Ethical and Legal Issues in nursing Essay

The nurse regulatory body, the Nursing and Midwifery Council requires totally registered nurses to have an understanding of the ripe and effective beliefs which underpin all aspects of nursing pr moldice(NMC,2010). A comprehensive understanding of current legal and honourable frameworks facilitates the tar of entrance skil lead nursing c ar. The purpose of this assignment go forth be to critically discuss an gaucherie of tutelage encountered whilst on clinical placement. The episode of care involves the secret administration of music to an elderly diligent. The determination to undergroundly manage the music impart be critically surveyed in this assignment. The Gibbs(1988) chiding personate will be functiond to guide the discussion. The discussion will in any(prenominal) case affect the legal, good and skipper issues surrounding masked medicinal drug.In the mental wellness sector, medication non-adherence remains a serious health-care line with far- r severallying ramifications for endurings, their relatives and health-care professionals. Harris et al. (2008) put that between 40 and 60% of mental health affected roles neglect to adhere to their medication word political program. This soma increased to 50 and 70% for elderly perseverings with dementia, and between 75 to 85% among patients with schizophrenia and bi-polar dis points. In such(prenominal) cases, where the patients well being is at risk and the handling is internal, health-care professionals may resort to disguising medications in intellectual nourishment and drink. The medication is crushed or liquefied and mixed with nourishmentstuff. This dress of concealment is called subterranean medication(NMC,2008). By unrevealedly administering medication, the patient consumes a drug with bulge out the required informed betroth over. The Gibbs(1988) reflection model has been chosen for the purpose of this assignment as it allows the author to reflect and vie w musical arrangementatically about the episode of care. The initial peak of Gibbs reflective beat is Description in which the author is required to describe the events which occurred.In order to succeed with the NMC(2010) code of conduct and guidelines on patient confidentiality, the patient will be called Mr baby-walker. Mr perambulator, an 80-year-old go recitationr was temporary placed at the breaking care home. Mr Walker had severe dementia, and was ineffectual to communicate effectively. He a great deal resisted all inbred nursing care. Mr Walkers medical exam record also included hypertension and angina. He was prescribed blood wring medication (enapril tablets) to stabilise his blood pressure and to reduce the risk of virgule and heart attacks. He was also prescribed diuretics and medication to prevent except angina attacks. Mr Walker frequently refused to take his medication spitting out the tablets and ref victimisation to swallow. The nurse in charge, concerned about the deterioration of Mr Walkers health, pick outed the option to subterraneously administer his medication. The MDT held a meeting and reached the conclusiveness to undercoverly administer Mr Walkers medication. The second stage of the Gibbs reflective rung is Feelings, requiring the author to briefly discuss her reactions and feelings. The author felt the determination to covertly administer medication was morally ameliorate and goodly allowable. The author refers to the deontology estimable theory to support her thoughts and feelings.The NMC code of conduct considered by Beckwith and Franklin(2011) as a model of rule deontology states that all health-care professionals should safeguard and promote the absorbs and well-being of patients. The act of covertly administering medication could therefore be deemed morally correct. The practiti geniusrs intended on acting in the outflank interest of Mr Walker ir regardive of the consequences of their actions (br eaching patient familiarity). Their actions promoted and safeguarded Mr Walkers health and well-being. Husted (2008) argues that from a deontological point of view, violating an individuals autonomy is close totimes necessary to promote the individuals scoop out interest. In this case it could therefore be estimablely permissible to covertly administer medication without Mr Walkers consent. The medication is subjective and promotes Mr Walkers long-term autonomy and safeguards his health and well-being. Similarly, the ethical principles of beneficence and non-maleficence could be used to justify the use of covert-medication (Wheeler 2008).The principle of beneficence is an ethical principle derived from the duty to provide benefits and to consider the benefits of an action against the risk. According to Masters(2005), health-care practitioners have a professional duty and an ethical obligation to carry out verifying actions with the aim of safeguarding their patients health and well-being. With this notion in mind, covert medication could be morally reassert if it safeguards the  eudaimonia of the patient. In this case, the discontinuation of medication would have had a detrimental effect on Mr Walker. therefrom administering the medication covertly was in accordance with the principle of beneficence. In this case, one could also argue that the medication was real acting as an autonomy restoring agent (Wong et al,2005). Mr Walkers autonomy was restored in that he was alleviated of severe pain. The medication also worked by improving his quality of