eMedicine - Domestic Violence : Article by Lynn Barkley Burnett
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MISCELLANEOUS
Section 7 of 9   
Authors and Editors
Introduction
Clinical
Differentials
Treatment
Follow-up
Miscellaneous
Further Reading
References
Medical/Legal Pitfalls
EvidenceThose untrained in forensic medicine may inadvertently overlook or destroy gross and/or trace evidence. Recent bite marks may well contain the assailant's saliva, thus DNA may be recovered. Do not wash away that potential evidence; instead, swab the skin surface with a sterile cotton-tipped applicator moistened with sterile saline. Such evidence rapidly degrades; therefore, obtain and send the swab to the crime laboratory as quickly as possible.DocumentationCareful documentation in the chart may assist in subsequent legal proceedings such as grants of temporary protective orders, permanent restraining orders, and child custody requests. Conversely, misinterpretation of physical injuries or other objective evidence may lead to an inaccurate opinion, which, if documented on the chart, may pose considerable problems when used in future court proceedings. Legibility and clarity of the medical record are vital. When the chart is illegible or unclear, the clinician frequently is subpoenaed to read and interpret the medical record. The chart should be dictated, typed, or neatly written. Adequate documentation in the chart should include narrative, diagrammatic, and photographic documentation. Reports suggest that more than half of the information for all assaults that is potentially obtainable at the time of the patient visit is not recorded on the medical record. Identity of the assailant, use of a weapon, and place of the assault should be routinely recorded. Yet, a study of 288 ED charts of intentional assault victims treated in a level 1 trauma center revealed absence of assailant identification in 67% of cases, no documentation of force or object used in 13%, and no documentation of place of assault in 79%. In a review of 100 patients (not limited to domestic violence) who presented to a level 1 trauma center in California, improper or inadequate documentation was found in 70% of the charts. In 38% of those cases, potential evidence was improperly secured, incorrectly documented, or inadvertently discarded.Mandatory reportingAnother potential pitfall in the medicolegal arena is that of reporting requirements. Homicidal threats that appear serious must be reported to law enforcement. The clinician also has a duty to attempt to warn potential victims of such threats. Review state law to determine what legal obligations, if any, EMS and ED personnel may have to report certain types of interpersonal violence. Other possible reporting requirements include those for the abuse or neglect of a child, elderly persons, or certain persons with disabilities. Most states have laws that may require health practitioners to report cases of domestic violence. The criteria for reporting and the authorities designated to receive such reports vary widely from state to state. Reporting facilitates timely steps to increase the victim's safety. Steps include immediate arrest of the perpetrator or obtaining an emergency protective order directing the suspect to stay away from the victim, thereby providing law enforcement a mechanism for making an arrest if the order is violated. Fears that mandatory reporting does more harm than good spring from concerns that the involvement of law enforcement against the will of the victim further strips power from someone who already feels powerless. Additionally, it may be possible that victims refuse to seek medical attention if they know that their partner will be reported and possibly arrested. Victims may fear that such reporting will anger the perpetrator and increase the level of violence. Mandatory reporting may raise conflicts between legal mandates and stated wishes of the patient, thereby creating an ethical dilemma. While the law must be obeyed, The Center for Healthcare Ethics (St Joseph Health System, Orange, CA) recommends a tripartite approach to the analysis of dilemmas with such multiple conflicts, examining in turn the medical, legal, and ethical issues in the case. The ethical principles operative in such case conflicts include patient autonomy, beneficence, and nonmaleficence, as well as the ethical obligation to respect confidentiality. Laws vary from state to state; therefore, emergency clinicians should obtain a copy of their state reporting statute and remain abreast of changes. Evaluate these statutes with the following questions in mind:What is the purpose of the statute? What is to be reported? Who makes the report? What level of knowledge or suspicion is required of the reporter? Who receives the report and what is their response? Are there penalties for failing to report? Is immunity from liability provided? Are there provisions for confidentiality of reports? Are provider-patient privileges explicitly revoked? Is there case law interpreting provider liability?Failure to report domestic violence as required has the potential for liability exposure. There may also be obligations under common law to report domestic violence. Conversely, reporting suspected but unsubstantiated domestic violence has potential for liability exposure. When reporting is required, however, state laws generally have statutory protections from liability similar to the reporting of suspected child abuse. When not required to do so, clinicians could be held liable for breaching confidentiality or privacy by reporting domestic violence. Routine inquiry about, diagnosis of, and prompt treatment and referral for victims of interpersonal violence is becoming recognized as the accepted standard of care. Failure to diagnose and treat can leave the clinician vulnerable to liability. A civil suit could be filed, under a theory of negligence, as a result of failing to diagnose and treat domestic violence. A group of 577 men and women were questioned in a 3-part study involving 2 EDs and a primary care clinic, an inner-city ED, and community outreach centers for battered women. Most people interviewed (85%) felt domestic violence screening was appropriate. One study of ED patients found that 62% of patients did not feel that mandatory reporting laws made a difference in seeking health care, with another 27% more likely to seek ED care, while 12% stated they were less likely to seek care when a mandatory reporting requirement existed. Another study, however, revealed almost the opposite, with two thirds of women indicating that mandatory reporting decreased the likelihood of disclosing abuse.
Special Concerns
Pregnant patientsInjury during pregnancy indicates direct questioning about domestic violence and requires thorough physical examination. Violence may be a more common problem for pregnant women than preeclampsia, gestational diabetes, and placenta previa. Most studies report the prevalence of violence during pregnancy in the range of 3.9-8.3%, although others indicate a much higher prevalence. In one study, approximately 23% of sexually exploited teens became pregnant by their perpetrator. The prevalence of battering during teen pregnancy reportedly ranges up to 22%. Two patterns of violence appear to occur as follows:Women who were not previously abused may become victims of acute violence. For women who experience abuse periodically or regularly, the pattern of violence may increase or decrease in severity or frequency during pregnancy.In fact, violence during the postpartum period may be more prevalent than during pregnancy. Ross reported that 13% of women first experience abuse during pregnancy,12 although Salber and Taliaferro indicated that 40% of battering begins during the first pregnancy. Twenty-one to 29% of women report increasing abuse during pregnancy, while some pregnant women report a decrease in abuse. Domestic violence during pregnancy, as with domestic violence in general, crosses all lines of class, race, and education. Pregnant women who are abused are 4 times more likely to have children with low birth weight.Pediatric patientsThe American Academy of Pediatrics reports that, while abused women are often reluctant to seek care for their own injuries, most women continue to obtain medical care for their children. Thus, seeing a pediatric patient may provide the only opportunity to recognize domestic violence in some women, and thereby the only opportunity for early intervention. Children are frequently silent victims of domestic violence, directly witnessing 85% of assaults. Approximately 10 million children are annually exposed to domestic violence in some form. Children not only witness battering, they also comprise 15% of victims injured in domestic assaults. Children of abused women are 57 times more likely to be harmed because of intimate partner violence between their parents, versus children of nonabused mothers. In a home in which a husband has hit his wife, there is a greater chance of child abuse. In 30-70% of domestic violence relationships, children are themselves being beaten. Among children of battered women, 34% of boys and 20% of girls demonstrate clinically significant behavioral problems. Men and women who have witnessed abuse are more likely to be in an abusive relationship, as is true of those who were abused as children. Children who are exposed to family violence may perceive such behavior as usual or acceptable, thus increasing the likelihood that they will imitate the roles of aggressors or victims and ensuring continuation of violence from generation to generation. Of children from violent households, 30% become abusive parents, a rate 10 times higher than for the general population. Children who experience multiple forms of psychological hardship, including an abusive home, demonstrate an increased risk for development of heart disease as adults, even when controlling for other factors such as obesity, smoking, and depression.Geriatric patients: Of female victims of elder abuse, approximately a third to half of women older than 65 years are being beaten by their partners.
FURTHER READING
Section 8 of 9
Authors and Editors
Introduction
Clinical
Differentials
Treatment
Follow-up
Miscellaneous
Further Reading
References
Family Violence Prevention Fund, Health Care Programs National Coalition Against Domestic Violence National Domestic Violence Hotline (with listing of individual state hotlines)
REFERENCES
Section 9 of 9 
Authors and Editors
Introduction
Clinical
Differentials
Treatment
Follow-up
Miscellaneous
Further Reading
References
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Domestic Violence excerptArticle Last Updated: Sep 23, 2008
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