Domestic Violence Treatment & Management
- Author: Lynn Barkley Burnett, MD, EdD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
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In addition to attention to ABCs and administration of treatment appropriate to the patient's presenting complaints, emergency medical services (EMS) personnel are in a unique position to identify problems associated with violence.
EMS personnel are the only health professionals who enter the environment where victimization occurs and are thus more likely to see evidence of domestic and sexual violence than the emergency department clinicians. This is especially true when called into a home for a problem not directly related to abuse. In such cases, EMS personnel may detect abuse and violence that might otherwise go unreported.
Victims of domestic violence frequently refuse ambulance transport, thereby avoiding medical care in the ED. In such situations, EMS personnel are the only health professionals in a position to recognize domestic violence and make suggestions for appropriate intervention.
In one study, 140 paramedics who annually respond to 44,000 emergency requests, received training directed at acquisition of assessment skills for violence-related injuries and screening of female patients for history and risk of domestic violence. As with other professionals, however, simply training EMS personnel is not enough. Attitudes must be addressed, because follow-up revealed reluctance in collecting specific violence-related data elements, particularly concerning domestic violence.
Emergency Department Care
The emergency care of a victim of domestic violence is simultaneously straightforward and challenging. Responsibilities when treating such patients, in addition to lifesaving interventions, include the following:
Provide a safe environment.
Inquire about domestic violence and/or recognize abuse from information obtained during the history and physical.
Establish the diagnosis of domestic violence.
Acknowledge the abuse and reassure the patient that she or he is not at fault.
Evaluate emotional status and treat the emotional injury.
Diagnose and treat physical injuries and other medical or surgical problems.
Clearly document the history, physical findings, and interventions in the medical record.
Determine the risks to the victim and any children and assess safety and available options.
Counsel the patient that violence may escalate.
Determine the need for legal information or intervention and report abuse when appropriate or mandated.
Develop a follow-up plan.
Offer referral to shelter, legal services, and counseling, facilitating such referrals with the consent of the patient.
Requirements mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO): Patients who possibly are victims of alleged or suspected abuse or neglect have special needs during the initial screening and assessment process. JCAHO requires hospitals to have policies for the identification, evaluation, management, and referral of adult victims of domestic violence, including the following:
The hospital has specific and unique responsibilities for safeguarding information and evidentiary material(s) that could be used in future actions as part of the legal process.
Hospitals must have policies and procedures that define their responsibility for collecting these materials. Hospital policy must define these activities and specify who is responsible for their implementation. The following elements are to be documented in the patient's medical record:
Consents from the patient, parent, or legal guardian or compliance with other applicable laws
Evidentiary material released by the patient
Legally required notifications and releases of information to authorities
Referrals made to private or public community agencies for victims of abuse
Providing a safe environment
The ED should provide a safe haven, albeit temporary, to the victim of domestic violence. An immediate concern is for the safety of the abused patient and any children. Interview the patient alone, a step that also removes him or her from the immediate reach of the batterer.
The patient needs to know that the situation is taken seriously by compassionate health professionals. One way of communicating the concern of the staff toward domestic violence is by placement of posters that give information about domestic violence in waiting rooms, treatment rooms, and restrooms.
Among the resources from which posters may be obtained are the American Medical Association (AMA) at 1-800-AMA-3211 and from the Family Violence Prevention Fund at (415) 252-8900 or 1-800-313-1310.
Evaluation of emotional status and treatment of emotional injury
Clinicians should ensure the patient feels respected, cared for, listened to, and encouraged to make her or his own choices to the extent allowable under the law. The following are primary messages to victims:
There is no excuse for domestic violence. Violence is not your fault–nobody deserves to be abused.
It must be very difficult for you to face your situation. You are not alone; there are people you can talk to for support, shelter, and legal advice.
Management of the immediate aftermath of violence
This can be a major determinant of the victim's response to psychologic trauma, the effects of which have the potential to be severe. Appropriate intervention lessens the likelihood of long-term conditions such as PTSD, depression, anxiety disorders, substance abuse, and counterphobic behavior.
Respect the patient's modesty and, when possible, touch the patient only with permission. Use plain language to honestly explain procedures and their importance.
Carefully explaining the physiologic and psychologic reactions to be expected in the posttrauma period provides an organizing framework and may assist in reestablishing some sense of control. The following responses may result from violent victimization:
Dissociation - Person feels separated from his or her body, from reality, or both
Eidetic memory - Flashbacks characterized by vividness, intensity, and experiencing the memory as currently happening each time it is recalled
Recall - Repetition of the full experience (ie, sights, sounds, smells, tactile perceptions, emotions), including the horror of the moment
Hyperarousal of the autonomic nervous system
Hypervigilance - Paranoid level of fear or mistrust, or intense awareness of every word and act of the ED staff, and a distorted sense of time
Treatment of physical injuries and other medical or surgical problems
In addition to injuries or other conditions identified during the workup, protection against sexually transmitted infections and pregnancy may be discussed.
