Client/Patient Rights

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I. Privacy

• Confidential information may only be released by signed consent of the client
• Unauthorized release of client data may be an invasion of privacy
• The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides clients with access to their medical records and more control over how their personal health information is used. Provides privacy protection for consumers of health care.
• You must release information when a court orders, or when statutes require it (as in child abuse or communicable diseases)
• Special regulations apply to release of information about psychiatric illness or HIV

II. Advance Directives (ADs)

• As part of the Omnibus Budget Reconcilliation Act (OBRA), congress established the Patient Self-Determination Act:
• requiring every Health Care Facility receiving Medicare and Medicaid funds to provide written information to adult clients outlining their rights to make health care decisions

OMNIBUS BUDGET RECONCILLIATION ACT of 1990 (OBRA)

• requires that states provide advanced directives as options for clients
• Advance Directives:

1. Document that allows clients to make legal decisions about how they wish to receive future medical treatment
2. May indicate who the client wishes to make medical decisions in situations in which the client is unable to do so
3. Needs to be signed and witnessed and copies kept on file in the physician's office and the hospital
4. Implementation varies among states. In many states the witness to this document should not be a hospital employee, relative or heir to the client's estate. Medical social workers are usually acceptable as witnesses in many states.

• Rights include:
1. right to refuse or accept treatment
2. right to formulate advance directives
• Nurses and other members of the health care team are required to:
1. assess the client's knowledge of advance directives and their status regarding the advance directives process
2. provide information and assistance to the client in developing advance directives
3. plan care that incorporates the client's decisions regarding advance directives
• Three common advance directives are:
• Living Will
• living will indicates the client's wishes regarding:
1. prolonging life using life support measures
2. refusing or stopping medical interventions
3. making decisions about their medical care
• living will is executed while the client is competent and able to make sound decisions
• as conditions change, a living will needs to be reevaluated for relevance
• living wills may differ as based on state laws
• Durable Power of Attorney for Health Care Decisions
• legal document allowing the client to name an adult to act as a personal advocate and make health care decisions if the client becomes incompetent
• can be used to accept or refuse treatment
• in the absence of a living will or a durable power of attorney the health care providers often turn to the family members
• however, in many states a family member does not have the legal authority to make health care decisions unless they are legally appointed guardians or parents
• Do Not Resuscitate (DNR) Status
• follow the facility policy on obtaining and implementing DNR orders
• generally the order must be written by a physician, some facilities may have a policy to allow verbal orders under specific conditions
• the order must be communicated clearly to all personnel caring for the client
• the client or their health care proxy can withdraw the order at any time
• a nurse who attempts to resuscitate a client with a valid DNR order may be committing battery

III. Refusal of Treatment - competent clients may refuse treatment, even life-sustaining treatment

IV. Freedom from Safety Devices/Restraints

• Physical restraints/safety devices require a signed, dated physician's order specifying the type of restraints/safety device and a time limit
• Types of restraints/safety devices

1. chemical
2. physical

• Use the least restrictive form of restraint/safety device
• Know agency guidelines for use of restraints/safety devices
• You must document three factors:

1. why you used restraints/safety devices
2. how the client responded
3. whether the client needs continued restraints/safety devices

• Restraining clients without consent or sufficient justification may be interpreted as false imprisonment

GUIDELINES FOR SAFETY DEVICES

• Health care providers can legally restrain a client under certain conditions defined by the law and by the health care facility's policies and procedures
• The safety devices/restraints must be necessary to meet the client's therapeutic needs or to ensure the safety of the client or others
• The least restrictive type of safety device/restraint must be used first
• Use of safety devices/restraints must be accompanied by the health care provider's orders except in emergency
• The client must be closely monitored when in safety devices/restraints
• Safety devices/restraints should be released periodically and the skin integrity of the area checked for breakdown
• Document all pertinent details including why the safety devices/restraints are being used and client's response
• Make sure that the orders for safety devices/restraints are written and updated according to the policy of the facility; more commonly every 24 to 48 hours

V. Informed Consent

• Mentally competent adult client must give his/her own consent; parents or legal guardians may give consent for minors
• Clients need to understand:

1. Purpose of the procedure
2. Any reasonable alternatives
3. Risks, consequences and benefits of the procedure and the alternatives
4. Risks and consequences if the treatment is refused

• The physician caregiver has the legal obligation of obtaining a client's informed consent to medical/surgical treatment
• The nurse may be assigned the task of obtaining and witnessing the client's signature
• The nurse who is concerned about the validity of an informed consent has a legal obligation of telling the physician and the nursing supervisor about the concern
• Basic Requirements

1. Capacity
2. Voluntarism
3. Information

• The client must understand:

1. purpose of the procedure and expected results
2. anticipated risks and discomforts
3. potential benefits
4. any reasonable alternatives
5. that client may withdraw consent at any time

• The care provider has the legal obligation to obtain informed consent for medical treatment but the nurse should confirm the consent and answer the client's questions

VI. Transition Planning

• recognizes that clients are not discharged from care but moved across the continuum to another level