Unit 11-Managing Mood Disorders and Adjunctive Tx Options. 900w initial response. 4 references.
Peer response- 2 replies 400w and 4 references.
Use the answers at the end of the page to guide the response. Keep in mind that mental health patients have the right to refuse care and legal steps must be taken if patients are labeled as legally or medically incompetent to make medical decisions.
Initial Response
Instructions:
Rebecca Cole is a 39 years old, single, African American female. She has never been married or had children. She has been institutionalized at a state mental health hospital for more than 7 years since she was diagnosed with unspecified schizophrenia. She was diagnosed at age 21 and has undergone more than 8 psychiatric hospital admissions over her lifespan. Ms. Cole has been transferred to a local acute care hospital due to uncontrolled diabetes and hypertension. She has been refusing blood glucose monitoring daily, so the charge nurse on the women’s floor has not been able to check her blood sugar for 2 days. She has also been refusing her antihypertensive and antipsychotic medication for 3 days. This has now led to more uncontrolled hypertension and an increase in psychosis and behavioral issues today. The nursing staff has become very frustrated and voiced their issues with hospital administration because they don’t feel the administration is listening to their concerns about the challenges faced on the psychiatric units, and particularly the challenges they are facing in caring for Rebecca.
You are the PMHNP who is assigned and is managing her psychiatric care while in the acute care hospital.
1. At this point, can Rebecca make her own healthcare decisions? Why or why not? What legal risk for the PMHNP could be associated with caring for Rebecca in the acute care hospital setting?
2. How can integrative care be an approach that is utilized with this patient?
3. What other specialties should be involved and when she they be involved?
4. Discuss the potential ethical issues facing the staff nurses caring for Rebecca in both the acute care hospital setting currently and the state psychiatric hospital setting?
5. Why is continued integrative care a better option for patient outcomes and a better option from an ethical and legal perspective?
Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with citations and references in APA format.
Peer Response
Instructions:
Please read and respond to at least two of your peers’ initial postings. You may want to consider the following questions in your responses to your peers:
· Compare and contrast your initial posting with those of your peers.
· How are they similar or how are they different?
· What information can you add that would help support the responses of your peers?
· Ask your peers a question for clarification about their post.
· What most interests you about their responses?
Please be sure to validate your opinions and ideas with citations and references in APA format.
Mental health patients have rights just like every other individual. Ethical dilemmas are
common in mental health settings. Often, they arise because the presence of mental disorders
causes many patients to lack capacity to make decisions for themselves and to depend on
clinicians to attend to their best interests in ethics and law (Silva, 2018). The rights of mental
health patients are liberty and autonomy, protection from seclusion and restraint, communityinclusion (American Association of Nurse Practitioners, 2021). As stated in the case study,
Rebecca has been institutionalized for many years therefore, so legal channel has been set into
play. I would contact her guardian or conservatorship to set play with legal action to do a force
treatment order. As her PMHNP, my role is providing care for her mental health. Her current
condition of self-neglect is directly related to her exacerbation of schizophrenia. If able to force
treatment for antipsychotic medications, then her mental status would stabilize allowing
treatment for the medical conditions. The risk as the provider of mental healthcare could be delay
of care if not acted on in an appropriate amount of time. This particular patient needs involuntary
treatment to help the patient become well.
How can integrative care be an approach that is utilized with this patient?
The role of individual in healthcare plays a critical role in providing adequate care to
each individual. Integration happens when both medical and mental health join forces to treat the
individual in a holistic manner (Mental Health America, 2021). This patient can benefit greatly
from having psych and medical on board treating the individual. Each specialty can make
necessary steps to improve her overall health.
What other specialties should be involved and when she they be involved?
This patient would benefit greatly with having a hospitalist, endocrinologist, and
cardiologist on board to help alleviate her medical concerns. Also, add to the team as case
manager and social worker to help maintain care and address social issues.
Discuss the potential ethical issues facing the staff nurses caring for Rebecca in both the
acute care hospital setting currently and the state psychiatric hospital setting?
