the nursing care plan with the client and family and identify their learning needs and learning readiness. • Document the teaching plan as part of the nursing care plan. • Document all nursing efforts to educate the client and family about health care management and also document the client's response. • If a client refuses health education or refers the nurse to a family member (eg, "Talk to my wife about my pills, she'll be giving them to me at home"), document this on the client's record.

LEGABIHTY

•

If client education greatly increases the, client's anxiety and the client requests not to be given any more information, the nurse should document the client's initial response to teaching, the client's request that it be stopped, and, if the nurse complied, the reason for doing so.

•

Because lack of time is a frequently offered reason for failing to document client education, nurses should: assess what type of client documentation is routinely offered on their unit and if possible, they should develop forms or checklists that will facilitate rapid documentation. For example, preoperative checklists have greatly facilitated the recording of preoperative teaching and are often introduced as evidence in court that; preoperative teaching was done. Other successful models include forms for documenting diabetic teaching, teaching after a myocardial infarction, and teaching postpartal and baby care to mothers.

„.■Executing Physician's Orders: Nurses are legally responsible for carrying out the orders of the physician in charge of a client unless an order is one their would lead a reasonable person to anticipate injury if were carried out. Guidelines when executing orders follow. 1. Be familiar with the parties, designated in your nurse practice act, who can legally write orders for the nurse to execute. 2.

Attempts to have all physician orders in writing, verbal and telephone orders should be signed within 24 hours. To eliminate errors caused by telephone orders:

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Executing Physician's-Orders:Nurses are legally responsible for carrying out the orders of the physician in charge of a client unless an order is one that would lead a reasonable person to anticipate injury if it were carried out. Guidelines when executing orders follow. 1. Be familiar with the parties, designated in your nurse practice act, who can legally write orders for nurse practice act, who can legally write orders for the nurse to execute (in many states, a physician's assistant cannot legally write orders for the nurse). 2. Attempt to have all physician's orders in writing. Verbal and telephone orders should be counters-signed within 24 hours. To eliminate errors caused by telephone orders: •

Limit telephone orders to true emergency situations in which there is no alternative.

•

Designate the nurses who may take telephone orders (those who have more education and experience, such as a primary nurse).

scessitating the ming the order f the order is a

• Repeat a telephone order back to the physician. Document the order, its time and date, the situation m order, the physician prescribing and reconfn as it is read back,

and your name; indicate i

VO (verbal order) or TO (telephone order). • ;ible, have two rder, with both

When telephone extensions make this poss nurses listen to a

questionable telephone o

nurses countersigning the order.

3, Question any physician order that is; • Ambiguous. •

Contraindicated by normal practice (e.g, dose of medication that is abnormally high).

• Contraindicated by the client's present condition (e.g, as a client's present condition improves, he or she may no longer need aggressive forms of treatment). It is good practice for the nurse to double check any order a client questions.

Nursing Malpractice Prevention Most frequent allegations against nurses

Failure to Ensure Patient Safety

Improper Treatment or performance of treatment

Prevention Tips for Nurses Prevention Tips for Hospitals

1. Monitor patient in a timely manner. 1. Maintain an adequate level Provide assistance for of staff. those patients who require 2. Clearly define criteria for it when they need to use use of bedrails and restraints. the lavatory or shower. 3. Provide education to Keep bedrails raised for nurses on patient safety. patients who are medicated or confused. Use restraints appropriately. _______________________ 1. Question treatments you Design a clear procedure believe are improper. for nurses to follow if 2. Use proper techniques they feel the medical when performing treatment is procedures. inappropriate. Provide 3. Follow hospital resources for nurses to procedures when consult regarding performing treatments. treatments. Provide 4. Seek consultation for appropriate procedures treatments beyond your for nursing treatments. abilities. 5. Update your clinical skills through continuing education classes.

Documentation:Careful documentation is a critical legal safeguard for the nurse. Documentation must be accurate, complete, and entered in timely fashion The presumption of the law is that if something was not documented, it was not done. This includes even routine acts such as taking vital signs, repositioning clients, and using side rails. Nurses should be sure that the nursing care plan is a part of the client's permanent record. Institutions should have flow sheets or some type of documentation form that enables nurses to check off routine aspects of care rapidly and completely. The nurse should write a comprehensive nursing note for each client problem the nurse addressed during his or her time of duty. The note should include the current nature of the problem, how the nurse intervened, the client's response, and, when appropriate, future priories for care. Once a problem is noted, nursing documentation should evidence continuity of care until the problem is solved. A common problem reported by nurses is not knowing Document an incident,ybr example, when the nurse believes the client needs medical attention and intervention but the responsible physicians are not responding to calls for assistance. In this case, the best legal safeguard for the nurse is to document the facts of the incident, being careful not to make incriminatory statements such as, "Anyone could see we were losing this client rapidly" or "Once again, Dr. Jones was unavailable when her client needed her." The note should document the time the physician was called and the time of response or lack of response, and the subsequent nursing response (e.g, nursing supervisor notified). Such a note documents that the nurse is carefully assessing the client,

