Nursing ethics,crnp.04.12

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ETHICS, DOCUMENTATION ETHICS, DOCUMENTATION and PUBLIC HEALTH and PUBLIC HEALTH

NURSINURSING

By John R. Wible, General Counsel (Retired)Alabama Department of Public Health

Department of Public HealthApril 13, 2012

An Ethical PersonAn Ethical Person

• Are you an ethical person?

• From where or whom did you learn your ethical principles?– Hint: “Yo Mama”

• “All I Ever Needed to Know, I learned in Kindergarten”

• Role of Supervisor as example

2John R. Wible, 2012

The Pareto PrincipleThe Pareto Principle• The “80-20 Rule” revisited

• 10% basically ethical

• 10% basically unethical or “aethical”

• 80% wandering in the middle

• The ethical job of the manager

• Differentiate the animals

• Lead the sheep in the right way3John R. Wible, 2012

John’s Five Action PrinciplesJohn’s Five Action Principles

• To tell the truth, the whole truth and nothing but the truth

• “We’ll Sing in the Sunshine”

• Casper the Friendly Ghost

• It’s not about me

• The “Nike Principle.”

Sources of Sources of PersonalPersonal Ethical PrinciplesEthical Principles• The Ancient Greeks• Religious teachings• Cultural teachings

-American Historical Documents – Declaration of Independence – United States Constitution

John R. Wible, 2012

Socrates, Plato, Aristotle; Greeks

• Socrates – “know thyself”

• Plato – human well-being, the highest aim of moral thought and conduct

• Aristotle – apply what we know in social settings

L:Plato and Aristotle by RaphaelR:Raphael’s Socrates

John R. Wible, 2012

Religious Ethical PrinciplesReligious Ethical Principles

American Historical DocumentsAmerican Historical Documents

• Declaration of Independence

• United States Constitution

Declaration of IndependenceDeclaration of Independence• Set forth the “self evident

truths” such as “equality”• Established an ethical

basis for independence• What Locke applied to

individuals, Jefferson applied to a people – John Adams

• Did not address African slavery

Constitutional PrinciplesConstitutional Principles• “We, the People” – social contract based in

personal autonomy• “Establish justice” –

– Equity– Equality– Fair process

• “Insure Domestic Tranquility” – peace• “Promote the General Welfare”

Professional EthicsProfessional Ethics

• Hippocratic Oath and Medical Ethics

• Augustine’s “Just War”

• Nursing Ethics

• The Public Health Code of Ethics

• Public Officer/Employee Ethics Laws

Utilitarianism vs. EgalitarianismUtilitarianism vs. Egalitarianism• Jeremy Bentham’s theory of

utilitarianism what is right or good based on whether the consequences will be good

• Immanuel Kant’s egalitarianism theory focuses on non-consequentially based notions of good - deciding what is right or good is based on meeting duties and obligations

• These contradistinguished ideas will clash over and over

ADPH, 2012

Oath of Hippocrates Oath of Hippocrates – Medical Ethics– Medical Ethics

• “Primum non nocere” – first do no harm• Always look to the good of the patient• Place a high value on human life• Perform only within one’s training and skill• Refrain from improper relations with

patient• Maintain patient’s secrets inviolate• Do not violate community laws or morals

Nursing’s Primary Ethical Nursing’s Primary Ethical PrinciplesPrinciples

• Respect for autonomy

• Non-malfeasance

• Beneficence

• Justice

Respect for Persons/AutonomyRespect for Persons/Autonomy

• People are treated as autonomous agents

• Protection for those of diminished capacity

• Informed consent defined

• Period reviews of status of subjects required

BeneficenceBeneficence

• Look out for the “broader good” of the subject

• Do no harm

• Does it actually do some good?

• Balance the risks against the benefits

“Beneficence” – Ball State University

JusticeJustice• Applies the allocation of risk or

burden to benefit to the subject and to the proposed benefited population– Are these welfare patients, – from a particular socio-economic or ethnic background, – confined populations such as prisoners

• Formulations for distributing benefits and burdens: – to each person an equal share, – to each person according to his or her need, – to each person according to societal contributions past

and future – to each person according to (perceived) merit

Secondary PrinciplesSecondary Principles

• Veracity – duty to tell the truth, the whole truth and nothing but the truth*

• Confidentiality – duty to respect privileged information

• Fidelity – duty to keep promises * Ask Former Coach Bobby Patrino

ANA Provision 2.3 AdditionsANA Provision 2.3 Additions• Identify and Avoid conflicts of interest

