Mrs. Brown’s Chart
Mrs. Brown has been diagnosed with invasive cancer. she has been having daily radiation treatments. her husband is a frequent visitor and seems to be a devoted husband. they are both very interested in her progress and prognosis. although they have asked many questions and you have given truthful answers, you know little because the physician has not shared much with the staff. today, you walk into Mrs. Brown’s room and find Mr. Brown sitting at Mrs. Brown’s bedside reading her chart. the radiation orderly had inadvertently left the chart in the room when Mrs. Brown returned from the X-ray department.
Assignment: identify several alternatives that you have. discuss what you would do and why. is there a problem here? What follow-up is indicated? attempt to solve this problem on your own before reading the sample analysis that follows.
Analysis
the nurse needs to determine the most important goal in this situation. possible goals include (a) getting the chart away from Mr. Brown as soon as possible, (b) protecting the privacy of Mrs.
Brown, (c) gathering more information, or (d) becoming an advocate for the Browns.
in solving the case, it is apparent that not enough information has been gathered. Mr. Brown now has the chart, and it seems pointless to take it away from him. Usually, the danger in patients’ families reading the chart lies in the direction of their not understanding the chart and thereby obtaining confusing information or the patient’s privacy being invaded because the patient has not consented to family members’ access to the chart.
Using this as the basis for rationale, the nurse should use the following approach:
1. clarify that Mr. Brown has Mrs. Brown’s permission to read the chart by asking her directly.
2. ask Mr. Brown if there is anything in the chart that he did not understand or anything that he questions. You may even ask him to summarize what he has read. clarify the things that are appropriate for the nurse to address, such as terminology, procedures, and nursing care.
The Patient Self-Determination Act
The PSDA, enacted in 1991, required health-care organizations that received federal funding (Medicare and Medicaid) to provide education for staff and patients on issues concerning treatment and end-of-life issues. This education included the use of advance directives (ADs), written instructions regarding desired end-of-life care. Most ADs address the use of dialysis and respirators; if you want to be resuscitated if breathing or heartbeat stops; tube feeding;
and organ or tissue donation (Medline Plus, 2013). They also likely include a durable power of attorney for health care, which names your health-care proxy, someone you trust to make health decisions if you are unable to do so (Medline Plus).
The PSDA requires acute care facilities to document on the medical record whether a patient has an AD and to provide written information to patients who do not. However, despite mechanisms within most health-care institutions to provide this information, the AD completion rate remains low and many patients do not understand what is included in the AD or whether this is something important they should have. Examining the Evidence 5.2 reveals evidence found in one study.
3. refer questions that are inappropriate for the nurse to answer to the physician, and let Mr. Brown know that you will help him in talking with the physician regarding the medical plan and prognosis.
4. When finished talking with Mr. Brown, the nurse should request the chart and place it in the proper location. the incident should be reported to the immediate supervisor.
5. the nurse should follow through by talking with the physician about the incident and Mr. Brown’s concerns and by assisting the Browns to obtain the information that they have requested.
Conclusion
the nurse first gathered more information before becoming the adversary or advocate. it is possible that the Browns had only simple questions to ask and that the problem was a lack of communication between staff and their patients rather than a physician–patient communication deficit. Legally, patients have a right to understand what is happening to them, and that should be the basis for the decisions in this case.
Source: Johnson, R. W., Zhao, Y., Newby, L., Granger, C. B., & Granger, B. B. (2012). Reasons for noncompletion of advance directives in a cardiac intensive care unit. american Journal of critical care, 21(5), 311–320.
This semistructured cross-sectional study asked all (n = 505) eligible patients 18 years or older admitted to the cardiac intensive care unit at Duke University Medical Center, Durham, North Carolina, the standard question required by the PSDA—Do you have an AD?—and three open- ended questions to ascertain the patient’s understanding of ADs. Most patients (64.4%; n = 325) did not have an AD before admission to the unit. Of the patients who initially declined the oppor- tunity to complete an AD (n = 213), 33.8% (n = 72) said they did not understand the question when initially asked and therefore just said no.
The researchers concluded that simply asking patients if they have an AD does not elicit an accurate reflection of a patient’s understanding of ADs and that confusion about ADs makes it difficult for patients to communicate their end-of-life wishes to the appropriate person. The resear- chers suggest a need to restructure the current implementation of the PSDA and to move beyond simply checking a box to providing more meaningful discussion with each patient and their family.
