Should domestic violence reporting be mandatory?
Should domestic violence reporting be mandatory?
Doctors say it may do more harm than good
Pennsylvania law, like that of most states, demands that whenever a physician treats someone who has suffered "serious bodily harm," the doctor must report the case to the local police.
Many physicians have begun to believe there is little legal recognition of what might happen next, if the patient is a victim of domestic violence: another good beating for tattling. And many experts in domestic violence are arguing that reporting the incident to the police is the wrong step and an easy out for hospitals.
A group of emergency medicine professionals from the greater Pittsburgh area met recently to discuss mandatory reporting and came away with this conclusion: "If reporting means we place the victim in a potentially more harmful situation and have to worry about her seeking health care, it is not the right ethical response," says Lee Ann Ranieri, RN, nurse manager of the emergency department at Magee-Womens Hospital in Pittsburgh.
Ranieri and other professionals in Pennsylvania and California have been working for three years on a model emergency department domestic violence program. The best way to help victims, say Ranieri and others, is to routinely screen every female who comes to the emergency department for signs of abuse, complete detailed documentation in the medical record, and offer the patient referral information on domestic violence.
Hospital ethics committees must think about the ethical implications of reporting the violence to police. "Develop guidelines for police reporting," she urges. "But even with policies to guide you, the emergency department staff still must think about their response on a case-by-case basis, depending on the circumstances," says Ranieri.
Magee is working on its own internal guidelines for police reporting and Ranieri says the Pittsburgh group will advocate for changes in the state’s law. Reporting domestic violence, experts maintain, is most critical on the patient’s medical record.
Despite the high incidence of domestic violence nearly 20% of all women who come to a hospital ED reveal they are victims medical records generally show only a 5% documentation rate, says Fred Schiavone, MD, clinical assistant professor of emergency medicine at the State University of New York at Stonybrook, and a member of the national advisory committee of the San Francisco-based Family Violence Prevention Fund.
Schiavone says a lack of screening and documentation is symptomatic of emergency medicine practice treat the emergency episode only. "Many physicians fear opening Pandora’s Box will involve lengthy, cumbersome, and possibly uncomfortable interactions," he says.
Although there has been no formal research, experience treating domestic violence has shown that it may take a woman several visits to a health care professional before she is willing to talk about the abuse she is experiencing, 7say Schiavone and Ranieri. Consequently, these patients should not be labeled noncompliant, they contend.
"The only way to identify as many victims of domestic violence as possible is to universally screen all women," says Schiavone.
Don’t be paternalistic
The first step in helping the victim is understanding that, "You can’t necessarily remove her from the violence. It is not the health care professional’s goal to get her out of there,’" says Ranieri.
Magee and other model programs have developed routine screening tools to assess domestic violence. Ask women this question, says Ranieri: "Are you currently or have your ever been in a relationship where you are threatened, feel afraid, or are being physically harmed?" Other possible questions are: "Did someone hit you? Was it your partner or your husband?" or "I am concerned that your symptoms/condition may have been caused by someone hurting you. Has someone been hurting you?"
Routine screening questions should be added to a patient history and intake form in primary and ED settings, says Debbie Lee, associate director of the Family Violence Prevention Fund. A written screening/documentation form should also be used, she recommends. (See sample form inserted in this issue.)
The organization recently published a domestic violence resource manual to help health care professionals identify and assist victims. The manual was produced in collaboration with the Pennsylvania Coalition Against Domestic Violence. It includes training handouts for staff, tips for identifying battered women, homicide assessment tools, sample medical documentation forms, and a model hospital intervention packet including safety planning and resource referral.
"It is important to document the abuse or suspected abuse in the patient’s medical record for the future," says Lee. Many battered women return to the doctor or emergency department and written records can help in future medical situations and when a victim presses charges against the abuser. "Many times we find that the primary physician never made the connection," says Lee.
Documentation is also critical if the victim should be incapacitated and the abuser then identified as a surrogate decision maker, says Lee. Each situation requires an individual response. Review your hospital’s policy and procedures regarding reporting and screening for domestic violence, urges Ranieri.
"We should ask trained physicians in the emergency department to identify domestic violence similar to the way we identify any medical illness," says Schiavone. "Based on historical and physical examination risk factors, formulate a differential diagnosis that guides us to reach the final diagnosis."
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