• Duty to collaborate not just get along

• Practice within professional boundaries

• Don’t further questionable practice

–Report it and get guidance

• Don’t practice in impaired condition

Provision 4 DelegationProvision 4 Delegation

• Make proper delegations, taking responsibility for such delegations

• Only delegate to a person capable of carrying out the task whether the pt, family member or subordinate

• Educate subordinates who are incapable

• Improper delegation = abandonment

ANA Provision 5 IntegrityANA Provision 5 Integrity

• Practice with integrity

• If you are a conscientious objector, advise supervisor of such

• Conscientious objection does not insulate from legal or administrative penalties

• If you can’t stand the heat, get out of the kitchen

Nondiscrimination & RiskNondiscrimination & Risk

• Provide care in a “non-discriminatory manner• There are limits to the amount of personal

harm required to risk• Cannot abandon a patient• Personal risk may depend on the

individual condition of the nurse• A “sacred duty”

– American Nursing Association – December 1994

Hierarchy of ObligationHierarchy of Obligation

Reconcile these or . . .23

Follow your principles

John R. Wible, 2012

Professional Implications - Casessional Implications - Case

• J.L. (17 WF) presents abdominal pain

• Mom signs admit forms & Pt. BOR, RN x2

• Temp – 100.8; U/S ≠ app’s

• RN assumes Mom to remain in exam R

• JL denies ♂, day 2 menses

• 2 hr delay – lost urine sample; Pelvic - difficult

• PG test (-), both informed24John R. Wible, 2012

A Public Health StudyA Public Health Study• Problems most often required

relational response not option choice

• Goal – optimize the pt. good/ maint. supportive relationship w/other staff

• Five consistent “themes”– Rel. w/staff – systems issues– Character of relationships; respect/pt– Putting self at risk

Public Health Code of Ethics Twelve Principles

1. Addresses causes of disease to prevent.2. Respects the rights of individuals in the community. 3. Utilizes community input in program development.4. Advocates “empowerment” of the disenfranchised.5. Seeks the information needed before acting. 6. Provides the community with information to decide.7. Acts in a timely manner on the information. 8. A variety of approaches anticipate and respect diversity. 9. Enhance the physical & social environment. 10. Confidentiality - Exceptions must be justified. 11. Professional competence.12. Work collaboratively to build the public's trust.

Public Health ValuesPublic Health Values• Reaffirms the Declaration of Human

Rights• Humans are inherently social and

interdependent, thus the principle of “community”

• Community is perpetually balanced as against the rights of the individual

• Public trust and transparency

Public Health Values - 2Public Health Values - 2

• People and their environment are interdependent

• Upheld by the science of prevention

• Appropriate gathering, use and dispersion of knowledge

• The Code requires action

Public Officer and Public Officer and Employee Ethics laws Employee Ethics laws

No public official or public employee shall use or cause to be used his or her official position or office to obtain personal gain for himself or herself, or family member of the public employee or family member of the public official, or any business with which the person is associated unless the use and gain are otherwise specifically authorized by law. Personal gain is achieved when the public official, public employee, or a family member thereof receives, obtains, exerts control over, or otherwise converts to personal use the object constituting such personal gain

Nature and Scope Nature and Scope of Public Ethics Lawsof Public Ethics Laws

• Very narrowly constructed and construed

• Contrasted with the broad sweep of professional codes

DocumentationDocumentation

• Baseline patient information

• Accessible details in the event litigation occurs

• Record of professional accountability

• Evaluation of performance and quality of care

• Show that standards of care have been met

• Provides continuity of care

• Substantiates proof of services (so you can bill)

Good DocumentationGood Documentation

• Use factual, consistent, accurate, objective and unambiguous patient information

• Use your senses to record what you did

• Use quotation marks where necessary

• Ensure there is a reasoned rationale (evidence) for any decision recorded

• Ensure notes are accurately dated, timed, and signed

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More Good DocumentationMore Good Documentation• Write up notes as soon as possible after

an event certainly w/in 24 hours

• Document any objections to care

• Do not include jargon & meaningless phrases

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The “Golden Rule of The “Golden Rule of Documentation”Documentation”

If it ain’t wrote down it didn’t happen!

