Briefly identify the topic you selected. Then, summarize the articles you selected, explaining the most salient ethical and legal issues related to the topic as they concern psychiatric-mental health practice for children/adolescents and for adults. Explain how this information could apply to your clinical practice, including specific implications for practice within your state. Attach the PDFs of your articles.

Week 2 Discussion
Ethical and Legal consideration of constraints
Restraints is a clinical treatment method used in hospitals for many reasons, such as protecting manic patients from harming themselves or others and preventing demented patients from pulling out their tubes. There are three types of restraints: physical restraints, chemical restraints, and environmental restraints. It is usually the last resort for healthcare providers after all other interventions such as verbal de-escalation failed.
Ethical Consideration of Restraints for Adult Patients
Restraints usually happen in emergencies, healthcare providers will apply them against the patient’s will, which caused considerable ethical dilemmas in clinical. Considering the patient’s safety and autonomy, providers have to weigh the outcome of its use against the outcomes of not using it. Healthcare providers have to receive professional training about the protocols of restraints, familiar with evidence-based guidelines, and legal problems associated with restraints. When restraints are used, they should only limit the movements that may cause harm to the patients or others. Restraints should never be used for the caregiver’s convenience or threatening. If all other less restrictive treatments are failed, restraints are inevitable, providers will make sure that the patients still have their rights during the restraints. Also, the further need for restraints should be assessed continually by healthcare authorities, so, the restraints can be discontinued as soon as possible (Salehi, & others, 2019).
Legal Consideration for Restraints for Adult Patients
Restraint should be used as a last choice and only be imposed when necessary to protect the patient from harming themselves or others. Patients’ rights should be always protected and promoted during the restraint period. Such as privacy, safety, and the right to be free from all forms of abuse or harassment. The attending physician must be consulted as soon as possible. Providers should debrief with the patient and family to discuss the previous interventions and alternatives to restraints. Each restraint order may only be renewed 4 hours later for adults, and it will expire within 24 hours. The restraint order must be discontinued at the earliest possible time (Public Health, 2018). The Code of Regulation also listed many other legal considerations related to restraints and seclusions.
Ethical Consideration of Restraints on Children/Adolescents
Physical restraint used for children and adolescents in mental health facilities requires particular ethical and legal consideration, it is often used as a reactive behavior management strategy for aggressive behaviors. We all realize that restraints limit the patient’s physical movement, and may cause some physical injuries if it is not used appropriately, but we can’t ignore that they could cause severe and long-term psychological consequences for children or adolescents who experienced restraints and seclusions (Nielson, 2021) ETHICAL AND LEGAL FOUNDATIONS OF PMHNP CARE.
Providers need to understand the consequences of physical restraint on a child’s physical and mental well-being. Children and adolescents are mentally immature, they may feel defended, and they will experience anger, fear, anxiety, and many other negative emotions. According to some patients’ retrospect reviews, being physically restrained is a severely traumatic experience, it caused physical injury as well as psychological damage. Also, reports suggested that the use of restraint within mental health facilities can damage the therapeutic relationship between patients and healthcare providers.
Legal Consideration to Restraints on Children/Adolescents
Due to the tension between the patient’s right to freedom and the healthcare provider’s duty, healthcare providers may face potential claims of improperly detaining patients, false imprisonment, or harming children when restraints are applied. The use of restraints is among the most controversial practices in mental health care, especially for children and adolescents. Children and adolescents are considered the most vulnerable population among mental health patients. Federal and state law shared a desire to provide minor patients with the greatest protections regarding the usage of restraints and seclusion. Providers are mandated to notify the parents and legal guardians of the use of restraints as soon as possible, they will supply a copy of the restraint policy and obtain a written acknowledgment of the policy from the parents. (Neiman, Pelkey, & Holloway, 2016).
Nielson, S., Bray, L., Carter, B., & Kiernan, J. (2021). Physical restraint of children and adolescents in mental health inpatient services: A systematic review and narrative synthesis. Journal of child health care: for professionals working with children in the hospital and community, 25(3), 342–367.