These measures also are indicated if the victim has been sexually assaulted or subjected to coercive sexual acts.
History, physical findings, and other interventions
The medical record could mean the difference between convicting an abuser or allowing him or her to go free and potentially assault again. Document the details of all findings, interventions, and actions in a legible medical record, which should contain as much of the following information as possible:
Include a description of the abusive event, including present complaints; use the patent's words verbatim (in quotation marks whenever appropriate). Include the patient's domestic violence history.
When indicated (eg, patient presents an inconsistent history suggesting the true problem is being concealed), it is appropriate to include an objective description of the patient's behavior in the medical record.
Include other health problems, physical or mental, that may be related to the abuse.
Include the alleged perpetrator's name, address, and relationship to the patient (and any children).
Detailed descriptions of the patient's injuries, including type, location, size, color, and apparent age.
Thoroughly document injuries via completion of anatomical diagrams and, when possible, color photographs that should be taken before any medical treatment.
When possible, and with the patient's consent (attached to the chart), document all injuries with photographs that allow assessment of their adequacy before the patient leaves the ED.
At least 1 of the photographs should be a full body shot that includes the patient's face (to link injuries to patient). Others include a mid range photograph to show torso injuries and close-ups of all wounds and contusions. Take photographs from different angles with at least 2 views of each injury, and include an object (eg, a ruler) that indicates the size of the injuries.
Write the name of the patient, medical record number, date and time of the photograph, name of the photographer, location, and names and titles of any witnesses on the back of each photograph before they are attached to the medical record. The photographer should sign the photograph.
Consider indicating on the back of the photograph the part of the body represented and the victim's stated cause of the injuries.
Torn and damaged clothing also may be photographed.
Document any injuries not shown clearly by photographs on a hand-drawn or preprinted body map.
Preserve any physical evidence (eg, damaged clothing, jewelry, weapons) that may be used for prosecution. Preserve the chain of evidence.
With rape or sexual assault, follow appropriate protocols for physical examination and for evidence collection and preservation during forensic examination.
Legal information and intervention, and reporting abuse
See the list below:
Inform the patient that battering is a crime and that help is available. Ascertain if the patient wants intervention from law enforcement or other legal referral. The provider should ensure priority assistance if the patient wants immediate help.
In those jurisdictions in which reporting of domestic violence is mandated, the legal obligation to report abuse should be discussed with the patient.
Explain how local authorities respond to such reports and outline follow-up procedures that may be necessary. Also, address the risk of reprisal and the possible need for shelter or an emergency protective order (available to battered women in every state and the District of Columbia).
If the patient believes that police intervention will jeopardize safety, the clinician should work with the patient and recipient of the report to best meet the patient's safety needs. The role of the clinician in the care of the abused patient thus goes beyond simply obeying the laws that mandate reporting. An attempt must be made to mitigate the potential harms resulting from those laws, to maximize the role of the patient's choices regarding future actions, and to provide appropriate ongoing care to the patient.
Ensure that the patient will be safe pending arrival of the police. If the patient desires, a health professional should remain with the patient during the police interview.
The medical record should reflect that the incident was reported to law enforcement, any subsequent police report, including the date and time the report was taken and the name and badge number of the officer(s) who responded to the ED call. Reporting domestic violence to law enforcement does not substitute for thorough documentation of the abuse in the medical record.
Determination of risk to victim and children
Ask the patient, "If you return home now, will you be in danger?" Risk also includes the potential for suicide. Accordingly, it is appropriate to ask, "Have you had thoughts of harming or killing yourself?"
Take threats by the perpetrator to kill the victim, children, or himself or herself very seriously. Any need to restrain an assailant is especially troublesome.
Development of a follow-up plan
Inquire as to the patient's state of mind.
What type of help would you like?
Are there any changes you would like to make in your situation?
What steps might help you make those changes?
How might we help?
Considerations when planning disposition
Does the patient need immediate medical or psychiatric intervention? Does she or he require admission or urgent follow-up for medical conditions? Is she or he suicidal or homicidal? Does she or he need urgent crisis counseling to deal with the stress of abuse? If so, arrange appropriate appointments or referrals.