Examining the Evidence 5.2
Good Samaritan Laws
Nurses are not required to stop and provide emergency services as a matter of law although most health-care workers feel ethically compelled to stop if they believe they can help. Good Samaritan laws suggest that health-care providers are typically protected from potential liability if they volunteer their nursing skills away from the workplace (generally limited to emergencies), provided that actions taken are not grossly negligent and if the health-care worker does not exceed his or her training or scope of practice in performing the emergency services. Hasley (2012) warns, however, that not being paid for your services alone will not provide Good Samaritan law protection. For example, nurses who volunteer at clinics or summer camps would typically not be covered since this does not constitute emergency assistance.
Good Samaritan laws apply only if the health-care worker does not exceed his or her training or scope of practice in performing the emergency services.
Protection under Good Samaritan laws varies tremendously from state to state. In some states, the law grants immunity to RNs but does not protect licensed vocational nurses (LVNs) or licensed professional nurses (LPNs). Other states offer protection to anyone who offers assistance, even if they do not have a health-care background. Nurses should be familiar with the Good Samaritan laws in their state.
Health Insurance Portability and Accountability Act of 1996
Another area of the law that nurses must understand is the right to confidentiality. Unautho- rized release of information or photographs in medical records may make the person who discloses the information civilly liable for invasion of privacy, defamation, or slander. Written authorization by the patient to release information is needed to allow such disclosure.
Many nurses have been caught unaware by the telephone call requesting information about a patient’s condition. It is extremely important that the nurse does not give out unauthorized information, regardless of the urgency of the person making the request. In addition, nurses must be careful not to discuss patient information in venues where it can be inadvertently overheard, read, transmitted, or otherwise unintentionally disclosed. For example, nurses talking in elevators, the hospital gift shop, or in a restaurant for lunch need to be aware of their surroundings and remain alert about not revealing any patient information in a public place.
Efforts to preserve patient confidentiality increased tremendously with the passage of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (also known as the Kassebaum–Kennedy Act). HIPAA gave Congress a deadline of August 1999 to pass legislation protecting the privacy of health information and to improve the portability and continuity of health insurance coverage. When this did not happen, the Department of Health and Human Services stepped in and issued the appropriate regulations. The first version of the privacy rule was issued in December 2000 under the Clinton administration, but it was modified by the Bush administration before it was ever implemented, and it continues to be modified on a regular basis.
HIPAA essentially represents two areas for implementation. The first is the Administrative Simplification plan, and the second area includes the Privacy Rules. The Administrative Simplification plan is directed at restructuring the coding of health information to simplify the digital exchange of information among health-care providers and to improve the efficiency of health-care delivery. The privacy rules are directed at ensuring strong privacy protections for patient without threatening access to care.
The Privacy Rule applies to health plans, health-care clearinghouses, and health-care providers. It also covers all patient records and other individually identifiable health
information. Although there are many components to HIPAA, key components of the Privacy Rule are that direct treatment providers must make a good faith effort to obtain written acknowledgment of the notice of privacy rights and practices from patients. In addition, health-care providers must disclose protected health information to patients requesting their own information or when oversight agencies request the data. Reasonable efforts must be taken, however, to limit the disclosure of personal health information to the minimum information necessary to complete the transaction. There are situations, however, when limiting the information is not required. For example, a minimum of information is not required for treatment purposes, since it is clearly better to have too much information than too little. The HIPAA Privacy Rule and Common Rule also require that individuals participating in research studies should be assured privacy, particularly regarding personal health information.
The Privacy Rule attempts to balance the need for the protection of personal health information with the need for disclosure of that information for patient care.
Because of the complexity of the HIPAA regulations, it is not expected that a nursing manager would be responsible for compliance alone. Instead, it is most important that the manager work with the administrative team to develop compliance procedures. For example, managers must ensure that unauthorized people do not have access to patient charts or medical records and that unauthorized people are not allowed to observe procedures.
It is equally important that managers remain cognizant of ongoing changes to the guidelines and are aware of how rules governing these issues may differ in the state in which they are employed. Some provisions of the Privacy Rules mention “reasonable efforts”
toward achieving compliance, but being reasonable is provision specific. The American Recovery and Reinvestment Act (ARRA) applies several of HIPAA’s security and privacy requirements to business associates and changes data restrictions, disclosure, and reporting requirements.