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Mental Health Nursing

Practice:

A Mental Health Nursing


Response to Ethical
Dilemmas

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Essential …
For people using health services
For the health professional
For healthcare organisations
For communities

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Basic rights
Fundamental Legislation

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Fundamental Legislation
NZ Bill of Rights 1990 Human Rights Act
„ Freedom of thought, 1993
belief, expression, „ To protect Human
association, Rights & Prohibits
movement discrimination
„ Right to refuse to
undergo medical
treatment

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For mental health services?
Absolutely essential that all clinicians have
a good understanding of ethical principles
because…..

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Mental Health Act

Takes away many


of a persons basic
Human Rights
Enforcement of
treatment

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Misunderstanding about the scope
of the MHA
Definition of being “Mentally Disordered”
..an abnormal state of mind…characterised by
delusions, or by disorders of mood or perception
or volition or cognition, of such a degree that it –
„ Poses a serious danger to the health
and safety of that person or of others; or
„ Seriously diminishes the capacity of that
person to take care of himself or herself;

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

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

„ Pursuing their lifestyle choices?


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

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Ethical principles
Respect for Autonomy
Nonmaleficence
Beneficence
Justice

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Mr B

49 yr old man, dysphasia, hemiplegia


Forensic psychiatric history and brain injury
Current client of Mental Health Service
Fear of needles and invasive procedures
Difficulty ascertaining his level of
understanding
Presenting with abdominal pain, dehydration
– there is a need for diagnostic testing

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Ethical dilemma

Gaining informed consent for medical


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

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Competence to consent

Specific capacities must be assessed


„ Communication of choice
„ Understanding of information provided
„ Appreciation of options available
„ Rational decision making
Mental illness does not equal
incompetence – this must be assessed.

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Contextual considerations
Mr B may have been competent to make
other decisions
He still has right to refuse treatment
Consider - Are interventions in the best
interests of Mr B or being done to satisfy
medical diagnoses?
Balance of benefit and discomfort is
subjective so continuing communication
with Mr B was vital

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Mr B outcome
Terminal Cancer - Primary and secondary
sites
Medical and nursing staff worked with Mr
B - time consuming but satisfying
Palliative care consistent with Mr B’s
wishes
Mr B died within two weeks of admission

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Mrs C
45 year old woman
Married with adult family
Diabetes and other health problems
No attempt at self care of diabetes
Frequent hospitalisations to prevent death
due to diabetes

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Mrs C
Has had contact with mental health
services for assessment purposes but no
diagnosable mental illness
Doesn’t want to live with diabetes
All general services referring back to
mental health “she must be mentally ill”
Where to from here?

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

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Mrs C outcome
Moralist perspective dominates - life
saving input as required
Mental health team input on request and
occasional admission to MH wards after
hours
Significant use of resources to maintain
life
Principle of Justice?

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Admitting to overcrowded wards

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

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Nursing autonomy
Control over ‘nursing practice’ only
Don’t control the patient
Don’t control other members of the MDT
Don’t ultimately determine the policy and
resource decisions
‘Meat in sandwich’ or ‘buffer’ between
patient and others = Moral distress

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In closing - Minimizing the opportunities
for moral distress
Ask the questions
Be aware of the different perspectives
including the wider contextual and cultural
issues
Contribute in an informed way to ethical
discussions
Contribute to policy/positioning documents
Reflect and discuss with colleagues
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