Neiman, E., Pelkey, E., & Holloway, M. (2016). An Analysis of Legal Issues-Child and Adolescent Behavioral Health, Part III: Patient Safety- Identifying and Addressing Legal Issues Involved When Treating Pediatric Patients with Behavioral Health Needs Teaching Hospitals and In-House Counsel Practice Groups, AUTHORS.
Public Health. (2018, October 1). Code of Federal Regulations.
Salehi, Z., Najafi Ghezeljeh, T., Hajibabaee, F., & Joolaee, S. (2019). Factors behind ethical dilemmas regarding physical restraint for critical care nurses. Nursing Ethics, 27(2), 598–608.
Your discussion piece on Restraints was informative. It got me thinking about recent and emerging trends in restraint use and isolation. I know that in my hospital there is a plan to move from restraining patients in a chair to using a bed. We are yet to see this change. This notwithstanding, studies have shown that seclusion and restraint use can be traumatic to patients (Chieze et al., 2019). The comprehensive systematic review by Chieze et. al. (2019) highlighted the negative physical and psychological impact of restraints on this patient population, especially those with a history of trauma. I remember working with a patient who was very disruptive and was pulling out all devices attached to him including extubating himself. He was subsequently physically restrained and placed in an enclosure bed. However, when the family was informed per protocol, they noted that the patient was a prisoner of war, and we were only traumatizing him further. This important part of the patient’s history should have been reflected in his plan of care and the use of physical restraints should have been contraindicated in this patient. As noted by this review, seclusion and restraint were associated with negative effects and they noted problems with arriving at any benefits. The study suggests a more robust patient-staff interaction and relationship which also makes me think of staffing ratios – are healthcare facilities adequately staffed to provide adequate patient-staff interaction to ameliorate or decrease the use of restraints? Meanwhile, I have observed that in my facility, the use of physical restraints is short (about two to four) as they are combined with chemical restraints (e-meds). The ideal for practice is non-malfeasance (do no harm).
Thanks for provoking my thoughts with your discussion piece.
Chieze, M., Hurst, S., Kaiser, S., & Sentissi, O. (2019). Effects of Seclusion and Restraint in Adult Psychiatry: A Systematic Review. Frontiers in Psychiatry, 10(491).
After reading Just Mercy, I understood the meaning of justice as not being limited to the judiciary system and all the attending laws but the hope that the system can and will work equally for everyone (Stevenson, 2014), age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status (“Ethical Principles of Psychologists and Code of Conduct,” n.d.) notwithstanding. This is the essence of the Ethical Principles of Psychologists and Code of Conduct (Principle D). The principle of Justice, as noted by the Code of Conduct, is geared towards ensuring fairness and equitable access to competent psychiatric care for all. The other principles (Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity, and Respect for People’s Rights and Dignity) make sense in a paradigm where fairness and access is available to ensure that no harm is done, and patients are able to trust their providers (therapeutic alliance) to provide confidential and culturally sensitive evidence-supported care.
Ethical Considerations for Adults
While factors like income security, comorbid health conditions, the need for long-term care, nutrition, housing, abuse, neglect, and age discrimination are some of the ethical issues impacting care for the elderly, the issue of ethical considerations has loomed large in the area of consenting for genetic testing for this population. Lawrie et al. (2019) noted that early detection has not been linked to greater efficacy of treatment. However, they also note that the ethical considerations here are confidentiality, communicating, and sharing of research findings. On the issue of communication, they note that stigma associated with mental illness is a barrier to both delivering the result to the patient/family and disseminating pertinent significant research findings to the provider community. These considerations also apply to children and adolescents as parental consent are required – sometimes by adolescent patients deferring to parents and/or legal guardians, in most cases, to carry out research.
Ethical Considerations for children/adolescents
Adolescence is a period rife with gender issues and emerging gender identity. Kimberly et al. (2018) noted a disparity in the treatment outcomes of cisgender youths and youths with gender dysphoria. The authors urge for a more cautious approach to ensure access and equitable care for this population. Specifically, they advocate for ethical considerations for this population to be gender-affirming and tailored to achieve optimal treatment outcomes (beneficence), with minimal harm (nonmaleficence). The ethical considerations should have a focused treatment plan that supports autonomy for even children during times of rapid development with an emphasis on justice to provide that hope for the future with assured access to care.