life. some(prenominal) studies on the chemical and physical restraint of aggressive dementia patients also a lot show a preference to covert medication (Treolar et al,2001). unseeable medication is often considered the least restrictive and inhumane way of administering medication when considering alternatives like physical and technical restraint to administer medication by force (Engedal,2005). Such alternatives to covert medication are unsafe and stub have long lasting negative psychological do on the patient (Wong et al, 2005).However, covert medication is not without its shortcomings. The aggroup was deceiving Mr Walker, an already confused, haplessly, frail, attenuate and vulnerable individual. In the Dickens et al(2007) subject area, many patients expressed this view of covert-medication as an act of deception. They considered covert medication as an extremely coercive apply violating their personal rights. This resultantly damaged the therapeutic nurse-patient relationship and patients felt they were no longitudinal in a safe, therapeutic environment. The nursing ethical principle of non-maleficence is in like manner relevant to this discussion. It requires practitioners to safeguard their patients welfare by not inflicting pain or harm (Koch et al,2010). This exigency poses serious ethical dilemmas. It is difficult to wield this ethical standard as all forms o f medical intervention entail some element of harm. Koch et al,(2010) suggest that peradventure for the harm posed to be ethically permissible it should be proportional to the benefits of the medical preaching. The author indeed feels that covert medication in Mr Walkers case could be ethically warrant under these ethical principles.The author will now focus on the Analysis stage of Gibbs reflection model. Here, the author will critically read the events which occurred including the decision making process and the decision itself. The author will for the initial time discuss the issue of consent in relation to covert medication. The covert administration of medication is indeed a complex issue. It derives from the essential principles of consent and patient autonomy which are deeply rooted in the UK statute, normal law and the Human right hands sour 1998 (Lawson and Peate,2009). The UK law light-coloredly considers bodily honor a fundamental human right a mentally f itting adult has the right to refuse medical sermon regardless of how essential the treatment is to their health and well being (Kilpi, 2000).The freedom of choice which is strengthened by the ethical principle of respect for autonomy is an cardinal right. The NMC(2008) march on highlights in the Code that it is the nurses professional, legal and ethical duty to respect and uphold the decision made by the patient. If a nurse administers covert medication to a mentally competent individual, the nurse will be acting unethically (disregarding autonomy) and in breach of the law which could constitute grounds for trespass, round off or battery (NICE,2014), as shown in the cases R v SS 2005 and R v Ashworth Hospital 2003. Thus practitioners have a professional, legal and ethical duty to respect the autonomous wishes of each patient.In Mr Walkers case an MDT meeting was held prior to the covert administration of medication to consider Mr Walkers lack of consent and his mental might t o consent. The MDT consisted of the command practitioner, psychiatrist, junior house officer, nurse-in-charge, home-manager, occupational-therapist, physio-therapist, speech and language therapist, pill pusher, dementia nurse specialist, disciple nurse, and two relatives. By holding an MDT meeting, the practitioners were acting in accordance with local policies and guidelines. The NICE(2014) guidelines state that health-care practitioners have a legal duty to investigate and take into account the patients wishes, as well as the views of their relatives, carers and new(prenominal) practitioners involved in the patients care. By reflecting with the relevant parties, the decision made will be, based on what the person would have wanted, not necessarily what is beat out for their physical or mental health(Latha,2010). Latha thus argues that decisions based on the patients wishes show some respect for the patients autonomy and are much more ethical than isolated decisions to cove rtly administer medication.As such, a failure to consult the relevant parties may constitute a breach of legal, professional and ethical duty as shown in the Gillick v West Norfolk Health case (Nixon,2013). However, the Dickens et al, (2007) study shows that nurses frequently administer covert medication without any prior discussion with the MDT, relatives or even the pharmacist. Such practice has led to some nurses being disciplined and charged with various offences (Wong et al,2005). Under UK law, covert medication could be legally justified and considered ethical if the patient is admitted to the hospital under the Mental Health Act (1982). It could also be justified if it is shown that the patient lacks capableness under the Mental readiness Act(2005). The MCA(2005) introduced the 2 stage capacity test. This 2 stage-capacity-test was used by the MDT in Mr Walkers case. The MCA test required the MDT to consider whether Mr Walkers cognitive declension rendered him mentally incompetent to make treatment decisions. The doc used the MacArthur competence Assessment Tool for Treatment (MacCAT-T) and the Mini-Mental Status Examination lance (MMSE) to assess Mr