LEG ABILITY

INTRODUCTION:

As the roles and duties of nurses have expanded in the current

health care system, so too has their legal accountability. In the past,
many nurses worked under the supervision of a physician, few carried
liability insurance, and even if a nurse's actions were the direct cause
of harm to a client, primary liability for the nursing action fell on the
employing agency or physician. Currently, nurses independently
assess and diagnose clients and plan, implement, and evaluate nursing
care. Full legal responsibility and accountability for these nursing
actions rest with the nurse.

Nurses who wish to avoid legal conflicts must develop trusting

nurse-client relationships, and identify potential liabilities in their
practice and develop prevention strategies. ^

Legal Concepts:

Definition of I AW:

A law is a standard or rule of conduct established and enforced

by the government of a society/

Laws are intended chiefly to protect the rights of the public.

Public law is a law in which regulates the relationships between
individuals and the government and also, describes the powers of the
government in authority.

Civil law; regulates the relationships among people. Civil law

includes laws relating to contracts, ownership of property, and the
practice of nursing, medicine, pharmacy, and dentistry.

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Sources of Laws:

Three sources of law are civil law, administrative law, and

criminal law.

t- Civil law generally governs actions by one individual against

another.

Criminal law involves actions by the government against an

individual for violations of criminal actions.

Administrative law involves actions by administrative

agencies against individuals or organizations.

Note: malpractice cases are generally the kind of civil law that
involve nurses, for example the client or family members sues the
nurse or the nurse's employer for malpractice because of a claim of
client injury caused by nursing care.

Professional and legal Regulation of nursing practice:

Standards developed and implemented by the nursing profession
itself are not mandatory but may be used as guidelines by Professional
nursing organizations continually reassess the functions, standards and
qualifications of their members. The organizations are guided by their
own assessment of society's need for nursing and by the public's
expectations of nursing. Examples of voluntary standards include the
American nurses Association (ANA) and Canadian nurses Association
(CAN) standards of practice/(will be discussed latter in this lecture)
including professional standards for the accreditation of education
programs and service organization and standards for the certification
of individual nurses in all areas of practice.

Legal standards are developed to determine minimum standards

for the education of nurses, to set requirements for licensure for
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registration and to decide when a nurse's license may be suspended or

revoked.

Credentialing:

Credentialing refers to ways in which professional competence

is ensured and maintained.

Three processes are used for Credentialing in nursing;

The first is accreditation, which is the process by which an

educational program is evaluated and then recognized as having met
certain predetermined standards of education.

The second is licensure, which is the process which determines

that a candidate meets certain minimum requirements to practice in
the profession of his or her choice and grants a license to do so.

The third is certification, which is the process by which a

person who has met certain criteria established by a nongovernmental
association is granted recognition.

• Accreditation:

Constitutions provide governments with the responsibility of

securing the public welfare and have used this principle to provide
certain controls on occupational and professional groups. One function
of these laws is to see that schools preparing practitioners maintain
certain minimum standards of education. Nursing is one group
operating under these laws that aim to promote the general welfare by
determining minimum standards of education through accreditation of
schools of nursing. In the United Stales, state-approved, or accredited,
educational programs in nursing include practical or vocational,
associate degree, diploma, baccalaureate, and graduate programs in
nursing.

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£^~ • Licensure and Registration:

Licensure is a specialized form of credentialing that has a legal

basis in laws.

A license is a legal document that permits a person to offer to

the public His [or her] skills and knowledge in a particular way, where
such practice would otherwise be unlawful without this license.
Licensure and registration are mandatory in Canada, Both must be
rene ration Revocation

wed Nurse Examiners in the United States (or the registering body in
perio Canada) may revoke or suspend a nurse's license or registration for
dicall drug or alcohol abuse (currently the most frequent reason). Other
y. reasons for revocation or suspension of a license or registration
include fraud, deceptive practices, criminal acts, negligence, and
L
iphysical or mental impairments, even those resulting from aging
c
e • Certification:
n
s Many U.S, professional organizations offer nursing
ucertification, including two primary organizations, (1) the American
r
eAssociation of Critical-Care Nurses, which represents the specialty
with the largest number of certified nurses, and (2) ANA, which began
o
rcertifying nurses in 1974.

