When we inform Ms. L of our findings, she frantically insists that her caretaker is beating her once a week and that the abuse has gone undetected. We become skeptical, recalling that Ms. L earlier said the beatings were daily.
Ms. L says she is afraid to go home and wonders where she can stay. Having no friends or other family members nearby, she requests hospitalization.
At this point, I would:
- discharge Ms. L to a safe house with close follow-up
- hospitalize her for safety and diagnostic clarification
- discharge her to her stepsister with close follow-up
The authors’ observations
Ms. L’s allegations pose a medical, ethical, and legal challenge. Physical examination and input from a protective services officer suggest Ms. L is fabricating the allegations. On the other hand, if the accusations are true, sending Ms. L home with her stepsister would endanger her.
We could hospitalize the patient and substantiate the allegations later, but we cannot justify taxing limited hospital resources when the need is questionable. We cannot send her to a safe house because of her severe physical disability, nor can we discuss the allegations with her stepsister because Ms. L instructed us not to.
Online help for caregivers
- Caregiver.com (online magazine)
www.caregiver.com - Caring Today
www.caringtoday.com - National Alliance for Caregiving
www.caregiving.org - National Alliance on Mental Illness
www.nami.org (Click on “Find Support,” then “Education, Training, and Peer Support Programs”)
DISPOSITION: Going home
After meeting with hospital officials and clinic staff, we decide that Ms. L does not meet admission criteria. We discharge her to her stepsister and see the patient again the next day.
The authors’ observations
Legal duty. Our legal duty to protect a suspected abuse victim depends on the jurisdiction in which treatment is delivered.
Many states do not require physicians to report suspected abuse, but this complicates the decision process. If the suspicion is correct, not reporting it might constitute malpractice or negligence and could provoke future lawsuits or complaints to the state medical board. Worse, the abuse may escalate and cause irreparable harm to the patient. Conversely, reporting unfounded suspicions of abuse can destroy the doctor-patient relationship, prompt the caregiver to retaliate against the patient, or inspire patients or caregivers to sue the physician.
If you suspect patient abuse and your state mandates reporting, contact the state protective services agency at once (seeRelated Resources,). Base your report on a thorough history and physical, psychiatric evaluation, and—when available—collateral information.
If your state does not mandate reporting, obtain the patient’s consent to file a complaint with state protective services. By providing informed consent, the patient gives permission to disclose protected health information, and confidentiality is not breached.
Be careful when obtaining informed consent, especially when the patient is ambivalent about reporting because of:
- fear of retaliation from the abuser
- fear of the social stigma associated with abuse
- or the patient’s false belief that she deserves the abuse.
Ethical responsibility. Even if our legal responsibility is minimal, we should go further to do what is best for the patient.
Texas, for example, does not require physicians to hospitalize or find a safe environment for a suspected abuse victim.2 But if you see evidence of abuse, notify authorities and offer the patient information about local safe houses, support groups, and social services—even if not mandated by law. If resources are available, consider hospitalizing the patient and work with his or her social worker, therapist, or clergy to orchestrate outpatient services.
Whether or not abuse has occurred, empathizing with the caretaker about the difficulty of caring for the patient could diminish the caretaker’s stress and reduce the risk of abuse.