recognizing significant cues, and reporting them appropriately. The nursing supervisor should write the next note after reviewing the case and choosing a course of action. Client noncompliance with the therapeutic regimen should also be documented along with the nurse's attempts to increase compliance. Adequate Staffing:Understaffing is a problem that results in reduced quality of nursing care and may jeopardize client safety. Temporary management solutions to understaffing, such as floating nurses from one unit to another or asking nurses to work overtime or double (back-to-back) shifts, are ineffective because they further jeopardize client safety. A nurse on an understaffed hospital unit will be held to a professional standard of judgment with respect to accepting responsibility for work and for delegating nursing responsibilities to others. If client injury results, the hospital employer and nurse employee will most likely be named as codefendants. Professional Liability Insurance:- \ Although a nurse's best legal safeguard is always competent practice, the increasing number of malpractice claims naming nurses as defendants make it wise for nurses to carry their own liability insurance. Nurses may obtain this insurance through ANA, through provincial nursing associations in Canada, and through other sources. Reasons ANA lists for purchasing a personal professional liability insurance policy are as follows: Protection of the nurse's best interests: If the nurse is named defendant in a malpractice action along with the hospital, a conflict of interest could arise between the nurse and the hospital. Nurses have no

of an emergency. However, in many situations, there would appear to be an ethical responsibility to assist. When health practitioners assist a person in an emergency situation and consent for the care is impossible, they are expected to use good judgment in determining whether an emergency exists and to give care that a reasonably prudent person with a similar background and in a similar circumstance would give. Student Liability:Student nurses are responsible for their own acts of negligence if these result in client injury. Moreover, they are held to the same standard of care that would be used to evaluate the actions of a registered nurse (RN). Legal responsibilities of student nurses include careful preparation for each new clinical experience and a duty to notify their clinical instructor if they feel in any way unprepared to execute a nursing procedure. For no reason should a student attempt a clinical procedure if unsure of the correct steps involved in its application. The student nurse is responsible for being familiar with agency policies and procedures. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. Nursing instructors may share a student's responsibility for damages in the event of client injury if the student's assignment called for clinical skills beyond the student's competency or the instructor failed to provide reasonable and prudent clinical supervision. Students should notify their instructor or a staff member of any significant changes in the client's condition even if they are unsure of the meaning of these changes.

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Laws affecting nursing practice:Occupational safety and health :The Occupational Safety and Health Act of 1970, commonly known as OSHA, set legal standards in the United States in effort to ensure safe and healthful working conditions men and women. The act is intended to reduce work related injuries and illnesses. It has affected health care agencies and has increased certain responsibilities for many nurses. Occupational health and safety acts are provincial statutes in Canada. The following examples illustrate situations that could violate standards, if care is not taken, because of the potential threat to worker safety: • Use of electrical equipment • Use of isolation techniques for clients with infectious diseases and the management of contaminated equipment and supplies. • Use of radiation, such as infrared or ultraviolet radiation; sound or radio waves; and laser beams. • Use of chemicals, such as those that are toxic or flammable. The law, which continues to be updated, is specific concerning its applications, and fines can be severe when infractions are noted. Nurses can assist in implementing this law by promoting health and safety precautions wherever hey work. Nurses employed in industrial settings have a particularly important role in conforming to the law's requirements. Reporting Obligations:• The unique nature of nurse-client interactions frequently result in the nurse's having knowledge (e.g, of child abuse, rape, or a

communicable disease) that a state (or province) requires to be reported. Legislation varies in this regard and the nurse is responsible for knowing what needs to be reported in the local area and to what authority. Controlled Substances:Both he United States and Canada have special laws governing the distribution and use of controlled substances (drugs with abuse potential), such as narcotics, depressants stimulants, and hallucinogens. Drug abuse laws are specific and violations are considered criminal acts. Nursing responsibilities for controlled substances include their storage in special locked compartments and documentation responsibilities. Wills:State and provincial laws regulate requirements for a will. The person who makes a will is called the testator. A will describes intentions a testator wishes carried out upon his or her death. A person who receives money or property from a will is called a beneficiary. Nurses are occasionally asked to witness a testator's signing of his or her will. The nurse should be familiar with the certain guidelines concerning a will and witnessing the testator's signature: • The witness should feel sure that the testator is of sound mind, that is, the testator knows what he or she is doing and is free of the influence of drugs that could likely distort his or her thinking. •

The witness should feel sure that the testator is acting voluntarily and is not being coerced in any way concerning the terms of his or her will.