Walkers cognitive function and his capacity to consent.The MacCAT-T interview tool was used to assess Mr Walkers ability to (1) understand his medical condition and the benefits/ risks of the medical treatment (2) his ability to appreciate this reading (3) his debate ability and (4) his ability to communicate and express his decision. The results showed Mr Walker as mentally incompetent and lacking the capacity to consent. Mr Walker was (1) unable to understand the information stipulation to him regarding his treatment (2) he was unable to retain or beseech up the information given to reach a decision (3) he was unable to communicate his decision effectively even when encouraged to use non-verbal communication such as blinking or squeezing a hand. The Mini-Mental Status Examination (MMSE) tool was also used by the atomic number 101 to assess Mr Walkers cognitive function. Mr Walker following the perspicacity scored a low score of 12 on the MMSE. The MDT provided further clinical evidence (screening tools, clinical data, memory tests, medical imaging results).There were some disadvantages associated with using the MacCAT-T assessment tool. The MacCAT-T tool itself does not give cut off score to clearly ascertain the boundary between capacity and incapacity.This is certainly a limitation. As shown in the Palmer et.al. (2002) study, this put forward lead to some patients with low make headway being wrongly assessed as lacking capacity. The MacCAT-T tool also fails to fuck the emotional aspects of decision making (Stoppe, 2008). It assumes that people only rely on a rational, analytic, rule-based thought process to make decisions. Breden and Vollman (2004) thus argue that, the limit to only logical rationality runs the risk of neglecting the patients normative ori entation. Other factors including situational anxiety, severity of the medical condition, medication could also affect on a persons ability to articulate their decision making process. Furthermore, assessment tools like the MacCAT-T tool, coarsely depend on the clinicians ability to carry out a clinical interview with the patient. It requires the physician to make an isolated evaluation and decision. Isolated judgements and evaluations can be unreliable as they can be influenced by factors such as internal impressions, professional experience, personal values, beliefs and even ageism as shown in the Marson et.al. falsifiable study (Sturman,2005). In the study only 56% of physicians who participated in the capacity assessment of patients were able to agree on a capacity judgement. umpteen physicians found that they were unable to agree due to differences in medical experience, personal beliefs and subjective impressions. Such empirical evidence certainly questions the reliabilit y of capacity assessment tools. Following on, effective communication skills were essential at this first stage of the capacity assessment as the team was required to consider whether Mr Walker was likely to recover capacity. Effective communication is certainly consequential in such MDT settings as, effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors and results in ameliorate patient safety (Bretl,2008). Several studies have shown ineffective communication as a contributing factor in medical error cases (Rothschild, 2009). done effective communication, each member of Mr Walkers MD team understood the discussion at hand and was thus able to conduce new suggestions and solutions. The team implemented communication skills such as negotiation, audience and goal setting skills.The MDT with input from Mr Walkers relatives concluded that a trounce interest decision would have to be made on Mr Walkers behalf. The general practitioner made it clear that the best interest decision would have to comply with the UK legal framework.The European meeting of Human Rights (ECHR) requires the medical treatment given to be respectful to the patient (Pritchard, 2009). In discussing Mr Walkers case, it was firstly established (during the medication suss out), that the treatment in question had both therapeutic necessity and therapeutic effects for the patient. The MDT when making a best interest decision also considered the risks and benefits of treatment in accordance with the ECHR requirements. The ECHR states that the medical treatment should not be given in a sadistic, inhumane or degrading manner (Human Right Review,2012). Similarly, the NICE(2014) guideline states that the harm that would be caused by not administering the medication covertly, mustiness be greater than the harm that would be caused by administering the medication covertly. This requirement was satisfied by the practitioners in Mr Walkers case. An in-depth risks and benefits assessment was carried out. The pharmacists input was essential at this stage. The pharmacist presented an evidence-based argument discussing the essential medication with medical necessity.The pharmacist also provided guidance on the just about appropriate form of administration for example he suggested prescribing enapril in its melted form (enaped). The pharmacist also provided guidance on the close to appropriate order of administration for example not mixing the medication with boastful portions of food or liquid. Following this discussion with the pharmacist, a best interest decision was made to covertly administer Mr Walkers medication. It was important for the MDT to consult with the pharmacist. The method of crushing, smashing tablets or opening capsules