RCrimes and Torts:

e
g A crime is a wrong against a person or his or her property.
i
s A tort is also a wrong committed by a person against another
t person or his or her property.

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Types of Torts:

• Intentional Torts:
It includes:

> Assault and Battery:

Assault is a threat, or an attempt to make bodily contact with

another person without that person's consent.

Battery is an assault that is carried out and includes every

willful, angry, and violent touching of another person's body or clothes
or anything attached to or held by that other person- Forcibly
removing a client's clothing, administering an injection after the client
has refused it, and shoving a client into a chair are all examples of
battery.

Informed Consent Every person is granted freedom from bodily

contact by another person unless consent has been granted. In
hospitals and other health care settings, a signed informed consent
form is needed on admission (for routine treatment); for each
specialized diagnostic procedure or medical or surgical treatment. The
consent must be written, be signed by the client or person legally
responsible for the client, and be for the procedure performed/A signed
consent is not needed in an emergency if there is an immediate threat
to life or health, experts agree that it is an emergency, and the client is
unable to consent and the legally authorized person cannot be reached.
Although some value informed consent as a protection against
lawsuits, the central values underlying informed consent include the
promotion of a client's well-being and respect for the client's self-
determination.
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Elements of informed consent: include {disclosure,

comprehension, competence, and voluntariness}.

Obtaining an informed consent is the responsibility of the

person who will execute the diagnostic or treatment procedure or
conduct the research study. The nurse's role is to confirm that a signed
consent is in the client's chart and to respond to any questions the
client has about the consent In some instances, the nurse may be
responsible for having the client sign the consent form after the
physician has explained to the client the procedure, its risks and
benefits, and alternative treatments. The documentation of the consent
process through the use of a printed consent form should not be
confused with the actual explanation given to the client and the
informed consent itself. When documenting consent, the nurse should
assess if the client understands what he or she is signing and report to
the physician any problems. Nurses often find themselves in a position
where they question the client's understanding of the proposed
procedure and its risks, or the client's ability to voluntarily consent to
the procedure. Impediments include effects of anxiety, pain,
medication, depression.

Checklist to Ensure informed Cones:

• Disclosure:

1. Patient has been informed of current medical status and course

of treatment.

2. Patient has been informed of the risks and benefits of various

treatment alternatives.

3. Patient has been told that no outcomes can be guaranteed.

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4. Patient has been given a professional opinion as to the best

alternative.

• Comprehension:

1. The nurse has been innovative in transmitting information to aid

understanding.

2. Interior impediments to comprehension (eg, anxiety, pain, and

medication) have been assessed.

3. Exterior impediments to comprehension (eg, transcultural

barriers, terminology, and speed of presentation) have been
assessed.

• Competence:

1. The nurse has assessed competence in terms of the abilities of

the client, considering age, education, and emotional stability.

2. The nurse has assessed the requirements of the task.

3. The nurse has assessed the possible effects of the client's

decision.

4. The client possesses a set of values and goals that make

possible reasonably consistent choices.

5. The client is able to communicate and understand the

information presented.

6. The client has the ability to reason and deliberate.

L^- • Voluntariness:

1. The nurse had determined that the client has not been forced to
consent.

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2. The nurse has been careful to avoid coercive influences by

herself/himself or others.

3. The nurse has been careful to avoid subtle manipulation of the

client by herself/himself or others. ^

Consequences of not obtaining a valid consent include Charges

of battery against the nurse, doctor, and hospital (the hospital has a
duty to protect clients and is responsible for its employees' actions). A
client's refusal to sign a consent should be documented and the client
should be informed of the possible consequences of the refusal. The
client should sign a release form indicating his or her refusal to
consent and releasing the nurse, physician, and hospital from
responsibility for outcomes of this act.

> Defamation:

Defamation of character is an intentional tort in which one party

makes derogatory remarks about another, diminishing the other party's
reputation.

Slander is an untruthful, oral statement about a person that

subjects that person to ridicule or contempt.

Libel is written defamation. Defamation of character is grounds

for an award of civil damages. Damages are awarded on the basis of
the degree of harm done to the plaintiff. Nurses who make false
statements about their clients or co-workers run the risk of being sued
for slander or libel, a person charged with slander or libel may not be
liable if it can be proved that his statement was made not to injure
another (eg, proof of consent, truth, or fair comment).

> Invasion of Privacy

This law protects citizens by giving them the right of privacy

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practice may be prosecuted under nurse practice acts. Also,

misrepresenting the outcome of a procedure or treatment may
constitute fraud.

■ Unintentional Torts:
> Negligence and Malpractice:

Negligence is defined as performing an act that a reasonably

prudent person under similar circumstances would not do, or
conversely, failing to perform an act that a reasonably prudent person
under similar circumstances would do. Malpractice is the term
generally used to describe negligence of professional personnel.

Elements of Liability:

Liability means legal responsibility to pay damage. It consists of four

elements that must be established to prove that malpractice or
negligence has occurred are {duty, breach of duty, causation, and
damages.}

Duty refers to an obligation to use due care and is defined by the

standard of care appropriate for the nurse-client relationship.

Breach of duty is the failure to meet the standard of care.

Causation, the most difficult element of liability to prove, refers to the

failure to meet the standard of care (breach) - this failure actually
causes the injury.

Damages are the actual harm or injury resulting to the client.

Examples of these four elements are presented in the following Table.
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Examples of Elements of Liability

Element Example
Duty Hospital staff nurses are responsible for:
• Accurate assessment, of clients assigned to their care
• Alerting responsible health care professionals to changes in a
client's condition.
• Competent execution of safely measures for clients. Breach
of • Failure to note and report that an elderly client assessed as duty
alert on admission is exhibiting periods of confusion.
• Failure to execute and document use of appropriate safety
measures (eg, upper and lower bedside rails, use of
restraints if necessary, assisted ambulation). Causation •
Failure to use appropriate safety measures; this failure
causes the client to fall while attempting to get out of
bed, resulting in a fractured left hip. Damages Fractured left hip,
pain and suffering, lengthened hospital stay, and need for rehabilitation.

Standards of Care:

To determine negligence, each nurse is responsible for following the

standards of care for his or her particular area of practice/For example, the
labor and delivery nurse must understand how standards for nursing
practice differ from those for medical obstetric practice (nurse practice act);
be familiar with specific standards for obstetric nursing (eg. Standards of
the Nurses' Association of the American College of Obstetricians and
Gynecologists); and execute the nursing responsibilities detailed in the
hospital's policies and procedures and in the job description, if hospital
policy dictates an assessment of each woman in the early stages or labor
every 30 minutes, the nurse must

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adhere to this standard unless the nurse documents a reason for doing otherwise.

The following table lists areas of potential liability associated with each of

the ANA standards of clinical nursing practice. Although any nurse can make an

error, nursing errors can result in serious outcomes for the client, as is in the

examples.

Standards of Areas of Potential Liability for Nurses

Care
Areas of Potential Liability Examples
Standard I; Assessment
The nurse - Incomplete data base obtained - Child too weak to be weighed on
collects client (occurs frequently when client is admission or chart contains no
health data: too ill at admission to respond to record of client's weight; or dosage
questions). of postoperative antibiotic therapy
(which should be calculated on
- Significant omissions or errors
child's weight) too small to prevent
in recording data base
infection; abscess develops
- Failure to note in the client's
- No record of client's allergies on
plan of care (and to execute) the
chart, medication administered that
need for more frequent nursing
led to anaphylactic shock
assessments
- Failure to recognize and to - Previously alert client was
report significant changes in the exhibiting periods of confusion.
client's condition - Mother's labor is failing to
progress, nurses unaware of signs of
fetal distress; obstetrician not
informed; irreversible cerebral
damage to fetus
- Healthy client making slower than
usual post-anesthesia recovery; signs
of developing cerebrovascular
accident (slurred speech, difficulty
moving extremities, falling to one
side) present and unnoted
Standard II: Diagnosis
The nurse - Failure to identify priority - Nowhere in the client's plan of
analyzes the nursing diagnosis critical to the care was it noted that the client had a
assessment data client's care history of choking on food
in determining ("impaired swallowing") and that
- Nursing diagnosis incorrectly
diagnoses. close supervision was indicated
developed and "labels" the client
during meals; client aspirated and
 LEGABILITY

negatively. died
- Homosexual male client without
AIDS admitted for gallbladder
surgery questions the few
interactions he has with staff,
nursing diagnosis on cardex reads
"High Risk for Violence. Directed at
Others (AIDS), related to homo-
sexuality."

Standard III: Outcome

The nurse identifies Identification
Obese client with a history of impaired
expected outcomes No indication in nursing
individualized to the circulation continually refuses to
client. care plan that nurses ambulate after major abdominal
were aware of and surgery, client dies following a
sensitive to the client's massive pulmonary embolism; plan of
health care priorities care showed no concern or attempt to
compensate for client's lack of
mobility
Standard IV: Planning
The nurse develops
a plan of care that
prescribes
interventions to
attain expected
outcomes
Standard V: implementation
The nurse Client's record Male client discharged from short-
implements the contains no procedure unit on crutches; falls first
interventions documentation of day home, refracturing leg; alleges his
identified in the attempts to teach not receiving instructions for crutch-
plan of care. walking caused fall; client record
appropriate self-care
contains no documentation of client,
measures to client and
education
family • Nursing
Skin breakdown on trail, elderly client
interventions deviate from
worsens with eventual muscle
usual standard of care
deterioration; sepsis; nurses seem
(understanding,
confused about treatment regimen for
indifference on part of
pressure ulcers; treatment is
nurse, inexperience of
inconsistent
nurse, faulty or inefficient
equipments or resources)
Standard VI: Evaluation
The nurse • No evidence in plan of
Male client newly started on insulin
evaluates the care and nursing notes
therapy discharged without
client's progress
 LEGABILITY

toward attainment that nurses evaluated understanding the relationship

of outcomes. whether the client among food, exercise, kind insulin
achieved target goals and after giving himself the insulin
• Client discharged only once-no referral made to
before goals are met visiting nurse; client readmitted
and without follow-up after 2 weeks with dangerously low
instructions blood sugar following overdose
with insulin

^^Malpractice Litigation:
• When a client believes that he or she has been injured through
the negligence of a nurse or other health care professional

National Nurses Claims Data Base:

The National Nurses Claims Data Base (NNCDB) was set up by
ANA in 1967 to provide information to the profession about
professional liability claims and incidents Involving nurses,
information from the NNCDB:

•
Is available to nurses who need help in defending
themselves against liability suits

Assists the nursing profession in negotiating with insurance

companies, assuring nurses adequate and available coverage
•
Provides data for development of programs that teach nurses
how to avoid malpractice

Legal Safeguards for the Nurse:

/ ■ Contracts:

A contract may be defined as the exchange of promises between

two persons. For a contract to be legally enforceable, it must contain
real consent of the parties, a valid consideration, a lawful purpose,
competent parties, and the form required by law.
 LEGABILITY

Practicing nurses enter into legally valid and binding contracts

with both their employers and their clients. It is thus important that
they understand and are able to fulfill the terms of their agreement
before giving consent.

-"*" Competent Practice:

Competent practice remains the nurse's most important and best

legal safeguard. Each nurse is responsible for making sure that
educational background and clinical experience are adequate to fulfill
the nursing responsibilities described in the job description. Legal
safeguards include the following:

• Respecting legal boundaries of practice.

• Following institutional procedures and policies.

• "Owning" personal strengths and weaknesses; seeking means of

growth, education, supervised experience, and discussions with
colleagues.

• Evaluating proposed assignments; refusing to accept

responsibilities for which the nurse is unprepared

• Keeping current and updated.

• Respecting client rights and developing rapport with clients.

• Keeping careful documentation.

• Working within the institution to develop and support

management policies.

