1 An Ethical Framework for Physicians to Learn the Knowledge and Skills to Address Intimate Partner Violence (IPV) Vijay Singh, MD, MPH University of Michigan Department of Family Medicine Robert Wood Johnson Clinical Scholar

2 Objectives

3 Learn effective behavior and communication around IPV

4 Objectives Learn effective behavior and communication around IPV Understand mandatory reporting for IPV

5 Objectives Learn effective behavior and communication around IPV Understand mandatory reporting for IPV Define ethical principles: beneficence, non- maleficence, autonomy

6 Objectives Learn effective behavior and communication around IPV Understand mandatory reporting for IPV Define ethical principles: beneficence, non- maleficence, autonomy Describe clinical ethics framework (Jonsen, 2006)

7 Case

8 CC/ID: CP, SOB in 40 year-old woman seen in primary care

9 Case CC/ID: CP, SOB in 40 year-old woman seen in primary care HPI/PMH: H/o anxiety attacks treated w BDZ. H/o previous visits for trauma from reported falls.

10 Case CC/ID: CP, SOB in 40 year-old woman seen in primary care HPI/PMH: H/o anxiety attacks treated w BDZ. H/o previous visits for trauma from reported falls. SH: Lives w boyfriend, daughter. Employed as salesclerk. Boyfriend watches daughter after school.

11 Case P/E, labs: (-) cardiac or respiratory disease. Physical signs of bruising on arms.

12 Case P/E, labs: (-) cardiac or respiratory disease. Physical signs of bruising on arms. Assessment: Anxiety attack, h/o trauma.

13 Case P/E, labs: (-) cardiac or respiratory disease. Physical signs of bruising on arms. Assessment: Anxiety attack, h/o trauma. Is there evidence to suggest she’s an IPV victim?

14 IPV screening components

15 IPV screening components Review medical history

16 IPV screening components Review medical history Know mandatory reporting requirements

17 IPV screening components Review medical history Know mandatory reporting requirements Ask direct questions

18 IPV screening components Review medical history Know mandatory reporting requirements Ask direct questions Safety planning and referrals

19 Review medical history What in case makes you suspect IPV?

20 Review medical history What in case makes you suspect IPV? –History of anxiety. Also look for depression, PTSD, substance use, suicide attempts

21 Review medical history What in case makes you suspect IPV? –History of anxiety. Also look for depression, PTSD, substance use, suicide attempts –Previous medical visits for injuries not fully explained

22 Mandatory reporting What are laws around IPV?

23 Mandatory reporting What are laws around IPV? –40 states mandate reporting of specified instances where patient has an injury

24 Mandatory reporting What are laws around IPV? –40 states mandate reporting of specified instances where patient has an injury –

25 Mandatory reporting What are laws around IPV? –40 states mandate reporting of specified instances where patient has an injury – –Colorado: “Physicians are required to report to law enforcement if they attend or treat an injury…they have reason to believe involves a criminal act including injuries resulting from domestic violence.” (Hyman, 2004)

26 Ask direct questions

27 Ask direct questions Be aware of mandatory DV reporting law and inform patient of requirement

28 Ask direct questions Be aware of mandatory DV reporting law and inform patient of requirement Explain limitations in confidentiality

29 Ask direct questions Be aware of mandatory DV reporting law and inform patient of requirement Explain limitations in confidentiality Consider use of 8-question screen (Rhodes, 2009)

30 Safety planning What are patient options when IPV is identified?

31 Safety planning What are patient options when IPV is identified? –Stay with abuser and formulate a safety plan

32 Safety planning What are patient options when IPV is identified? –Stay with abuser and formulate a safety plan –Remove abuser through arrest or protective orders

33 Safety planning What are patient options when IPV is identified? –Stay with abuser and formulate a safety plan –Remove abuser through arrest or protective orders –Leave the relationship temporarily or permanently

34 Safety planning What questions can you ask to assess safety?

35 Safety planning What questions can you ask to assess safety? –Are you or your family members in danger?

36 Safety planning What questions can you ask to assess safety? –Are you or your family members in danger? –Has violence escalated recently?

37 Safety planning What questions can you ask to assess safety? –Are you or your family members in danger? –Has violence escalated recently? –Are there weapons in the home?

38 Safety planning What questions can you ask to assess safety? –Are you or your family members in danger? –Has violence escalated recently? –Are there weapons in the home? –If you aren’t safe, do you have a safety plan?