which is a usually used when covertly administering medication is an unlicensed form of administration (NMC, 2008). It can inflict harm by altering the therapeutic pr operties which can cause adverse reactions and fatalities. When using this unlicensed method of administration, the practitioner is also unable to establish whether the patient has received the prescribed amount. If the patient is not receiving the correct dosage required for his treatment, the treatment is ineffective (Wong et al,2005).The pharmacist should therefore be consulted with. However, as demonstrated by the McDonald et al,(2004) study pharmacists are rarely consulted with. In the study, 60% of nurses working in UK care homes admitted to crushing tablets on each drug round to help patients with swallowing difficulties without firstly consulting with a pharmacist. Fortunately, in Mr Walkers case, the pharmacist was able to provide guidance on the most appropriate method of administration. Following on, in such cases where the patient is  turn out to lack capacity to consent to medical treatment, the Mental Capacity Act promotes the use of best interest decisions. In Mr Walkers case, the MDT reached a best interest decision to covertly administer his medication. However, there are some problems associated with the practice of relying on best interest decisions. Baldwin and Hughes (2006), highlight the legion(predicate) problems associated with making best interest decisions. In their empirical study, Baldwin and Hughes found that practitioners and relatives often evaluate a patients quality of life differently. The results showed the poor performance of relatives and practitioners at predicting patients medical treatment preferences. Differences in cultural backgrounds, professional experiences, values and beliefs mean that decisions made may actually go against what the patient would have wanted.The failure to consider the patients values and believes was found to be a common occurrence in the Dickens et al,(2007) study. In this study, 18% of the nursing staff interviewed admitted that they would be willing to covertly administer medication to ev en those patients with capacity to consent, regardless of their values and beliefs, if the treatment was essential for their well-being. The legal framework in the UK was indeed established with the aim of safeguarding the welfare of the incapacitated person. However, with such results, it remains unclear the extent to which health-care professionals are actually adhering to the legal requirements. The Mental Health Foundation(2012) argues that the MCA, needs revising to enable more effective best interests decisions by health and social care staff. In its investigation, the Mental Health foundation found that although a large number of health-care staff found the MCA to be an effective tool in match the ethical principle of autonomy and safeguarding patients lacking capacity, 63% of health-care practitioners felt the definition of mental capacity was not made clear, with many expressing the view that the legal framework does not encompass the complexity of capacity assessments in practice (MHF, 2012).The Griffith (2008) study and the Roy et al. (2011) further found that due to this lack of understanding, a large number of mental-health patients were wrongly assessed as lacking capacity, depriving them of their personal rights. These results suggest that health-care professionals perhaps require further training and education about the legality and practicalities of covert medication. When used without the correct legal safeguards in place, covert medication doubtlessly becomes an extremely paternalistic unlawful and unethical practice. Following the anonymous best interest decision to covertly administer Mr Walkers medication. The decision making process was clearly documented the mental capacity assessment, the best interest decision, method of administration (stating explicitly that the least restrictive method will be used) were all documented in Mr Walkers care-plan and medication-chart. Accurate documentation and record keeping is essential as it sa feguards service users human rights and ensures that health care professionals follow the legal framework as well as local policies and guidelines.Article 6 of the HRA, right to a fair and public hearing, also requires clinical records to be comprehensible, clear and concise so that they can be referred to if needed in a fair and public hearing. Following the MDT meeting, Mr Walkers care plan was frequently discussed and reviewed by the MDT in monthly formal review meetings in compliance with local policies and guidelines. NICE (2013) guidelines state that it is important to frequently review covert medication decisions. Each individual is different and an individuals mental state and capacity can change over time. By carrying out the monthly formal review meetings, the practitioners safeguard their clients rights by ensuring that covert medication is still the most appropriate, lawful and ethical method of administration.In conclusion, the nurses of today certainly practice in a co mplex health care system. It is thus essential for nurses to have a good understanding of the ethical principles which underpin good nursing practice. In the nursing literature, nurses are often described as the moral agents of the health-care system (Sellman,2011). This means that nurses should value ethical reasoning acting in such a way which balances good intentions against