Legal Considerations for Adults
As noted above, income security, health care decisions, long-term care, nutrition, housing, utilities, protective services, defense of guardianship, abuse, neglect, and age discrimination are some of the factors that come with adulthood and become even more significant with age. Bipeta (2019) cautions that the mentally ill have the same right as everyone else and must be treated with respect to the principles enshrined in the Code of Ethics ETHICAL AND LEGAL FOUNDATIONS OF PMHNP CARE. He warns of the need to treat each patient as a legal entity by understanding the unique aspects of each individual patient. He also recommends patience and learning over time for the practitioner to ensure that no harm comes to the patient in the process of care delivery to a mentally impaired patient.
Legal Considerations for Children/Adolescents
The issue of informed consent also looms large in caring for minors. Levin et al. (2022) note barriers to these include erroneous and biased professional assumptions, and inadequate initial assessments, which may lead to a paucity of information shared with the patients and their parents. They note that this is especially so with the gender dysphoric patient. At work, I noted that some children/adolescents have consented to treatment but have not shared their preferred gender identity with their parents/legal guardians. This limits the provider’s ability to share with the parents. According to Levin et al. (2019), this disagreement or disconnection from parents is a legal barrier to care. They also note that the presence of mental health problems may impair cognition and creates doubt about the minor’s ability to understand and be informed enough to consent to care.
Application to Clinical Practice in Colorado
It is important to practice within the Nurse Practitioner Scope of practice in Colorado. While the NP has full practice rights, it is important to have in mind the ethical and legal considerations noted above as they impact care. The age of consent for minors in CO has been lowered to 12 by the passing of Bill # HB17-1320. Even children as young as 10 can obtain psychotherapy treatment without parental consent. While the provider of care is protected by law, it is pertinent to have the Code of Conduct in mind to ensure that the principles of Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity, and Respect for People’s Rights and Dignity, and of course Justice are not compromised in the delivery of care to minors or the cognitively impaired mental patient ETHICAL AND LEGAL FOUNDATIONS OF PMHNP CARE.
Bipeta R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. to an external site.
Ethical principles of psychologists and code of conduct. (n.d.). Https:// to an external site.
Kimberly, L. L., Folkers, K. M., Friesen, P., Sultan, D., Quinn, G. P., Bateman-House, A., Parent, B., Konnoth, C., Janssen, A., Shah, L. D., Bluebond-Langner, R., & Salas-Humara, C. (2018). Ethical Issues in Gender-Affirming Care for Youth. Pediatrics, 142(6), e20181537. to an external site.
Lawrie, S. M., Fletcher-Watson, S., Whalley, H. C., & McIntosh, A. M. (2019). Predicting major mental illness: ethical and practical considerations. BJPsych Open, 5(2). to an external site.
Levine, S. B., Abbruzzese, E., & Mason, J. M. (2022). Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults. Journal of Sex & Marital Therapy, 1–22. to an external site.
Stevenson, B. (2014). Just Mercy. Delacorte Press.
‌ Wiesen, K. (2022). Nurse Practitioner Scope Of Practice By State – 2021.
This discussion aims to discuss the ethical and legal considerations of involuntary hospitalization, the due process of civil commitment in adolescents and adults, and explain how this topic concerns psychiatric-mental health practice for children, adolescents, and adults.
Involuntary hospitalization and due process of civil commitment
In the United States, involuntary hospitalization, also known as civil commitment, is a legal intervention where individuals who pose a danger to themselves or others or are gravely disabled (unable to provide basic needs for food, clothing, or shelter) due to a psychiatric illness or substance abuse can be detained in a psychiatric hospital or receive supervised outpatient treatment for some length time (Gi Lee & et al., 2021).
