Ethical Foundation

Ethical and Legal Foundations of PMHNP Care Across the Lifespan

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In your role as a PMHNP, you will regularly encounter situations that require your ability to make sound judgments and practice decisions for the safety and well-being of individuals, families, and communities. There may not be a clear-cut answer of how to address the issue, but your ethical decision making must be based on evidence-based practice and what is good, right, and beneficial for patients. You will encounter patients who do not hold your values, but you must remain professional and unbiased in the care you provide to all patients regardless of their background or worldview. You must be prepared to critically analyze ethical situations and develop an appropriate plan of action.

Learning Objectives

Students will:

· Analyze salient ethical and legal issues in psychiatric-mental health practice

· Analyze the impact of cultural considerations on ethical/legal decision making in advanced practice nursing

· Evaluate mastery of nurse practitioner knowledge in preparation for the nurse practitioner national certification examination*

*Assessed in Week 3 Assignment

Learning Resources

Required Readings


(click to expand/reduce)

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). 
Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.

· Chapter 19, “Legal Issues in the Care and Treatment of Children with Mental Health Problems”

Zakhari, R. (2020).
The psychiatric-mental health nurse practitioner certification review manual. Springer.

· Chapter 1, “Preparing to Pass the Psychiatric-Mental Health Nurse Practitioner Certification Exam”

Reminder: Keep Your Library of Advanced Practice Nursing Texts at Your Fingertips

Several textbooks are assigned in multiple courses in your program. That is, you will see reading assignments from the books assigned in the Learning Resources of more than one course. You should, however, keep all prior textbooks—not just the ones explicitly assigned—readily accessible. The expectation is that you will independently consult these prior textbooks to synthesize information needed to complete your final courses. This is your time to “put it all together” and to more fully embrace the advanced practice nursing role. Part of the responsibility of advanced practice is developing information literacy skills to know where to locate needed information for your clinical practice. 

Discussion: Ethical and Legal Foundations of PMHNP Care

Advanced practice nursing in all specialties is guided by codes of ethics that put the care, rights, duty, health, and safety of the patient first and foremost. PMHNP practice is also guided by ethical codes specifically for psychiatry. These ethical codes are 
frameworks to guide clinical decision making; they are generally not prescriptive. They also represent the aspirational ideals for the profession. Laws, on the other hand, dictate the requirements that must be followed. In this way, legal codes may be thought to represent the minimum standards of care, and ethics represent the highest goals for care. 

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For this Discussion, you select a topic that has both legal and ethical implications for PMHNP practice and then perform a literature review on the topic. Your goal will be to identify the most salient legal and ethical facets of the issue for PMHNP practice, and also how these facets differ in the care of adult patients versus children. Keep in mind as you research your issue, that laws differ by state and your clinical practice will be dictated by the laws that govern your state.

To Prepare

· Select one of the following ethical/legal topics:

· Autonomy

· Beneficence

· Justice

· Fidelity

· Veracity

· Involuntary hospitalization and due process of civil commitment

· Informed assent/consent and capacity

· Duty to warn

· Restraints


· Child and elder abuse reporting

· Tort law

· Negligence/malpractice

· In the Walden library, locate a total of four scholarly, professional, or legal resources related to this topic. One should address ethical considerations related to this topic for adults, one should be on ethical considerations related to this topic for children/adolescents, one should be on legal considerations related to this topic for adults, and one should be on legal considerations related to this topic for children/adolescents. 


Involuntary hospitalization and due process of civil commitment

 Involuntary commitment (IVC) is an intervention ruled by a judge or someone in the judiciary system when someone with severe mental illness symptoms meets specific criteria to be admitted to a locked-door psychiatric hospital or receive supervised treatment in an outpatient setting. In each state, state law provides commitment standards, and each commitment process must carry the due process protections according to the state and federal law as well as constitutional rights as granted by the U.S supreme court. Constitutional rights include treatment refusal and confinement rejection unless the person poses a high risk of harm to themselves or others. According to federal and state laws, evidence of involuntary commitment or other mental disability will remarkably affect other rights, such as the right to possess a firearm (SAMHSA, 2019).


