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Mental Health Nursing Mental Health Nursing Practice:Practice:

A Mental Health Nursing A Mental Health Nursing Response to Ethical Response to Ethical

DilemmasDilemmas

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Essential … Essential …

For people using health servicesFor people using health servicesFor the health professional For the health professional For healthcare organisations For healthcare organisations For communities For communities

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Basic rightsBasic rights

Fundamental LegislationFundamental Legislation

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Fundamental LegislationFundamental LegislationNZ Bill of Rights 1990NZ Bill of Rights 1990

Freedom of thought, Freedom of thought, belief, expression, belief, expression, association, association, movementmovementRight to refuse to Right to refuse to undergo medical undergo medical treatmenttreatment

Human Rights Act Human Rights Act 19931993

To protect Human To protect Human Rights & Prohibits Rights & Prohibits discriminationdiscrimination

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For mental health services?For mental health services?

Absolutely essential that all clinicians have Absolutely essential that all clinicians have a good understanding of ethical principles a good understanding of ethical principles because…..because…..

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Mental Health ActMental Health Act

Takes away many Takes away many of a persons basic of a persons basic Human RightsHuman RightsEnforcement of Enforcement of treatmenttreatment

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Misunderstanding about the scope Misunderstanding about the scope of the MHAof the MHA

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

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

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Common mental health issuesCommon mental health issues

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

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Risky behavioursRisky behavioursSome people self harm (cut themselves) as their Some people self harm (cut themselves) as their way of coping way of coping -- they have no intention of killing they have no intention of killing themselvesthemselvesPeople take risks with their lives all the time People take risks with their lives all the time ––base jumping, mountain climbing?base jumping, mountain climbing?People knowingly damage their health People knowingly damage their health ––smoking, dietsmoking, dietAre they considered to be suicidal or to be self Are they considered to be suicidal or to be self harming?harming?Do we have legislation that stops people from, Do we have legislation that stops people from,

Competing in their chosen sports?Competing in their chosen sports?Pursuing their lifestyle choices?Pursuing their lifestyle choices?

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Perspectives Perspectives

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

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Ethical principlesEthical principles

Respect for AutonomyRespect for AutonomyNonmaleficenceNonmaleficenceBeneficenceBeneficenceJustice Justice

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Mr BMr B

49 yr old man, dysphasia, hemiplegia49 yr old man, dysphasia, hemiplegiaForensic psychiatric history and brain injuryForensic psychiatric history and brain injuryCurrent client of Mental Health ServiceCurrent client of Mental Health ServiceFear of needles and invasive proceduresFear of needles and invasive proceduresDifficulty ascertaining his level of Difficulty ascertaining his level of understandingunderstandingPresenting with abdominal pain, dehydration Presenting with abdominal pain, dehydration –– there is a need for diagnostic testingthere is a need for diagnostic testing

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Ethical dilemmaEthical dilemma

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

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Competence to consentCompetence to consent

Specific capacities must be assessedSpecific capacities must be assessedCommunication of choiceCommunication of choiceUnderstanding of information providedUnderstanding of information providedAppreciation of options availableAppreciation of options availableRational decision makingRational decision making

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

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Contextual considerationsContextual considerationsMr B may have been competent to make Mr B may have been competent to make other decisionsother decisionsHe still has right to refuse treatmentHe still has right to refuse treatmentConsider Consider -- Are interventions in the best Are interventions in the best interests of Mr B or being done to satisfy interests of Mr B or being done to satisfy medical diagnoses?medical diagnoses?Balance of benefit and discomfort is Balance of benefit and discomfort is subjective so continuing communication subjective so continuing communication with Mr B was vitalwith Mr B was vital

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Mr B outcome Mr B outcome

Terminal Cancer Terminal Cancer -- Primary and secondary Primary and secondary sitessitesMedical and nursing staff worked with Mr Medical and nursing staff worked with Mr B B -- time consuming but satisfyingtime consuming but satisfyingPalliative care consistent with Mr B’s Palliative care consistent with Mr B’s wisheswishesMr B died within two weeks of admissionMr B died within two weeks of admission

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Mrs C Mrs C

45 year old woman45 year old womanMarried with adult family Married with adult family Diabetes and other health problems Diabetes and other health problems No attempt at self care of diabetesNo attempt at self care of diabetesFrequent hospitalisations to prevent death Frequent hospitalisations to prevent death due to diabetesdue to diabetes

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Mrs CMrs C

Has had contact with mental health Has had contact with mental health services for assessment purposes but no services for assessment purposes but no diagnosable mental illnessdiagnosable mental illnessDoesn’t want to live with diabetesDoesn’t want to live with diabetesAll general services referring back to All general services referring back to mental health “she must be mentally ill”mental health “she must be mentally ill”Where to from here?Where to from here?

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Ethical issueEthical issue

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

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Mrs C outcomeMrs C outcome

Moralist perspective dominates Moralist perspective dominates -- life life saving input as requiredsaving input as requiredMental health team input on request and Mental health team input on request and occasional admission to MH wards after occasional admission to MH wards after hourshoursSignificant use of resources to maintain Significant use of resources to maintain lifelifePrinciple of Justice?Principle of Justice?

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Admitting to overcrowded wardsAdmitting to overcrowded wards

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Ethical issuesEthical issues

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

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Nursing autonomyNursing autonomy

Control over ‘nursing practice’ onlyControl over ‘nursing practice’ onlyDon’t control the patientDon’t control the patientDon’t control other members of the MDTDon’t control other members of the MDTDon’t ultimately determine the policy and Don’t ultimately determine the policy and resource decisionsresource decisions‘Meat in sandwich’ or ‘buffer’ between ‘Meat in sandwich’ or ‘buffer’ between patient and others = Moral distresspatient and others = Moral distress

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In closing In closing -- Minimizing the opportunities Minimizing the opportunities for moral distressfor moral distress

Ask the questionsAsk the questionsBe aware of the different perspectives Be aware of the different perspectives including the wider contextual and cultural including the wider contextual and cultural issues issues Contribute in an informed way to ethical Contribute in an informed way to ethical discussionsdiscussionsContribute to policy/positioning documentsContribute to policy/positioning documentsReflect and discuss with colleaguesReflect and discuss with colleagues