Under California law, short-term emergency detention often referred to as a “5150”, is when a person is held in legal custody for 72 hours. Only designated personnel, such as deputy officers, members of a mobile team, or mental health workers for psychiatric evaluation, can place a person on a 5150 legal hold.  After the 72-hour legal hold, a psychiatrist will evaluate the individual, after which the individual may be placed on a 14-day ‘5250’ involuntary hold or can agree to be admitted or discharged. The subsequent step is expected to continue if a court or psychiatrist orders a commitment extension for up to 14 days, subject to legal review (Gi Lee & et al., 2021).  Within four days after the patient is placed on a 14-day involuntary hold, there must be a certification evaluation hearing, also called a probable cause hearing.  The hospital/facility must present a substantiation as to why the patient necessitates further psychiatric management.  The patient is aided by a patient’s rights advocate who can rationalize why there is no need for an additional hospital stay.  A hearing deputy will decide whether or not there is probable cause to hold the patient in the hospital/facility against their will for a period not exceeding 14 days.
Suppose the hearing officer decides there is probable cause, and the patient disagrees with the decision. In that case, the patient has the right to request a Writ of Habeas Corpus and have a hearing in the Superior court of the county where the patient is being held. The hospital may keep a patient for 180 days after the 5250 legal hold if they are still a danger to themselves or others.  In tremendous cases, when an adult has an extensive history of mental illness and non-adherence, family members or professional personnel may request an LPS (mental health) conservatorship; this gives an adult legal authority to make choices for a seriously mentally ill individual who cannot care for themselves.
The purpose of commitment is to guarantee treatment for individuals who need treatment to alleviate the symptoms of psychiatric disorders that contribute drastically to an individual’s higher risk of harm to self or others (Nussbaum, 2020). A psychiatric patient with involuntary hospitalization often has overlapping vulnerabilities of language, sexual orientation, religion, and disrupted education. These vulnerabilities may either withhold vital services or deliver services coercively (Nussbaum, 2020).  Mental illness affects a person’s ability to make rational decisions and live a normal life. Sometimes, a patient’s capability to make choices is so incapacitated by a psychiatric illness that practitioners manage them against their will to restore their ability to make reasonable choices (Nussbaum, 2020).
Applications to clinical practice and the specific implications for practice within California
Practitioners are profoundly challenged to be ethical when a patient is involuntarily hospitalized due to civil commitment. When patients are held against their will, they are also intensely vulnerable to illness and social structure.  These situations obligate our profession to provide evidence-based patient care and advocate for better care of people with psychiatric disorders.  Civil commitment has obtained punitive legal criticism. The hearing process is criticized for being a “charade” for lacking a specific, meaningful chance for vulnerable individuals to dispute the liberty restriction they face (SAMSHA, 2020).
In California, under the Lanterman-Petris Short Act (LPS), patients admitted under 5150 retain all their rights when hospitalized or receiving services, except for freely leaving the facility where they are admitted (SAMSHA, 2020).  Patients have all rights given to a voluntarily admitted patient.
The practitioners define the decision to commit a patient as resolving the pressure between the ethical principle of nonmaleficence and autonomy (Evans & et al., 2020).  They are obliged to predict the occurrence of a patient causing harm to themselves or others, consider when to intervene to avoid harm, and protect and warn those who may be harmed by the patient’s behavior.  As practitioners, we are guided to respect a patient’s ability to make choices and to neither unduly influence nor coerce a patient we are treating simultaneously. We should also act in ways not to cause harm to patients (SAMSHA, 2020).
Ethical and legal issues concerning psychiatric-mental health practice for children/adolescents and adults
In an article explored by Rice, Xing Tan & Li.  2021, adolescents navigated their treatment from admission to discharge.  Adolescents brought to the hospital by law enforcement officials after being placed under involuntary psychiatric hold because of the danger to themselves have a sense of shame that leads to tagging themselves negatively. The patient’s perceptions of their psychiatric mental health were too severe to be managed within standard community-based settings. Consequently, they were transferred to a locked psychiatric hospital for treatment.  The legal concern is that the patient has the right to privacy, human care, and dignity and cannot be denied this right as a situation of admission or as part of a treatment strategy.  In this study, it was established that practitioners should advocate an appropriate treatment intervention to meet the adolescent’s needs and revealed significant insight into ways of engaging and explaining the treatment to avoid rehospitalizations.