39 Referrals Refer patient to National DV Hotline – SAFE

40 Referrals Refer patient to National DV Hotline – SAFE –Staffed 24 hours a day in English, Spanish and more than 170 different languages through interpreter services

41 Referrals Refer patient to National DV Hotline – SAFE –Staffed 24 hours a day in English, Spanish and more than 170 different languages through interpreter services –

42 Case You feel there’s enough evidence to suggest IPV

43 Case You feel there’s enough evidence to suggest IPV Pt reports IPV but she wants to stay with partner

44 Case You feel there’s enough evidence to suggest IPV Pt reports IPV but she wants to stay with partner She requests no IPV reporting because she fears:

45 Case You feel there’s enough evidence to suggest IPV Pt reports IPV but she wants to stay with partner She requests no IPV reporting because she fears: –retaliation from partner

46 Case You feel there’s enough evidence to suggest IPV Pt reports IPV but she wants to stay with partner She requests no IPV reporting because she fears: –retaliation from partner –child protective services might remove daughter from home

47 Case You feel there’s enough evidence to suggest IPV Pt reports IPV but she wants to stay with partner She requests no IPV reporting because she fears: –retaliation from partner –child protective services might remove daughter from home What are the ethical problems involved?

48 Ethical principles

49 Ethical principles Beneficence: duty to assist patient

50 Ethical principles Beneficence: duty to assist patient Non-maleficence:

51 Ethical principles Beneficence: duty to assist patient Non-maleficence: –duty to refrain from causing harm

52 Ethical principles Beneficence: duty to assist patient Non-maleficence: –duty to refrain from causing harm –“do no harm”

53 Ethical principles Beneficence: duty to assist patient Non-maleficence: –duty to refrain from causing harm –“do no harm” Autonomy: duty to respect patient preferences

54 Ethical principles Beneficence: duty to assist patient Non-maleficence: –duty to refrain from causing harm –“do no harm” Autonomy: duty to respect patient preferences Dilemma is when beneficence and non- maleficence come in conflict with autonomy

55 How do the ethical principles connect with the case?

56 How do the ethical principles connect with the case? Clinical ethics framework (Jonsen, 2006)

57 How do the ethical principles connect with the case? Clinical ethics framework (Jonsen, 2006) –Medical indications: diagnose and manage conditions

58 How do the ethical principles connect with the case? Clinical ethics framework (Jonsen, 2006) –Medical indications: diagnose and manage conditions –Patient preferences: desires for treatment and care

59 How do the ethical principles connect with the case? Clinical ethics framework (Jonsen, 2006) –Medical indications: diagnose and manage conditions –Patient preferences: desires for treatment and care –Quality of life: subjective (patient) and objective (provider) assessment

60 How do the ethical principles connect with the case? Clinical ethics framework (Jonsen, 2006) –Medical indications: diagnose and manage conditions –Patient preferences: desires for treatment and care –Quality of life: subjective (patient) and objective (provider) assessment –Contextual factors: family, religion, law

61 Medical Indications (Tilden, 1994) How can the patient receive benefit from medical care?

62 Medical Indications (Tilden, 1994) How can the patient receive benefit from medical care? –Establish anxiety disorder as reason for CP, SOB.

63 Medical Indications (Tilden, 1994) How can the patient receive benefit from medical care? –Establish anxiety disorder as reason for CP, SOB. –Limiting use of BDZ to relieve anxiety symptoms.

64 Medical Indications (Tilden, 1994) How can the patient receive benefit from medical care? –Establish anxiety disorder as reason for CP, SOB. –Limiting use of BDZ to relieve anxiety symptoms. –Above are examples of beneficence

65 Medical Indications (Tilden, 1994) How can the patient receive benefit from medical care? –Establish anxiety disorder as reason for CP, SOB. –Limiting use of BDZ to relieve anxiety symptoms. –Above are examples of beneficence How can harm be avoided?

66 Medical Indications (Tilden, 1994) How can the patient receive benefit from medical care? –Establish anxiety disorder as reason for CP, SOB. –Limiting use of BDZ to relieve anxiety symptoms. –Above are examples of beneficence How can harm be avoided? –Identify IPV and treat appropriately

67 Medical Indications (Tilden, 1994) How can the patient receive benefit from medical care? –Establish anxiety disorder as reason for CP, SOB. –Limiting use of BDZ to relieve anxiety symptoms. –Above are examples of beneficence How can harm be avoided? –Identify IPV and treat appropriately –Above is an example of non-maleficence

68 Patient preferences (Tilden, 1994) What does the patient want?

69 Patient preferences (Tilden, 1994) What does the patient want? –Example of autonomy

70 Patient preferences (Tilden, 1994) What does the patient want? –Example of autonomy Is the patient competent to make decisions?