Legal considerations for adults

   Borecky et al. (2019) described suicide as the 10th leading cause of fatality in the United States and the second cause of death among young people between 15 and 25 years old. The typical standard of care for suicidal ideations is an involuntary commitment hospitalization commonly ordered by a psychiatric provider. The article argued the IVC for suicidal patients, focused on the overlooked harm caused by this practice, and recommended more research in the future. The authors described that accruing harms associated with involuntary commitment is neglected, recommended reevaluating the necessity of IVC, and proposed using more effective alternative measures. The authors described one of the harms caused by IVC as the use of intimidation and loss of self-sufficiency. Secondly, they argued there is not enough evidence that IVC hospitalization is an effective measure to reduce suicide fatality. The authors also explained that therapeutic interventions that increase and maintain autonomy and personal responsibility could benefit suicidal patients. The authors recommended IVC hospitalization should be limited to individuals who don’t have decision-making capability.


Legal considerations for children

 Santillanes et al. (2020) explained the importance of involuntary commitment to ensure the safety of young people with mental illness during emergencies. Because IVC considerably disregards patients’ rights, therefore, IVC hospitalizations should only be utilized when fewer restraining measures have not been effective or there is a high safety risk. The authors argued IVC orders should be discontinued when sufficient safety measures are in place. The study aimed to identify the role of psychiatric services and the necessity of evaluating IVC by a psychiatric provider in the emergency department. The study results show that psychiatric child and adolescent providers discontinue more IVC holds than a general psychiatric provider. They further explained emergency responders sometimes start the IVC process when there is an immediate danger to patients, or they need to control the situation for safe patient transport to emergency departments. In the emergency department, patients should be evaluated when they are calm because the continuation of IVC may lead to patients’ extended stay in the emergency room awaiting admission to a higher level of care. The study analysis recommended approaches for initial access to psychiatric care for the child and adolescent providers that may expedite timely IVC discontinuation and benefit both youth and the emergency department.


Implications for practice

  In South Carolina, the state of the writer’s residency, an individual may involuntarily be committed to a public hospital, mental health clinic, or mental health emergency department. An affidavit under oath by someone indicating they believe mentally ill individuals pose a high risk of harm to themselves or others if they are not instantly hospitalized. A licensed physician must evaluate individuals and complete a certification that confirms the necessity of withholding the IVC. The IVC certification will expire after three days, according to the South Carolina legislature. The affidavit and certification must be sent to the court within 48 hours after admission to the individual’s residency or the location where IVC leads to hospitalization. The court decides if the IVC should be discontinued based on sufficient evidence and issues the appropriate order. The treatment facility will appoint two examiners, one must be a physician, and the examination must be completed within seven days from the admission date and submitted to the court. Five days before the hearing, the court will send a notice to the person and other people involved in the case to testify in favor of releasing involuntary commitment.


 Informed assent/consent and capacity

 Medical decision-making ascertains patients’ right to make their medical decisions meanwhile safeguarding their treatment when patients’ capacity is impaired to make their medical decisions. Patients have the right to understand why they need to make a specific medical decision, such as consent to treatment or involvement in research. It is crucial to remember that if someone is incapable of making one medical decision, they may be capable of making other decisions. It is challenging for the providers when patients refuse their treatment, or the treatments may implicate possible risks. The assessment of decision-making capability is required before informed consent is obtained. Patients must receive sufficient information about the type, necessity, risks, benefits, and alternatives of the recommended treatment. Patients must make their own decisions voluntarily and without pressure if they are competent to make medical decisions. Competency is defined as understanding the information about the treatment, consequences of their choice, potential risks and benefits, and the ability to articulate their choice (AMA, 2017).