risk and the best outcome. Through good ethical reasoning nurses are able to promote patient comfort, patients safety, ease suffering, and promote patient welfare to enhance recovery. The covert administration of medication should therefore not be an isolated decision, it should comply with the legislation, ethical principles, local policies and guidelines.BibliographyThe National Institute for Clinical Excellence, (2014). Managing care fors incare homes. online NICE. acquirable at http//www.nice.org.uk/media/B5F/28/ManagingMedicinesInCareHomesFullGuideline.pdf Accessed 17 Apr. 2014. Beckwith, S. and Frankl in, P. (2011). Oxford handbook of prescribing for nurses and allied health professionals. maiden ed. Oxford Oxford University Press. Breden, T. and Vollmann, J. (2004). The cognitive based approach of capacity assessment in psychiatry A philosophical critique of the MacCAT-T. Health Care Analysis, 12(4), pp.273283. Bretl, A. (2008). patient role safety rounds. 1st ed. Oak Brook, Ill. Joint Commission on Accreditation of healthcare Organizations. Nursing and Midwifery Council, (2010). The Code. online NMC. Available at http//www.nmc-uk.org/Documents/Standards/nmcTheCodeStandardsofConductPerformanceAndEthicsForNursesAnd- Midwives_LargePrintVersion.PDF Accessed 16 Apr. 2014.Dickens, G., Stubbs, J. and Haw, C. (2007). Administering medication to senior(a) mental health patients. Nursing times, 103(15), pp.30-31.Engedal, K. and Kirkevold, O (2005). Concealment of drugs in food and beverages in nursing homes cross sectional study. BMJ, 330(7481), p.20.Equality Human Rights (2012). Arti cle 3 Freedom from torture and inhumane and degrading treatment or punishment. online Available at http//www.equalityhumanrights.com/uploaded_files/humanrights/hrr_article_3.pdf Accessed 12 Apr. 2014. Gibbs, G. (1988). Learning by doing. 1st ed. London FEU. Griffith, R. and Tengnah, C. (2008). Mental Capacity Act 2005 assessing decision-making capacity 2. British journal of community nursing, 13(6), pp.284-293.Harris, N., Baker, J. and Gray, R. (2009). Medicines management in mental health care. 1st ed. Chichester, U.K. Wiley-Blackwell. Hughes, J. and Baldwin, C. (2006). Ethical issues in dementia care. 1st ed. London Jessica Kingsley Publishers. Husted, J. and Husted, G. (2008). Ethical decision making in nursing and health care. 1st ed. New York Springer Pub. Co.Koch, S., Gloth, F. and Nay, R. (2010). Medication management in one-time(a) adults. 1st ed. Totowa, N.J. Humana. Latha, K. (2010). The noncompliant patient in psychiatry The case for and against covert/surreptitious medi cation. Mens sana monographs, 8(1), p.96. Lawson, L. and Peate, I. (2009). Essential nursing care. 1st ed. Chichester, West Sussex, UK Wiley-Blackwell. Leino-Kilpi, H. (2000). Patientsautonomy, privacy, and informed consent. 1st ed. Amsterdam IOS Press. Macdonald, A., Roberts, A. and Carpenter, I. (2004). De facto imprisonment and covert medication use in general nursing homes for older people in south-central East England. Ageing clinical and experimental question,16(4), pp.326-330. Masters, K. (2005). Role development in professional nursing practice. 1st ed. Sudbury, Mass. Jones and Bartlett. Mental Health Foundation, MCA Code of shape needs revising to enable more effective best interests decisions to be made. (2012). MHF News Archieve, online p.1. Available at http//www.mentalhealth.org.uk/our-news/news-archive/2012/12-01-31/ Accessed 12 May. 2014. Nixon, V. (2013). Professional practice in paramedic, emergency and urgent care. 1st ed. Chichester, West Sussex Wiley-Blackwell . NMC, (2008). Standards for medicines management. online Available at http//www.nmc-uk.org/Documents/NMC-Publications/NMC-Standards-for-medicines-management.pdf Accessed 16 Apr. 2014. Palmer, B., Nayak, G., Dunn, L., Appelbaum, P. and Jeste, D. (2002). Treatment-related decision-making capacity in middle-aged and older patients with psychosis a preliminary study using the MacCAT-T and HCAT.The American journal of geriatric psychiatry, 10(2), pp.207-211. Pritchard, J. (2009). Good practice in the law and safeguarding adults. 1st ed. London Jessica Kingsley Publishers. Rothschild, A. (2009). Clinical manual for diagnosis and treatment of psychotic depression. 1st ed. Washington, DC American Psychiatric Pub. Roy, A., Jain, S., Roy, A., Ward, F., Richings, C., Martin, M. and Roy, M. (2011). Improving save of capacity to consent and explanation of medication side effects in a psychiatric service for people with learning disability scrutinise findings. Journal of Intellectual Disabilit ies, 15(2), pp.85-92.Sellman, D. (2011). What makes a good nurse. 1st ed. London Jessica Kingsley Publishers. Stoppe, G. (2008). competence assessment in dementia. 1st ed. Wien Springer. Sturman, E. (2005). The capacity to consent to treatment and research a review of standardized assessment tools. Clinical psychology review, 25(7), pp.954-974. Treloar, A., Beats, B. and Philpot, M. (2000). A pill in the sandwich covert medication in food and drink.Journal of the Royal Society of Medicine, 93(8), pp.408-411. Treloar, A., Beats, B. and Philpot, M. (2000). A pill in the sandwich covert medication in food and drink.Journal of the Royal Society ofMedicine, 93(8), pp.408-411. Wheeler, K. (2008). Psychotherapy for the advanced practice psychiatric nurse. 1st ed. St. Louis, Mo. Mosby Elsevier. Wong, J., Poon, Y. and Hui, E. (2005). I can put the medicine in his soup, Doctor. Journal of medical ethics,31(5), pp.262-265.