71 Patient preferences (Tilden, 1994) What does the patient want? –Example of autonomy Is the patient competent to make decisions? –Mood disorder can impair judgment

72 Patient preferences (Tilden, 1994) What does the patient want? –Example of autonomy Is the patient competent to make decisions? –Mood disorder can impair judgment Has the patient been informed of intervention benefits?

73 Patient preferences (Tilden, 1994) What does the patient want? –Example of autonomy Is the patient competent to make decisions? –Mood disorder can impair judgment Has the patient been informed of intervention benefits? –Safety planning, legal interventions, and mental health treatment can all be beneficial

74 Quality of life What is the patient’s subjective QOL assessment?

75 Quality of life What is the patient’s subjective QOL assessment? –Patient experiences anxiety attacks

76 Quality of life What is the patient’s subjective QOL assessment? –Patient experiences anxiety attacks –Patient may want to stay with partner out of fear, further suggestion poor QOL

77 Quality of life What is the patient’s subjective QOL assessment? –Patient experiences anxiety attacks –Patient may want to stay with partner out of fear, further suggestion poor QOL What are the views of the care providers?

78 Quality of life What is the patient’s subjective QOL assessment? –Patient experiences anxiety attacks –Patient may want to stay with partner out of fear, further suggestion poor QOL What are the views of the care providers? –IPV will likely continue without intervention, and continue patient’s poor QOL

79 Contextual factors

80 Contextual factors How does the law influence treatment decisions?

81 Contextual factors How does the law influence treatment decisions? –Physicians in most states (CO, MI) are mandated to report IPV if injury is present

82 Contextual factors How does the law influence treatment decisions? –Physicians in most states (CO, MI) are mandated to report IPV if injury is present What social circumstances influence the decision?

83 Contextual factors How does the law influence treatment decisions? –Physicians in most states (CO, MI) are mandated to report IPV if injury is present What social circumstances influence the decision? –Boyfriend provides child-care; patient must find other caregiver if he is removed from relationship

84 Contextual factors How does the law influence treatment decisions? –Physicians in most states (CO, MI) are mandated to report IPV if injury is present What social circumstances influence the decision? –Boyfriend provides child-care; patient must find other caregiver if he is removed from relationship –Unknown if daughter witnesses parental abuse or if daughter is being abused

85 Ethical dilemmas with mandatory reporting (Rodriguez, 2001)

86 Ethical dilemmas with mandatory reporting (Rodriguez, 2001) Why might victims want control over reporting?

87 Ethical dilemmas with mandatory reporting (Rodriguez, 2001) Why might victims want control over reporting? –Protect confidentiality

88 Ethical dilemmas with mandatory reporting (Rodriguez, 2001) Why might victims want control over reporting? –Protect confidentiality –Maintain autonomy

89 Ethical dilemmas with mandatory reporting (Rodriguez, 2001) Why might victims want control over reporting? –Protect confidentiality –Maintain autonomy –Fear of retaliation from abuser

90 Ethical dilemmas with mandatory reporting (Rodriguez, 2001) Why might victims want control over reporting? –Protect confidentiality –Maintain autonomy –Fear of retaliation from abuser –Fear of family separation

91 Ethical dilemmas with mandatory reporting (Rodriguez, 2001) Why might victims want control over reporting? –Protect confidentiality –Maintain autonomy –Fear of retaliation from abuser –Fear of family separation –Immigration status: fear of deportation

92 Effective communication to minimize harm under reporting law

93 Effective communication to minimize harm under reporting law Discuss with patient your obligation to report IPV if injuries are present

94 Effective communication to minimize harm under reporting law Discuss with patient your obligation to report IPV if injuries are present Address the risk of perpetrator retaliation and the need for precautions and safety planning

95 Effective communication to minimize harm under reporting law Discuss with patient your obligation to report IPV if injuries are present Address the risk of perpetrator retaliation and the need for precautions and safety planning Work with the patient and authorities to meet the patient’s needs when reporting

96 Effective communication to minimize harm under reporting law Discuss with patient your obligation to report IPV if injuries are present Address the risk of perpetrator retaliation and the need for precautions and safety planning Work with the patient and authorities to meet the patient’s needs when reporting Maximize the role of the patient’s input

97 Recommendation Goals of care

98 Recommendation Goals of care –Preserving the doctor-patient relationship

99 Recommendation Goals of care –Preserving the doctor-patient relationship Inform patient of duty to report IPV if injuries are present

100 Recommendation Goals of care –Preserving the doctor-patient relationship Inform patient of duty to report IPV if injuries are present –Getting the patient the care she needs

101 Recommendation Goals of care –Preserving the doctor-patient relationship Inform patient of duty to report IPV if injuries are present –Getting the patient the care she needs Safety planning and referral to safe housing, crisis hotline, and legal services

