The Mentally Ill - Essay Example

? The Mentally Ill The essay aims to address a two-fold objective to wit to identify and describe atleast one ethical or legal issue related to their nursing care in your journal; and (2) to summarize at least three articles, comparing and contrasting each article and how it affected your thoughts, feelings, values, or actions in your practice. The Mentally Ill A. Journal Writings I am a psychiatric nurse from a local community hospital and was taking care of Patient X (not the real name to protect confidentiality of patient information). Patient X was diagnosed with schizophrenia and was treated with clozapine (Clozaril), an atypical psychotropic drug used to treat psychotic symptoms, hallucinations, and breaks with reality (NIMH, 2012, 6). For a period of four weeks, I usually give Patient X a 200 mg oral preparations of clozapine twice a day as ordered. After series of inpatient medication regimen, Patient X’s symptoms of schizophrenia decreased and the patient is now stabilized. With this, Patient X requested to be discharged and be treated through outpatient commitment. I told Patient X that I will relay his request to the health care team and will inform him of the decision made. Upon discussing it with the health care team, we were put in a dilemma whether to grant Patient X’s request to respect his autonomy and independence or denied it to uphold the principle of nonmaleficence because the client might not take medications on time or not take medications at all and may result to an imminent threat or danger to self or to others due to relapse of schizophrenic symptoms. In addition, putting Patient X, who is receiving clozapine, on an outpatient commitment may present a serious harm as a WBC check every week or two is necessary to avoid occurrence of agranulocytosis or loss of the white blood cells that help a person fight infection. B. Ethical Dilemma In responding to a psychiatric patient’s request of discharge and treatment on an outpatient commitment, which ethical and legal principle should be considered – the legal right of a patient and the ethical principle of autonomy and independence or the professional responsibility of the nurse to do no harm and practice paternalism? C. Ethics Paper Summaries. Elbogen and Tomkins authored the article entitled “From the Psychiatric Hospital to the Community: Integrating Conditional Release and Contingency Management” in 2000. The article proposed involuntary outpatient commitment with therapeutic jurisdiction as one possible solution for psychiatric recidivism in the community. The article also emphasized that clinicians find it hard to discharge patients and are often put in a dilemma whether the discharge decision will benefit the patient or will end up in a relapse of chronic mental illness. In addition, discharge from the psychiatric hospitals also corresponds in legal status changes which might predispose the individual to heightened stress and independent living (Elbogen & Tomkins, 2000, 428). Thus, the article had raised a question whether outpatient commitment can provide continuity of care and reduce incidence of rehospitalization. Elbogen & Tomkins (2011) found therapeutic jurisprudence framework as the key to analyze legal and beneficial mental health interventions for the individual, conflicting values, and generated or implemented laws, policies and practice (p. 429). In patients with chronic mental illness, therapeutic jurisprudence preferred a discharge plan that maximizes convergence between self-determination, individual well-being, and public safety through integration of risk assessment technology and effective rehabilitative treatment, particularly contingency management. Absolute discharge might be the best promoter of self-determination as there are no strings attached; however it predisposed the patient for rehospitalization unlike outpatient commitment that discharged patient with therapeutic jurisprudence and reduced incidence of rehospitalization. No matter how good an outpatient commitment is, several loopholes arise such as unclear legal criteria that might implicate issues of due process, clinical concerns (inefficacies, inconveniences and studies indicating no therapeutic benefits), practical problems (high cost, lack of resources and enough mental health staff, and longer hearing times), and ethical dilemmas on the part of inpatient provider to act as both treatment provider and law enforcement agent. On the second article, Harnett & Greaney (2008) wrote “Operationalizing autonomy: solutions for mental health nursing practice” and discussed the new Mental Health Act (MHA) of 2001 which reflects the international legislative norms, outlines the mental health services in Ireland, and aims to maximize patient autonomy (p. 2). The new MHA had changed the traditional role of nurses and had provided the patient the right to appeal against detention in a mental hospital. However, conflict of autonomy occur when it is enacted differently by the service user (patient) and the mental health nurse, where the nurse was left in an ethical dilemma between balancing autonomy and other morally justifiable principles. The article delineated the etymological definition of autonomy from Greek words autos meaning self and nomos meaning laws (Harnett & Greaney, 2008, 3). Putting the terms together, autonomy is defined in the article as the act of self-governance or self-determination. The concept of autonomy in the psychiatric setting is so complex and cannot be simply refer to the acknowledgement of individual right to choose and act in accordance with own choice but to the individual’s capacity to decide rationally and free from coercion, whether or not to accept or refuse treatment. Ethical dilemmas in health care practice are often guided by the normative approach to ethics which include four principles, namely: autonomy, beneficence, non-maleficence, and justice (Harnett & Greaney, 2008, 3). Under the principle of autonomy, the legal concept of informed consent applies and legal sanctions are applied when consent is not carried out. However, patients with mental illness are exempted because personal limitations denied the conditions necessary for autonomy to exist. This creates tension among mental health nurses as personal limitations may not be permanent despite diagnosis of mental illness (Harnett & Greaney, 2008, 4). In addition, the article suggested that imprudent decisions such as administering medications without consent to a mentally ill patient should not overrule autonomy unless a test of functional capacity coupled with code of practice is conducted. The principle of autonomy might found ethical and legal conflict with the principles of beneficence and non-maleficence. Under these principles, nurses act in the best interests of patients, regardless if the treatment is applied involuntarily or coercively. In fact, under the new Mental Health Act, it is permissible and legal for a nurse to act against patients’ wishes for his/her own benefit (Harnett & Greaney, 2008, 4). On the part of the nurse, it is indeed a difficult decision to choose between patients’ rights and acting in best interests of a certain treatment as promoting autonomy may put the mental patient at harm while promoting beneficence and justice might end up restraining patients against their will for the benefit of the patients and others. The article highlighted the narrowed perception of autonomy as a principle which results in an ethical dilemma or distress among mental health nurses; thus, suggesting a more contextualized perspective and concept of autonomy as it is not an absolute philosophy to be upheld above other principles. In 2011, Lavelle & Tusaie co-authored the article entitled “Reflecting on Forced Medication” and addressed multiple concerns about forced medication practice in clients with mental illness (p. 274). Medication is an integral part of treating mental health illness and without this, clients may experience relapse where treatment becomes more difficult. Non-adherence to medication plan signals an impending danger – the reason why clinicians are often fearful about discharging patients and putting them in an outpatient commitment. In case like this, the principle of paternalism and the current legal system override the patient’s right to autonomy. In addition, the article cited a situation in which the liberty afforded by people with physical illness is not the same as those with mental illness as legalities denied mentally ill people the freedom to make choices that would harm self or others (Lavelle & Tusaie, 2011, 275). Ethical dilemma between autonomy and paternalism arises when patients refuse medication. According to Lavelle & Tusaie (2011), patients may refuse medication due to perceived beliefs that the side effects outweigh the benefits, absence of illness, and fear of medication addiction (p. 275). Meanwhile, clinicians prescribed medications to promote the well-being of others by deciding on a treatment that the clinician believed could be the most effective for the patient. A nurse may find it difficult to decide because respecting patient’s autonomy might address all the side effects but may also put the patient at risk for relapse and the nurse at risk for litigations while respecting paternalism might promote the best interest of the patient but may violate the individual right of the patients to decide on their own through forced medication or restraints. Two underlying issues arise from the ethical conflict: belief about the differences in brain functioning and the process of determining the client’s current competence and ability for self-care (Lavelle & Tusaie, 2011, 275). In reality, patients with mental