The way it is wrote down is the way it happened regardless of

the way it happened!34

John R. Wible, 2012

Confidentiality and Confidentiality and Access to RecordsAccess to Records

Imperatives for Protecting PHIImperatives for Protecting PHI

• Responsible sharing of some PHI is necessary

• All we have to sell is the patient’s trust in us

• Individual privacy protections must balance with legitimate community uses of PHI

Confidentiality- Confidentiality- Access to RecordsAccess to Records

• All patient information is strictly confidential

• Bad scenarios usually equal bad liability– Mom’s friend at the window– Nurse’s BFF’s boy friend

• Prior written consent

–Patient

–Parent/guardian

• Subpoena in accordance with departmental/institutional policy

• Otherwise provided by law

Conditions for Release Conditions for Release of Informationof Information

Written Authorization Written Authorization Not RequiredNot Required

• Transfer information to physicians, health professionals with contract or other provider arrangements to provide care

• Some practitioners require consents to transfer out of abundance of caution

• Description of the info released• Name or description of info receiver• Name of patient• Description if the use of the info• Expiration date or continuous• Right of revocation by patient• Notice of possible re-disclosures• Signature of pt or representative

A Valid AuthorizationA Valid Authorization??A Valid AuthorizationA Valid Authorization??

• If a minor is qualified to consent and signs the “consent for treatment”, only the minor can sign to release the information regarding those services

• If the parent/guardian signs the consent for treatment, the parent/guardian or the minor may consent for the release

Confidentiality - Access to Confidentiality - Access to Minor’s Medical RecordsMinor’s Medical Records

• All information pertaining to a child must be equally available to both parents–However, if the child gave consent for services, neither parent may have access to the records without that child’s consent

–Code of Ala, § 30-3-154

Access to Minor’s Medical Access to Minor’s Medical Records - Parents’ RightsRecords - Parents’ RightsAccess to Minor’s Medical Access to Minor’s Medical Records - Parents’ RightsRecords - Parents’ Rights

• Criminal § 13A-11-35

–“Divulging illegally obtained information”

• Civil actions (lawsuits v. the RN & Dept.)

–Suits for invasion of privacy

–Outrage - willful and wanton misconduct

–Breach of implied contract

• Administrative

–Loss of license or of job

State Law PenaltiesState Law PenaltiesUnlawful Release Of InfoUnlawful Release Of Info

• Protected Health Information (PHI)

–Individually-identifiable health information used or disclosed by a covered entity in any form, whether electronically, on paper, or orally

–45 C.F.R. §160.103

The Privacy Rule:The Privacy Rule:What is Covered?What is Covered?The Privacy Rule:The Privacy Rule:What is Covered?What is Covered?

• Treatment

• Payment

• Operations

• Where required by law

Uses Without Written ConsentUses Without Written ConsentUses Without Written ConsentUses Without Written Consent

“When using or disclosing PHI, a covered entity must make reasonable efforts to limit such information to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request”

Minimum Necessary Rule: Minimum Necessary Rule:

Who Needs to know?Who Needs to know?

• Outside the “need to know” never reveal a patient’s name, what he said, unusual behaviors or conditions or lifestyle

• Don’t even discuss patients with co-workers outside the need to know

• Never discuss patients outside the workplace unless authorized

“Minimum” info may be disclosed to:–Public officials–Public health–Law enforcement (LE)–National security & intelligence

agencies–Judicial authorities–Researchers–DHR or LE for abuse reporting

HIPPA - Disclosures PermittedHIPPA - Disclosures PermittedHIPPA - Disclosures PermittedHIPPA - Disclosures Permitted

• When there is a breach of protected info, the CE has a duty

–To report to or notify clients

–To report to HHS and the media if >500

–To mitigate the damage

–To examine employees, policies, equipment and facilities to prevent it happening again

HIPPA BreachesHIPPA BreachesHIPPA BreachesHIPPA Breaches

• Breach may subject employees and the Department:

–To criminal penalties up to $250,000

–To HHS civil penalties or HHE or private lawsuits

–To adverse employment action

–I.e., . . . . . . . . . . . . . . . . . . . .

HIPAA Breaches - PenaltiesHIPAA Breaches - PenaltiesHIPAA Breaches - PenaltiesHIPAA Breaches - Penalties

Individual Methods to Individual Methods to Avoid LiabilityAvoid Liability

• Avoid inappropriate behaviors

• Participate in Con-Ed programs

• Know and follow policies , protocols, procedures, laws and regulations

• Strictly adhere to training protocols

• Strictly follow instructions of medical direction and superiors

• Document, document, document51John R. Wible, 2012

For A Copy of Presentation and a Paper

►See “ETHICS, DOCUMENTATION and PUBLIC ETHICS, DOCUMENTATION and PUBLIC

HEALTH NURSIHEALTH NURSING”

►See several presentations & documents also: http://www.slideshare.net/jwible

►Blog: http://www.johnwible.blogspot.com

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