Competent practice includes developing sensitivity to common

sources of client injury, such as falls, use of restraints, and
malfunctioning equipment, and then taking specific measures to
prevent client injury.

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 LEGABIHTY

~~f Client Education:

The client's right to know and client education is the legal duty
of the nurse. Standards for client education are derived from national
professional standards, as well as the local standards described in
hospital policies, procedure manuals, and job descriptions. Special
forms for documenting the nurse's assessment of the client's learning
needs and for subsequent teaching are available at some agencies.
Failure to conduct or document the assessment of learning needs and
teaching may later be construed as negligence.

General guidelines for the nurse wishing to execute client

education responsibilities competently include the, following:

• Determine in your practice setting what specific aspects of

client education are the responsibility of nursing. Consult your
job description and be familiar with agency policies regarding
client education and its documentation.

• Remember that an important aim of nursing is to assist clients in

managing their own care.

• Discuss the nursing care plan with the client and family and
identify their learning needs and learning readiness.

• Document the teaching plan as part of the nursing care plan.

• Document all nursing efforts to educate the client and family

about health care management and also document the client's
response.

• If a client refuses health education or refers the nurse to a

family member (eg, "Talk to my wife about my pills, she'll be
giving them to me at home"), document this on the client's
record.
 LEGABIHTY

• If client education greatly increases the, client's anxiety and the

client requests not to be given any more information, the nurse
should document the client's initial response to teaching, the
client's request that it be stopped, and, if the nurse complied, the
reason for doing so.

• Because lack of time is a frequently offered reason for failing to

document client education, nurses should: assess what type of
client documentation is routinely offered on their unit and if
possible, they should develop forms or checklists that will
facilitate rapid documentation. For example, preoperative
checklists have greatly facilitated the recording of preoperative
teaching and are often introduced as evidence in court that;
preoperative teaching was done. Other successful models
include forms for documenting diabetic teaching, teaching after
a myocardial infarction, and teaching postpartal and baby care
to mothers.

„.■Executing Physician's Orders:

Nurses are legally responsible for carrying out the orders of the
physician in charge of a client unless an order is one their would lead
a reasonable person to anticipate injury if were carried out. Guidelines
when executing orders follow.

1. Be familiar with the parties, designated in your nurse practice

act, who can legally write orders for the nurse to execute.

2. Attempts to have all physician orders in writing, verbal and

telephone orders should be signed within 24 hours. To eliminate
errors caused by telephone orders:

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 Executing Physician's-Orders:-

Nurses are legally responsible for carrying out the orders of the
physician in charge of a client unless an order is one that would lead a
reasonable person to anticipate injury if it were carried out. Guidelines
when executing orders follow.

1. Be familiar with the parties, designated in your nurse practice act,

who can legally write orders for nurse practice act, who can legally
write orders for the nurse to execute (in many states, a physician's
assistant cannot legally write orders for the nurse).

2. Attempt to have all physician's orders in writing. Verbal and

telephone orders should be counters-signed within 24 hours. To
eliminate errors caused by telephone orders:

• Limit telephone orders to true emergency situations in which

there is no alternative.

• Designate the nurses who may take telephone orders (those

who have more education and experience, such as a primary
nurse).

• Repeat a telephone order back to the physician. Document

the order, its time and date, the situation m
scessitating the
ming the order order, the physician prescribing and reconfn
as it is read back, and your name; indicate i
f the order is a
VO (verbal order) or TO (telephone order). •

;ible, have two When telephone extensions make this poss

rder, with both nurses listen to a questionable telephone o

nurses countersigning the order.
 3, Question any physician order that is;
• Ambiguous.

• Contraindicated by normal practice (e.g, dose of medication

that is abnormally high).

• Contraindicated by the client's present condition (e.g, as a

client's present condition improves, he or she may no longer
need aggressive forms of treatment).

It is good practice for the nurse to double check any order a client
questions.