In another article researched by Jones & et al., 2021 adolescents who experience involuntary hospitalizations positively and negatively impact their mental health treatment.  In this study, the participants describe the negative impact of involuntary hospitalization.  The participants reported distrust and inability to disclose their suicidal feelings as the environment was more punitive than therapeutic. Others suggested examination and evaluation be constantly incorporated into the clinical practice and addressed the need to evaluate interventions intended to promote patient-centered practices in hospitals (Jones & et al., 2021). Any time a right is denied under a “good cause,” it must be acknowledged in the patient’s medical record and clarified to the patient ETHICAL AND LEGAL FOUNDATIONS OF PMHNP CARE.
In an article by Gather & et al., 2019 an adult patient who is actively psychotic and dangerous to themself and others is no longer considered competent to evaluate their need for psychiatric health services. The article substantiates that a commitment promotes the ethical obligation of the practitioner to encourage beneficence to the patient.  Involuntary hospitalization during this course becomes essential to treating the adult patient and initiating preventive services to promote patient and public safety (Gather & et al., 2019).
According to the article “Incidences of Involuntary Psychiatric Detentions in 25 U.S. States,” involuntary hospitalization in adults improves the patient’s clinical condition and overall well-being and protects their safety and others while valuing their rights (Gi Lee & et al., 2021).
It is imperative to balance the significance of self-determination and the social responsibility to care for a person with a lessened capacity to act in their best interest (Gi Lee & et al., 2021).
Evans, E. A., Harrington, C., Roose, R., Lemere, S., & Buchanan, D. (2020).  Perceived Benefits and Harms of Involuntary Civil Commitment for Opioid Use Disorder. The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics, 48(4), 718–734. to an external site.
Gather, J., Kalagi, J., Otte, I., & Juckel, G. (2019). Interviewing a Person with Bipolar Disorder Under Involuntary Commitment: A Case Report. Journal of Empirical Research on Human Research Ethics: JERHRE, 14(5), 472–474. to an external site.
Gi Lee, M. S. W., & David Cohen, M. (2021).  Incidences of Involuntary Psychiatric Detentions in 25 U.S. States. Psychiatric Services, 72(1), 61–68. to an external site.
Jones, N., Gius, B. K., Shields, M., Collings, S., Rosen, C., & Munson, M. (2021).  Investigating the impact of involuntary psychiatric hospitalization on youth and young adult trust and help-seeking in pathways to care. Social Psychiatry and Psychiatric Epidemiology, 56(11), 2017–2027.
Nussbaum, A. M. (2020). Held Against Our Wills: Reimagining Involuntary Commitment. Health Affairs (Project Hope), 39(5), 898–901. to an external site.
Rice, J. L., Tan, T. X., & Li, Y. (2021).  In their voices: Experiences of adolescents during involuntary psychiatric hospitalization. Children and Youth Services Review, 126. to an external site.
SAMSHA.  (2021).  Civil Commitment and the Mental Health Care Continuum: Historical Trends and Principles for Law and Practice. to an external site.
D2.In their voices_ Experiences of adolescents during involuntary psychiatric hospitalization _ Elsevier Enhanced Reader.pdf Download D2.In their voices_ Experiences of adolescents during involuntary psychiatric hospitalization _ Elsevier Enhanced Reader.pdf
D2.Held_Against_Our_Wills_Reimag.pdf Download D2.Held_Against_Our_Wills_Reimag.pdf
D2.Investigating the impact of involuntary psychiatric hospitalization on youth and young adult trust and help-seeking in pathways to care.pdfDownload D2.Investigating the impact of involuntary psychiatric hospitalization on youth and young adult trust and help-seeking in pathways to care.pdf
D2.Incidences of Involuntary Psychiatric Detentions in25 U.S. States.pdf Download D2.Incidences of Involuntary Psychiatric Detentions in25 U.S. States.pdf
D2.Interviewing.pdf Download D2.Interviewing.pdf ETHICAL AND LEGAL FOUNDATIONS OF PMHNP CARE


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