• Witnesses should watch the testator sign his or her will and they should sign in the presence of each other. State law indicates how

i

many witnesses must acknowledge the testator's signature on a will. Two or three witnesses are most commonly required. •

Witnesses to the signature on a will do not need to read it, but they should be sure that the document being signed is a will and not some other type of document.

• In most states, a person who is a beneficiary in a will is disqualified to act as a witness to the testator's signature. Legal issues related to dying and death:Death occurs when there is an absence of brain function despite the function of other body organs. It is the nurse's duty to recognize legal death. In some states, the nurse may pronounce death at the bedside. In most states, however, the physician has the legal responsibility of pronouncing the person dead. Euthanasia. Physician- or nurse-caused death (active euthanasia) is controversial. Many healthcare providers believe that actively causing a client's death violates professional ethics. Active euthanasia, deliberately hastening a person's death, is considered murder in all states and almost all other countries. Despite these concerns, there is growing support for physician-assisted suicide and related measures to reduce suffering at the end of life. Passive euthanasia measures are those that withhold or withdraw treatment to allow death to occur naturally over time. Advance Directives. In 1990, the federal legislature passed the Patient Self-Determination Act, which requires that each hospital, nursing home, visiting nurse agency, hospice, or health maintenance organization admitting clients to their services inform clients about their rights regarding end-of-life decisions. The agency is required to inform clients

of state law, local policy, and agency policies, if any, regarding end-oflife decisions. Nurses must become familiar with statutes in their states 'regarding the execution of living wills or directives to physicians (ANA, 1991). These statutes list specific procedures to follow while granting civil and criminal immunity to those following the guidelines. The living will should be prepared before people become incapacitated. Be aware of the requirements for witnessing a living will. Usually, the state's Natural Death Act prohibits an employee of the healthcare provider caring for the client to be a witness. Also, be familiar with the ANA standards for these areas. These practice requirements are absolute. Thus, each nurse is accountable for providing care congruent with these standards. Resuscitation. Nurses must always know the code status of their clients regarding resuscitation, verify the code status on the client's order sheet, and follow agency policy. When nurses are unaware and encounter a client in cardiac arrest, they should resuscitate the client pending confirmation that there is a no code order. If there is a no code order, resuscitation may be stopped once initiated. And if there is not a code order and the client's wishes for end-of-life care are not followed because of this lack of order, then the nurse is responsible for ensuring that an order is obtained. Issues have occurred around do not resuscitate orders for home care clients. A community-based no code order can be obtained in many states and have various names including EMS-No CPR orders, portable no code orders, or community-based DNR orders. These documents generally require the signatures of the physician and the patient or their legal surrogate. Unlike advance directives, these orders must be obtained through a healthcare provider. A community-based no

code order allows emergency medical personnel, if called, to provide care and support to the patient and family without attempting resuscitation. Death Certificate. Laws are specific in each of the states regarding who may sign death certificates. Determine that information for your state. Care of the Body. After the physician pronounces death, the nurse is responsible for preparing the body for the morgue or mortuary. Be familiar with the facility's instructions for care and the wishes of the deceased and family. Always treat the body with dignity. Organ Donation. Always check to see if the deceased wished to donate organs to a transplant program. If the death was accidental and no donor card is available, the nurse may discuss with the family the possibility of donating the deceased person's organs. Figure 6-2 shows a sample organ donor card. A section of the living will also may provide this information. If functional organs are to be donated, the hospital should have specific care instructions for the body. State law governs the procurement process while safeguarding donor intentions and designates procedures for use and distribution of organs. Some states use the driver's license to identify those persons who agree to organ donation in the event of their untimely death. Signed Dy the donor and the following two witnesses in the presence of each other

J^LusMAAssAi^____s//o/i^'

—/2/J/J99

go

_____/ffattutytuj m

Dotesicjnea Witness

DateofBirtn of Donor

tf

(/

c7rv,ina state* Witness

Tnis is .1 lecjjl document miner the uniform ArMtomic.il Gift Act or

similar uws in .111 so states

A

,., , For further information call,

PROGRAM

Philadelphia. PA .9103

1

,

UNIFORM DONOR CARD

______Oophie Cy7e,\Aj*ki ______________ Print or rype name of don6r in trie nope that i may help others. I hereby make this anatomical gift, if medically acceptaoie. to take effect upon my death me words and marks below indicate my desires i give a) . .^f__any needed organs or parts D)________only the following organs or parts Specify the organisi or cart(s) for the purpose of transplantation, therapy medical researcn or education ., ci Afo mv oodv for anatomical study if needed Limitations or special wishes if any

F I G U R E Sample 6 - 2 of an organ donor card. Autopsy. An autopsy is a postmortem examination of the body's organs and tissues to determine the cause of or pathologic conditions contributing to death. Except in certain circumstances, consent for an autopsy is required. The patient May consent to an autopsy before death or a close family member may consent after death. State laws require an autopsy regardless of consent if the death meets certain state criteria such as suspected murder or suicide.

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