illness are deprived of the right to refuse treatment or medication provided that there is a possible threat to the safety of the patients and others. In addition, medication is intended to alleviate both positive psychotic symptoms and negative behavioral symptoms (Lavelle & Tusaie, 2011, 275). If the patient posed no threat to self and others, the Supreme Court could aid in patients refusal for treatment. The U.S. adopted versions of “Kendra Laws” outlined the procedures for obtaining court orders for certain individuals with mental illness to receive and accept outpatient treatment (Lavelle & Tusaie, 2011, 276). There is a fine line between ethical principles and legal concepts and nurses must act in concordance with the law and what the profession requires for the benefit of self and others. Comparison and Contrast. The three articles discussed the common ethical conflict faced among mental health nurses – respect for patient’s autonomy and beneficence/paternalism. The ethical dilemmas in the three articles all occurred during receiving of treatment or medication and discharge decisions. Among other similarities noted are: lack of clarity regarding legal criteria, narrowed and complex concept of autonomy, clinicians’ concerns of relapse from mental illness, and conflict between professional roles and legal mandates among health care providers. In the article of Elbogen & Tomkins, outpatient commitment is viewed as one possible solution for relapse of chronic mental illness, provided that it is involuntary and with therapeutic jurisprudence. Meanwhile, article of Harnett & Greaney took several considerations on deciding an outpatient commitment by weighing ethical principles of autonomy, beneficence, nonmaleficence, and justice. In the third article by Lavelle & Tusaie, outpatient commitment posed concerns of relapse as the patient may not take the medication, leading to imminent harm to self and others. Elbogen and Tomkins believed that the autonomous right of the patient to decide on outpatient commitment must overrule as long as there is therapeutic jurisprudence while Harnett & Greaney depend on the situation and the provision of the new Mental Health Act in which the patient can practice autonomy if he/she is rational and competent enough to make decisions or the patient autonomy may be withheld if the nurse act in benefit of the patient. The article of Harnett & Greaney also found it legally permissible for a nurse to act against patient’s wishes under the Mental Health Act. Meanwhile, the article of Tusaie decides on outpatient commitment and administration of medication through principle of paternalism. With imminent presence of harm to self and others, a person with mental illness cannot practice autonomy in terms of discharge or refusal from medication. Patient with no potential to harm self or others cannot also easily be discharged or refused any type of prescribed medication as patient requires the approval of the Supreme Court. Reflection. The articles have created a significant impact on my thoughts, feelings, values, and actions in practice. Initially, I thought that patient’s autonomy must be upheld at all times in respect for human dignity. I felt relieved to learn that due to the narrowness and complexity of the concept of autonomy, absolute autonomy is not possible in the psychiatric settings. The ambivalent feelings I have towards two conflicting ethical principles of autonomy and beneficence/paternalism turned into a feeling of fear due to the fine line between the ethics of nursing and legalities of nursing actions. As a health care team, if we let Patient X be discharged on an outpatient commitment, he may not take his medications, experience relapse, and eventually harm self and others. On the other hand, if we forced him to remain in the hospital and take his medication, we violate his right of autonomy and might face legal sanctions. In line with this, it is our obligation as a nurse to assess the functional capacity of the mental health patient before ruling out their autonomy. To avoid legal sanctions, the nursing profession and state law must work in concordance and resolution of the ethical dilemma through seeking the approval of the Supreme Court to grant Patient X’s request if assessment revealed good functional capacity and no harm to self and others. References Elbogen, E.B. & Tomkins, A. (2000). From the psychiatric hospital to the community: integrating conditional release and contingency management. Behavioral Sciences and the Law, 18: pp. 427-444. Harnett, P.J. & Greaney, A.M. (2008). Operationalizing autonomy: solutions for mental health nursing practice. Journal of Psychiatric and Mental Health Nursing, 15: pp. 2-9. Lavelle, S. & Tusaie, K.R. (2011). Reflecting on forced medication. Issues in Mental Health Nursing, 32: pp. 274-278. DOI: 10.3109/01612840.2011.552749 Read More