Nursing Malpractice Prevention

Most frequent Prevention Tips for Nurses
allegations against Prevention Tips for
nurses Hospitals
Failure to Ensure 1. Monitor patient in a
Patient Safety timely manner. 1. Maintain an adequate level
Provide assistance for of staff.
those patients who require 2. Clearly define criteria for
it when they need to use use of bedrails and
the lavatory or shower. restraints.
Keep bedrails raised for 3. Provide education to
patients who are medicated nurses on patient safety.
or confused.
Use restraints
appropriately.
Improper _______________________
1. Question treatments you Design a clear procedure
Treatment or believe are improper. for nurses to follow if
performance of 2. Use proper techniques they feel the medical
treatment when performing treatment is
procedures. inappropriate. Provide
3. Follow hospital resources for nurses to
procedures when consult regarding
performing treatments. treatments. Provide
4. Seek consultation for appropriate procedures
treatments beyond your for nursing treatments.
abilities.
5. Update your clinical
skills through continuing
education classes.
Documentation:-

Careful documentation is a critical legal safeguard for the nurse.

Documentation must be accurate, complete, and entered in timely fashion
The presumption of the law is that if something was not documented, it
was not done. This includes even routine acts such as taking vital signs,
repositioning clients, and using side rails.

Nurses should be sure that the nursing care plan is a part of the
client's permanent record. Institutions should have flow sheets or some
type of documentation form that enables nurses to check off routine
aspects of care rapidly and completely.

The nurse should write a comprehensive nursing note for each

client problem the nurse addressed during his or her time of duty. The
note should include the current nature of the problem, how the nurse
intervened, the client's response, and, when appropriate, future priories
for care. Once a problem is noted, nursing documentation should
evidence continuity of care until the problem is solved.

A common problem reported by nurses is not knowing Document

an incident,ybr example, when the nurse believes the client needs medical
attention and intervention but the responsible physicians are not
responding to calls for assistance. In this case, the best legal safeguard for
the nurse is to document the facts of the incident, being careful not to
make incriminatory statements such as, "Anyone could see we were
losing this client rapidly" or "Once again, Dr. Jones was unavailable
when her client needed her." The note should document the time the
physician was called and the time of response or lack of response, and the
subsequent nursing response (e.g, nursing supervisor notified). Such a
note documents that the nurse is carefully assessing the client,
recognizing significant cues, and reporting them appropriately. The
nursing supervisor should write the next note after reviewing the case and
choosing a course of action. Client noncompliance with the therapeutic
regimen should also be documented along with the nurse's attempts to
increase compliance.

Adequate Staffing:-

Understaffing is a problem that results in reduced quality of

nursing care and may jeopardize client safety. Temporary management
solutions to understaffing, such as floating nurses from one unit to
another or asking nurses to work overtime or double (back-to-back)
shifts, are ineffective because they further jeopardize client safety. A
nurse on an understaffed hospital unit will be held to a professional
standard of judgment with respect to accepting responsibility for work
and for delegating nursing responsibilities to others. If client injury
results, the hospital employer and nurse employee will most likely be
named as codefendants.

Professional Liability Insurance:- \

Although a nurse's best legal safeguard is always competent

practice, the increasing number of malpractice claims naming nurses as
defendants make it wise for nurses to carry their own liability insurance.
Nurses may obtain this insurance through ANA, through provincial
nursing associations in Canada, and through other sources.

Reasons ANA lists for purchasing a personal professional liability

insurance policy are as follows:

Protection of the nurse's best interests: If the nurse is named

defendant in a malpractice action along with the hospital, a conflict of
interest could arise between the nurse and the hospital. Nurses have no
of an emergency. However, in many situations, there would appear to be
an ethical responsibility to assist. When health practitioners assist a
person in an emergency situation and consent for the care is impossible,
they are expected to use good judgment in determining whether an
emergency exists and to give care that a reasonably prudent person with a
similar background and in a similar circumstance would give.

Student Liability:-

Student nurses are responsible for their own acts of negligence if

these result in client injury. Moreover, they are held to the same standard
of care that would be used to evaluate the actions of a registered nurse
(RN). Legal responsibilities of student nurses include careful preparation
for each new clinical experience and a duty to notify their clinical in-
structor if they feel in any way unprepared to execute a nursing
procedure. For no reason should a student attempt a clinical procedure if
unsure of the correct steps involved in its application. The student nurse is
responsible for being familiar with agency policies and procedures.

A hospital may also be held liable for the negligence of a student

nurse enrolled in a hospital-controlled program because the student is
considered an employee of the hospital.

Nursing instructors may share a student's responsibility for

damages in the event of client injury if the student's assignment called for
clinical skills beyond the student's competency or the instructor failed to
provide reasonable and prudent clinical supervision.

Students should notify their instructor or a staff member of any

significant changes in the client's condition even if they are unsure of the
meaning of these changes.
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Laws affecting nursing practice:-

Occupational safety and health :-

The Occupational Safety and Health Act of 1970, commonly

known as OSHA, set legal standards in the United States in effort to
ensure safe and healthful working conditions men and women. The act is
intended to reduce work related injuries and illnesses. It has affected
health care agencies and has increased certain responsibilities for many
nurses. Occupational health and safety acts are provincial statutes in
Canada. The following examples illustrate situations that could violate
standards, if care is not taken, because of the potential threat to worker
safety:

• Use of electrical equipment

• Use of isolation techniques for clients with infectious diseases and

the management of contaminated equipment and supplies.

• Use of radiation, such as infrared or ultraviolet radiation; sound or

radio waves; and laser beams.

• Use of chemicals, such as those that are toxic or flammable.

The law, which continues to be updated, is specific concerning its

applications, and fines can be severe when infractions are noted. Nurses
can assist in implementing this law by promoting health and safety
precautions wherever hey work. Nurses employed in industrial settings
have a particularly important role in conforming to the law's
requirements.

Reporting Obligations:-

• The unique nature of nurse-client interactions frequently result in

the nurse's having knowledge (e.g, of child abuse, rape, or a
 communicable disease) that a state (or province) requires to be
reported. Legislation varies in this regard and the nurse is
responsible for knowing what needs to be reported in the local area
and to what authority.

Controlled Substances:-

Both he United States and Canada have special laws governing the
distribution and use of controlled substances (drugs with abuse potential),
such as narcotics, depressants stimulants, and hallucinogens. Drug abuse
laws are specific and violations are considered criminal acts. Nursing
responsibilities for controlled substances include their storage in special
locked compartments and documentation responsibilities.

Wills:-

State and provincial laws regulate requirements for a will. The

person who makes a will is called the testator. A will describes intentions
a testator wishes carried out upon his or her death. A person who receives
money or property from a will is called a beneficiary. Nurses are
occasionally asked to witness a testator's signing of his or her will.

The nurse should be familiar with the certain guidelines concerning

a will and witnessing the testator's signature:

• The witness should feel sure that the testator is of sound mind, that
is, the testator knows what he or she is doing and is free of the
influence of drugs that could likely distort his or her thinking.

• The witness should feel sure that the testator is acting voluntarily
and is not being coerced in any way concerning the terms of his or
her will.

• Witnesses should watch the testator sign his or her will and they
should sign in the presence of each other. State law indicates how

i
 many witnesses must acknowledge the testator's signature on a
will. Two or three witnesses are most commonly required.

• Witnesses to the signature on a will do not need to read it, but they
should be sure that the document being signed is a will and not
some other type of document.

• In most states, a person who is a beneficiary in a will is

disqualified to act as a witness to the testator's signature.

Legal issues related to dying and death:-

Death occurs when there is an absence of brain function despite the

function of other body organs. It is the nurse's duty to recognize legal
death. In some states, the nurse may pronounce death at the bedside. In
most states, however, the physician has the legal responsibility of
pronouncing the person dead.

Euthanasia. Physician- or nurse-caused death (active euthanasia) is

controversial. Many healthcare providers believe that actively causing a
client's death violates professional ethics. Active euthanasia, deliberately
hastening a person's death, is considered murder in all states and almost
all other countries. Despite these concerns, there is growing support for
physician-assisted suicide and related measures to reduce suffering at the
end of life. Passive euthanasia measures are those that withhold or
withdraw treatment to allow death to occur naturally over time.

Advance Directives. In 1990, the federal legislature passed the

Patient Self-Determination Act, which requires that each hospital, nursing
home, visiting nurse agency, hospice, or health maintenance organization
admitting clients to their services inform clients about their rights
regarding end-of-life decisions. The agency is required to inform clients
of state law, local policy, and agency policies, if any, regarding end-of-
life decisions.

Nurses must become familiar with statutes in their states 'regarding

the execution of living wills or directives to physicians (ANA, 1991).
These statutes list specific procedures to follow while granting civil and
criminal immunity to those following the guidelines. The living will
should be prepared before people become incapacitated. Be aware of the
requirements for witnessing a living will. Usually, the state's Natural
Death Act prohibits an employee of the healthcare provider caring for the
client to be a witness. Also, be familiar with the ANA standards for these
areas. These practice requirements are absolute. Thus, each nurse is
accountable for providing care congruent with these standards.

Resuscitation. Nurses must always know the code status of their

clients regarding resuscitation, verify the code status on the client's order
sheet, and follow agency policy. When nurses are unaware and encounter
a client in cardiac arrest, they should resuscitate the client pending
confirmation that there is a no code order. If there is a no code order,
resuscitation may be stopped once initiated. And if there is not a code
order and the client's wishes for end-of-life care are not followed because
of this lack of order, then the nurse is responsible for ensuring that an
order is obtained.

Issues have occurred around do not resuscitate orders for home

care clients. A community-based no code order can be obtained in
many states and have various names including EMS-No CPR orders,
portable no code orders, or community-based DNR orders. These
documents generally require the signatures of the physician and the
patient or their legal surrogate. Unlike advance directives, these orders
must be obtained through a healthcare provider. A community-based no
code order allows emergency medical personnel, if called, to provide care
and support to the patient and family without attempting resuscitation.

Death Certificate. Laws are specific in each of the states regarding

who may sign death certificates. Determine that information for your
state.

Care of the Body. After the physician pronounces death, the nurse
is responsible for preparing the body for the morgue or mortuary. Be
familiar with the facility's instructions for care and the wishes of the
deceased and family. Always treat the body with dignity.

Organ Donation. Always check to see if the deceased wished to

donate organs to a transplant program. If the death was accidental and no
donor card is available, the nurse may discuss with the family the
possibility of donating the deceased person's organs. Figure 6-2 shows a
sample organ donor card. A section of the living will also may provide
this information. If functional organs are to be donated, the hospital
should have specific care instructions for the body.

State law governs the procurement process while safeguarding

donor intentions and designates procedures for use and distribution of
organs. Some states use the driver's license to identify those persons who
agree to organ donation in the event of their untimely death.

Signed Dy the donor and the following two witnesses in

the presence of each other

J^LusMAAssAi^____s//o/i^-
' go DateofBirtn of Donor
—/2/J/J99 _____/ffattutytuj m
Dotesicjnea tf c7rv,ina state*

Witness (/ Witness
Tnis is .1 lecjjl document miner the uniform ArMtomic.il Gift Act or
similar uws in .111 so states ,., ,
For further information call,

A PROGRAM Philadelphia. PA .9103

1
 , UNIFORM DONOR CARD
______Oophie Cy7e,\Aj*ki ______________
Print or rype name of don6r
in trie nope that i may help others. I hereby make this anatomical
gift, if medically acceptaoie. to take effect upon my death me
words and marks below indicate my desires i give a) .
.^f__any needed organs or parts
D)________only the following organs or parts

Specify the organisi or cart(s)

for the purpose of transplantation, therapy medical researcn or
education .,
ci Afo mv oodv for anatomical study if needed

Limitations or special wishes if any

F I G U R E Sample
6 - 2 of an organ donor card.

Autopsy. An autopsy is a postmortem examination of the body's

organs and tissues to determine the cause of or pathologic conditions
contributing to death. Except in certain circumstances, consent for an
autopsy is required. The patient May consent to an autopsy before death
or a close family member may consent after death. State laws require an
autopsy regardless of consent if the death meets certain state criteria such
as suspected murder or suicide.