Patient-centered care encourages patients and their families to participate actively in the
development of new care models as well as treatment decision-making. Patient-centered care is
defined by the Institute of Medicine as “providing care that is respectful of and responsive to
individual patient preferences, needs, and values, and ensuring that patient values guide all
clinical decisions.” In addition to safer medical systems and greater patient involvement in
healthcare delivery and design, patient-centered care is also one of the overarching goals of
health advocacy. In relation to this, a patient’s bill of rights is made which is composed of a set of
protections for those who are receiving medical treatment. It might be in the form of a legislation
or a non-binding statement. A patient’s bill of rights often promises, among other things,
information, fair treatment, and control over medical decisions. Patients’ autonomy, beneficence,
nonmaleficence, (distributive) fairness, the patient-provider fiduciary (trusting) relationship, and
the inviolability of human life are some of the most widely recognized ethical concepts.
Bioethics in healthcare promotes medical practice awareness and knowledge among healthcare
workers. Medical practitioners are capable of tagging along ethical rules when practicing,
especially when dealing with challenges, by focusing on the ethical components of bioethics.
Bioethics not only serves as a guide for medical practitioners in terms of clinical decisionmaking
and medical technology improvements, but it has also played an important part in recent
legislative changes and legislation. Bioethics strives to research and analyze how health care
choices are made by applying ethical concepts to the realm of medicine. It’s a crucial part of
ensuring that medical practices and procedures benefit the whole society.
Why is continued integrative care a better option for patient outcomes and a better option
from an ethical and legal perspective?
Holistic approach, given this patient refusal, there must be a clear understanding of the
relationship you would want to establish with the patient in order to fully used and incorporate
the integrative health care and a comprehensive medical model system that would work best for
her to use all therapeutic approaches. This indicates a patient’s right to autonomy but clearly this
patient is unable to make decision own her own.
Reference
American Association of Nurse Practitioners. (2021, April 27). Are You Considering a Career as
Psychiatric Mental Health Nurse Practitioner? Retrieved July 19, 2022, from
https://www.aanp.org/news-feed/are-you-considering-a-career-as-psychiatric-mental-healthnurse-
practitioner
Center of Excellence for Integrated Health Solutions: SAMHSA. (2021).
https://www.thenationalcouncil.org/integrated-health-coe/resources/
Gawande, A. (2017). Being Mortal: Medicine and What Matters in the End (Reprint ed.).
Picador.
Mental Health America. (2021). Integrated Care. https://www.mhanational.org/issues/integratedcare
Silva, E. (2018, January 2). Ethical dilemmas in psychiatry: When teams disagree | BJPsych
Advances. Cambridge Core. Retrieved July 19, 2022, from
https://www.cambridge.org/core/journals/bjpsych-advances/article/ethical-dilemmas-inpsychiatry-
when-teams-disagree/1F0EFA9B961AE7A0CA4FBA8A7401F86D
1. At this point, can Rebecca make her own healthcare decisions? Why or why
not? What legal risk for the PMHNP could be associated with caring for Rebecca in the
acute care hospital setting?
Clearly this is a tension between autonomy and beneficence, competent patients have a right to
refuse treatment. A psychiatrist evaluation can be used to identify if patient deemed competent
or incompetent. Once this occur, if deemed incompetent a guardian will be appointed for
medical care approval. If patient is deemed competent to make informed care decision, then
there is nothing we do. This idea is supported not only by the ethical principle of autonomy but
also by U.S. statutes regulations and case law (US Constitution, 1990). Competent adults can
refuse care even if the care would likely save or prolong the patient’s life (Cite).1 Basically, the
patient’s opinion about what would be best for her care differed from the physician’s
recommendations about what was most likely to benefit her.
2. How can integrative care be an approach that is utilized with this patient?
Integrative care can be an approach; however there must be a clear understanding of this
patient’s fear, pain or other issues that may be creating barriers to her understanding of her care
plan. According to Mayo clinic, (2020) Integrative medicine can help people with cancer,
persistent pain, chronic fatigue, fibromyalgia and many other conditions better manage their
symptoms and improve their quality of life by reducing fatigue, pain and anxiety. In this case due
to the uncontrolled hypertension and an increase in psychosis and behavioral issues, integrative
care may note be the best approach as this patient needs to be stabilized. What the PMHNP can
do is to have good documentation and the discussion with witness of the appropriately informed
the patient about the risks of refusing care.