Who is waiting outside for the patient? Leaving via a less visible exit might be best for a patient. Does the patient think that it is safe to go home? Where is the batterer now? Was she or he arrested? Was she or he released? Does the batterer have access to a firearm or other weapon? Has she or he been threatening to kill the victim? Does she or he believe the threats? Has she or he been harassing or stalking the victim? Are abusive behaviors escalating?
Does the patient have friends or family with whom she or he can stay? Does she or he feel safe at their home or afraid the batterer will come there? Is the patient confident that family and friends will not inadvertently collude with the batterer in the mistaken belief that they are helping the couple?
In what type of situation are children and other dependents? Does the patient think they are safe? Is the patient afraid they will be harmed if she or he does not go home?
Does the patient want immediate access to a shelter or other temporary living situation? Ask where the patient will go if she or he leaves the ED. If the patient wants to go to a shelter now, where should she or he go? If no beds are available, what other options exist (eg, motel vouchers, overnight stay in the ED, admission to the hospital)?
If the patient does not want to go to a shelter, give the victim telephone numbers for domestic violence or crisis hotlines in the community in case she or he wants or needs them at a later time. Be mindful that written materials may pose a danger once the patient returns home.
If the patient wants to go home, a referral should be made to a primary care provider or other appropriate resource.
Advise the patient to have a safety plan.
Elements of a safety plan
This plan is adapted from the San Diego City Attorney's Personalized Safety Plan of April, 1990. Copies of a fill-in-the-blank, personalized safety plan may be obtained from the Family Violence Prevention Fund, 383 Rhode Island St, Suite 304, San Francisco CA 94103-5133, telephone (415) 252-8900 or 1-800-313-1310, fax (415) 252-8991.
Safety during a violent incident that occurs in the home
Try to avoid arguments in small rooms, rooms with access to weapons (eg, kitchen), or rooms without access to an outside door. Be aware that alcohol and other drugs can decrease your ability to act quickly to protect yourself and your children.
Know which doors, windows, or fire escapes you and your children would use if you must quickly escape to safety. Know where you will go once you leave the house. If possible, practice taking this route.
If you can, tell a friend or neighbor to call the police if they hear suspicious noises coming from your home or over the telephone.
Arrange use of a code word with children or friends so they know when they should call for help
Teach children how to use the telephone to contact police or fire agencies (911, if available, is preferable to dialing "0").
Hide the following items where they may quickly be accessed in an emergency:
Identification for self and children (eg, driver's license, social security cards, birth certificates, green cards, passports)
Important documents (eg, school and health records, welfare identification, insurance records, automobile titles, lease or rental agreements, mortgage papers, marriage license, address book)
Copies of any protective or restraining orders, divorce or custody papers, or court documents
Money, checkbook, bankbook, and credit card (in your own name if possible)
A small supply of any prescription medicines or a list of the drugs and dosages and the name, address, and telephone number of the prescribing clinician
Clothing, toys, and other comfort items for self and children
Items of special sentimental value
Small, sellable objects
Extra set of keys to the car, house, office, and safe-deposit box
Safety if you no longer live with the batterer
Change the locks on doors and windows as soon as possible.
Try to live where doors are secure (eg, steel or metal instead of wood).
When possible, install safety devices, such as extra locks, window bars, motion-detecting outdoor lights, and electronic security systems.
Install smoke detectors, purchase fire extinguishers, and have rope ladders for upper floor windows (kept inaccessible from the outside until needed).
Safety on the job
Is there someone at work (eg, coworker, supervisor, employee assistance counselor) who can be informed of the situation?
Can calls be screened by voice mail? Can a receptionist or coworker screen calls or visitors?
Have a plan for safely arriving at and leaving work and other public places. Vary the time of arrival and departure and the routes used to and from work and children's school.
Referral and shelter
A primary aim of ED intervention is to bring the victim of domestic violence into contact with helping resources such as the 1500 domestic violence shelters in the United States, social services, legal assistance, and support groups. The social worker is a valuable asset for making appropriate referrals.
If the patient has no safe place to go, consider overnight hospitalization, emphasizing that such action is only for the patient's protection and not because the patient is mentally ill.
Reiterate the options available to the patient, including obtaining an emergency protective order or restraining order, going to a friend's home or shelter, and accepting services offered through hotlines and support groups.
The patient may choose to return to the battering relationship after the ED visit; nevertheless, important therapeutic interventions may have begun that can help extricate the person from violence.
The World Health Organization published “Responding to intimate partner violence and sexual violence against women” in June of 2013. Although directed to general medical care, and not specifically the emergency department, said publication does provide evidence-based recommendations, although the quality of some is low to moderate.
Obtain a consultation with a psychiatrist if the patient is suicidal or homicidal.
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