Ethical considerations for Adults

 Hur et al. (2021) evaluated the role of informed consent to treatment, feeling empowered, and its effect on patients’ emotions and overall human well-being. The study explained people with mental disorders are perceived as incapable of making their treatment decisions due to a lack of good insight and judgment and impaired cognitive and thinking processes. In addition, stigma against people with mental illness and lack of self-confidence in seeking treatment has resulted in patients with mental illness in social isolation. The authors described that people with mental illness are judged to be mentally incapable and incompetent to make proper treatment decisions leading to clinicians making decisions for them without giving adequate information, considering their concerns, and obtaining informed consent. Most people with mental illness reside outside mental health facilities and live in communities; therefore, it is an excellent opportunity to evaluate their competency and obtain informed consent to rectify the stereotype that all mentally ill patients are incompetent. Most people with mental illness face challenges in improving their quality of life due to psychosocial factors influencing their life even if their symptoms improve. The idea that patients are incompetent to consent to treatment, and focus on their quality of life, has become significantly challenging. Happiness is one of the most important aspects of improving quality of life, and patient’s satisfaction when actively participating in their treatment may increase happiness and improves patients’ well-being.


Ethical considerations for children

   Mandarelli et al. (2017) studied treatment decision-making in clinical psychiatric children and adolescents and evaluated the informed consent in this population. Legally speaking, minors are considered incompetent in making decisions, including medical and psychiatric treatments; therefore, their parents or legal guardians make all their health care decisions. The authors suggested that minors’ capability to understand and retain information from their environment, their concrete and abstract reasoning, communication capabilities, and the ability to plan and organize are affected by severe mental illness. The study results show that severe mental disorders do not certainly result in decision-making impairment. The study data confirmed that patients’ cognitive impairment significantly affected treatment decision-making and choices and recommended assessing and evaluating children and adolescents utilizing a cognitive assessment tool and treatment decision-making feasibility in the absence of cognitive impairment. The authors’ preliminary results indicate the necessity for increasing the interaction and relationship between children, adolescents, parents, and legal guardians in treatment decisions.


Implications for practice

 In South Carolina, an authorized healthcare provider can provide care, treatment, and healthcare services, including an advanced practice registered nurse, a physician assistant, or a psychiatrist. Informed consent is required for medical examinations and treatments, excluding emergency procedures. Informed consent is the signed document explaining the treatment by an individual who is legally and mentally competent to give consent. Two physicians must evaluate the patient if a caregiver questions the person’s mental capacity. If the patient cannot consent, an immediate family member will be contacted to make healthcare decisions on behalf of the patient. If the patient does not have family members, the hospital’s ethic committee will designate a person to make healthcare decisions for the incompetent patients. Minors 16 years and older can consent to their healthcare services other than surgeries. Minors’ legal guardians can consent to surgeries unless the minor is married or they are determined to be capable of providing consent for surgeries by the court (Code of Laws – Title 44 – Chapter 22 – Rights of Mental Health Patients, n.d.).


Borecky, A., Thomsen, C., & Dubov, A. (2019). Reweighing the ethical tradeoffs in the involuntary hospitalization of suicidal patients. 
The American Journal of Bioethics, 
19(10), 71–83.

Civil-commitment-continuum-of-care [PDF]. (2019). Substance Abuse and Mental Health Services Administration.

Code of laws – title 44 – chapter 17 – care and commitment of mentally ill persons. (n.d.). South Carolina Legislature.

Code of laws – title 44 – chapter 22 – rights of mental health patients. (n.d.).

Hur, Y.-J., Park, J.-H., & Rhee, M. (2021). Relationship between competency to consent to treatment and psychological well-being: Mediating effect of empowerment and emotion. 
International Journal of Environmental Research and Public Health, 
18(15), 8170.

Influence of psychiatric symptoms on decisional capacity in treatment refusal. (2017). 
AMA Journal of Ethics, 
19(5), 416–425.

Mandarelli, G., Sabatello, U., Lapponi, E., Pace, G., Ferrara, M., & Ferracuti, S. (2017). Treatment decision-making capacity in children and adolescents hospitalized for an acute mental disorder: The role of cognitive functioning and psychiatric symptoms. 
Journal of Child and Adolescent Psychopharmacology, 
27(5), 462–465.

Reweighing the Ethical Tradeoffs in the

This is a journal article from the American Journal of Bioethics

Discontinuing involuntary mental health holds for children

This is a research article from the American Journal of Emergency Medicine

Treatment Decision-Making Capacity in Children

This is a research article from  the Journal of Child and Adolescent Psychopharmacology

Relationship between Competency to Consent to Treatment

This is a research article from the International Journal of Environmental Research and Public Health 

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