3. What other specialties should be involved and when she they be involved?
It may be a good idea to involved a case worker to help patient understand the risk with further
education of what the consequences, in addition to involving the Risk Management, and I would
go even further and have this patient signed an informed refusal consent on her decision. The
PMHNP must have good, objective documentation with a clear picture of what happened in
addition to subjective documentation, if in chase the patient turned out for the worst with a
potential lawsuit. In addition I would also involve risk management of the situation.
Risk Management Recommendations — Interactions in which Patients Insist on Unconventional
Care
Work with and listen to patients and take their medical problems and emotional needs
into account when establishing a treatment plan.
Discuss differences of opinion with patients to try to reach a mutual understanding.
Recognize that patients’ nonadherence to care recommendations may sometimes be
caused by their lack of comprehension. Use simple language and avoid medical jargon
when communicating about medical issues and treatment options with patients.
Do not cast aside the standard of care in order to cater to unreasonable patient demands.
Consider reframing information about a situation or treatment plan to help a patient better
understand the circumstances. Keep in mind that a patient’s fear, pain or other issues can
create barriers to his or her understanding.
Consider obtaining a consult to get another opinion about a patient’s condition or care.
Document the rationale for all care decisions in the patient’s record. Include details of
efforts to educate the patient about treatment recommendations and to advise the patient
about the risks of declining treatment.
If you and the patient cannot reach concurrence about appropriate treatment, you may
need to terminate the physician-patient relationship. Minimize the possibility of being
charged with patient abandonment by formalizing the decision to dissolve the relationship
in a letter and by extending an offer to continue caring for the patient for a reasonable
time period. If the patient has an active medical problem, stabilize the patient before
terminating your relationship with him or her, and consider taking extra measures to
ensure he or she has established care with another doctor.
4. Discuss the potential ethical issues facing the staff nurses caring for Rebecca in both
the acute care hospital setting currently and the state psychiatric hospital setting?
An ethical issues could be the patient rights for respect and autonomy. However, other ethical
problems are encountered in the areas of privacy, beneficence, non-maleficence, and justice, this can
become very complex not only for the patient but all those that are engage in this patient centered care.
5. Why is continued integrative care a better option for patient outcomes and a better
option from an ethical and legal perspective?
This maybe more from a holistic approach, given this patient refusal, there must be a clear
understanding of the relationship you would want to establish with the patient in order to fully
used and incorporate the integrative health care and a comprehensive medical model system that
would work best for her to use all therapeutic approaches. There must be evidence of education,
alternative to treatments, reason for refusing care and must be discuss with patient with a
witness. It is suggest to use Consider using “hope and worry” statements to aid in discussion of
refusals: “I hope that you don’t have a serious disease, but I worry that your symptoms may
indicate serious disease is already present.”4
a collaborative model in which the patient takes a more active role in healthcare decisionmaking.”
1 The more recently evolved model for healthcare allows patients to have dignity and a
voice;
Educate the patient as fully as possible about the benefits of treatment recommendations
and the risks of no treatment.
As much as possible, discover the patient’s reasons for refusing care and discuss these
with the patient to see if there are ways to negotiate so that the patient can receive care
that is in his or her best interests.
With the patient’s permission, speak with family, clergy or another mediator if you think
this might help the patient reconsider his or her refusal.
Consider a mental health referral if the patient has overwhelming anxieties about
receiving care or shows psychiatric comorbidities and is willing to be evaluated.3
Consider using “hope and worry” statements to aid in discussion of refusals: “I hope that
you don’t have a serious disease, but I worry that your symptoms may indicate serious
disease is already present.”4
Document your efforts to educate the patient, the rationale for your recommended
treatment, and the patient’s refusal of care.
Ask the patient to sign a refusal of care form.
References
1. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical
Decisions in Clinical Medicine. 7th ed. New York, NY: McGraw Hill; 2010:74.