102 Recommendation Goals of care –Preserving the doctor-patient relationship Inform patient of duty to report IPV if injuries are present –Getting the patient the care she needs Safety planning and referral to safe housing, crisis hotline, and legal services –Provide close follow-up and continuing care

103 Recommendation Goals of care –Preserving the doctor-patient relationship Inform patient of duty to report IPV if injuries are present –Getting the patient the care she needs Safety planning and referral to safe housing, crisis hotline, and legal services –Provide close follow-up and continuing care Primary care follow-up

104 Case for discussion

105 Case for discussion CC/ID: 40 year-old man self-discloses he feels at risk for IPV perpetration

106 Case for discussion CC/ID: 40 year-old man self-discloses he feels at risk for IPV perpetration HPI/PMH: H/o chronic pain, screens positive for depression.

107 Case for discussion CC/ID: 40 year-old man self-discloses he feels at risk for IPV perpetration HPI/PMH: H/o chronic pain, screens positive for depression. SH: Lives with female partner. H/o incarceration for assault of previous partner.

108 Case for discussion CC/ID: 40 year-old man self-discloses he feels at risk for IPV perpetration HPI/PMH: H/o chronic pain, screens positive for depression. SH: Lives with female partner. H/o incarceration for assault of previous partner. Are you required to report patient’s disclosure?

109 Case for discussion CC/ID: 40 year-old man self-discloses he feels at risk for IPV perpetration HPI/PMH: H/o chronic pain, screens positive for depression. SH: Lives with female partner. H/o incarceration for assault of previous partner. Are you required to report patient’s disclosure? How can we maximize safety for patient and partner?

110 Discussion How do you approach case through Jonsen clinical ethics framework?

111 Discussion How do you approach case through Jonsen clinical ethics framework? What data and evidence are necessary to use framework?

112 Discussion How do you approach case through Jonsen clinical ethics framework? What data and evidence are necessary to use framework? What resources are available to the patient, partner and you?

113 Discussion How do you approach case through Jonsen clinical ethics framework? What data and evidence are necessary to use framework? What resources are available to the patient, partner and you? What recommendations do you make?

114 Discussion How do you approach case through Jonsen clinical ethics framework? What data and evidence are necessary to use framework? What resources are available to the patient, partner and you? What recommendations do you make? How can you incorporate what you learned into teaching students and residents?

115 Discussion

116 Clinical ethics framework Medical indications: diagnose and manage conditions –Treat depression: offer SSRI, counseling –Assess pattern of abuse, lethality risk, willingness to change –Refer to batterer intervention program (BIP), but let patient know this may not prevent violent behavior

117 Clinical ethics framework Patient preferences: desires for treatment and care –Patient’s self-disclosure of feeling at-risk for perpetrating abuse suggests he desires treatment

118 Clinical ethics framework Patient preferences: desires for treatment and care –Patient’s self-disclosure of feeling at-risk for perpetrating abuse suggests he desires treatment Quality of life: subjective (patient) and objective (provider) assessment –Patient endorses depressed symptoms; his mood and affect are congruent and all suggest poor QOL

119 Clinical ethics framework Contextual factors: law, family –Reporting necessary only if injury is present –This patient has no injury and therefore no report is necessary –Partner’s assessment of situation and safety are important

120 Recommendations Goals of care –Preserving the doctor-patient relationship Address IPV in non-judgmental manner

121 Recommendations Goals of care –Preserving the doctor-patient relationship Address IPV in non-judgmental manner –Getting the patient care he needs Referral to BIP, treat depression

122 Recommendations Goals of care –Preserving the doctor-patient relationship Address IPV in non-judgmental manner –Getting the patient care he needs Referral to BIP, treat depression –Provide close follow-up and continuing care Primary care F/U

123 Recommendations Goals of care –Preserving the doctor-patient relationship Address IPV in non-judgmental manner –Getting the patient care he needs Referral to BIP, treat depression –Provide close follow-up and continuing care Primary care F/U –Assess partner safety by asking if you can speak with partner about his health issues

124 References Jonsen AR, Siegler M, Winslade WJ. “Introduction,” in Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 6th Edition. McGraw-Hill, Hyman A. Domestic violence: Legal Issues for Health Care Providers. Trainer’s Manual for Health Care Providers, Family Violence Prevention Fund, Tilden VP, Schmidt TA. Family Abuse and Neglect: A Case-based Ethics Model. Academic Emergency Medicine. 1(6): Nov-Dec. PMID: Council on Ethical and Judicial Affairs, AMA. Physicians and Domestic Violence: Ethical Considerations. JAMA 267(23): , 1992 Jun. PMID: