Health Care Providers on Front Lines of Domestic Violence Defense

HERSHEY – Domestic violence has become recognized as a health-care issue over the last 15 years. This is significant because every year, millions of people, mostly women, are beaten in the United States. Their injuries may be serious. Of women evaluated in the emergency room for domestic violence, about 25 percent require hospitalization. Despite the severity of injury, most who have experienced domestic violence say the psychological harm is the most difficult to deal with.

It has become the standard of care for health workers to screen for domestic violence and be prepared to appropriately refer patients who disclose abuse in their lives. The rationale for including health-care workers in the multidisciplinary team effort — which includes members of the criminal justice system, social workers, lawyers, advocates, psychologists and others — is complex.

Foremost is the fact that physicians and other caregivers have the opportunity to identify and intervene in domestic violence at all stages of the life cycle, from the neonatal period until patients become elders. Also, there is reason to believe that early intervention is more successful than late intervention. Finally, it is very apparent that violence, particularly that brought on by loved ones, at any stage of life, has dire consequences to health and well-being.

We know that family violence is a common issue; however, patients most often will not discuss it unless they are asked directly. When asked in a confident, nonjudgmental tone, studies show patients are not upset in any way by these questions. In fact, they say it makes them feel their caregivers care about them. These conversations should always be private. Confidentiality and safety of the patient are primary concerns.

Domestic violence can also become apparent to health-care workers when they see certain signs. Physical examples would be injuries, particularly multiple injuries from different times. Other signs include partners who refuse to let the patient be alone with the health-care worker or who appear overly attentive or controlling or actually mean or belittling. Victims often complain of chronic abdominal, back or pelvic pain, headaches or irritable bowel. Depression and anxiety are commonly associated with domestic violence as well.

When a patient discloses domestic violence there are a number of things health-care workers can do. First, they can assure the victim that patient confidentiality will be respected and maintained. Second, they can remind their patient that they do not deserve to be treated that way. Caregivers can determine the victim’s current degree of safety. Noting a simple history of when the first episode occurred, the last and the worst incident can help determine the current risk.

Health-care workers can help victims establish plans for what to do under certain circumstances, such as if things get worse, or if certain threats are made by the perpetrator. Threats of violence to the victim or of suicide by the perpetrator often predict lethal events and need to be viewed with utmost concern and action.

Victims of domestic violence may not fully understand the risk they are facing. Referral to a domestic violence advocate, the county shelter or a domestic violence hot line is crucial and should be part of the safety plan developed by caregivers and their patients. Close follow-up is necessary and health-care workers should keep the door open and encourage discussion on safety at each visit.

Documentation in the medical record is another important issue. The visit should be recorded and remain confidential. The history should be recorded in the patient’s own words, without opinion interjected. If there are physical findings they should be carefully recorded, in detail. Photographs are the gold standard for injuries, but not readily available from most health-care workers.

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