Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 2
Jennifer is a 32-year-old married woman who presents for an annual exam with her 6 year old daughter. She works full-time as an ophthalmologist and appears clean, professional, and poised. Jennifer and her husband have been your patients for 5 years, and her overall health is good, with only minor health concerns in her past medical history. Jennifer’s appointment is in the afternoon, and you are running late after a series of delays with previous patients. You review her vitals and start to perform a physical exam. You glance at the clock and see you are already out of time for this appointment. To save time, while you are performing a breast exam, you ask Jennifer “Do you feel safe in your relationship?” To your surprise, she suddenly tears up and averts her eyes. She does not immediately respond to the question.
1. What are some examples of communication strategies you should avoid when collecting more information?
2. What IPV-specific documentation should you include in your progress note for this encounter?
Discussion: In the interview with Jennifer, it is important to refrain from asking questions in a manner that might frighten or intimidate your patient, increase the sense of humiliation and shame about the violence, or be interpreted as blaming the survivor for the situation. Since discussing IPV can be very difficult and can leave patients feeling vulnerable, Jennifer may feel more comfortable having a discussion while fully clothed. Discussions about IPV should be avoided in the presence of children who can comprehend the situation, so it may be best to have Jennifer’s daughter leave the room or have Jennifer call the clinic later to discuss when she is alone. In addition, Jennifer should be assured that patient confidentiality will not be broken by disclosing any information or discussing concerns with her husband. When documenting the encounter in a progress note, it is important to use Jennifer’s words in quotations whenever possible to detail her description of her relationship safety. If any injuries are found during the physical exam, they should be described in detail, as well as an opinion on whether the injuries were adequately explained. Photographs or additional imaging studies may be included if appropriate.
Many IPV programs staff a daytime or 24- hour hotline, or link with regional or state-wide hotlines. A 24-hour national hotline is available at 1-800-799-SAFE (7233). It is not unusual for survivors in the community to use hotline services anonymously and also to call multiple times before actually visiting an agency for in-person help. Crisis hotlines are available not only to survivors but also to concerned friends and family, as well as professionals who are seeking more accurate information about community-based services. Some IPV programs offer legal advocacy, and in some cases, actual legal representation. Legal advocates can educate survivors about their legal rights and options, including applying for orders of protection, or representation in divorce and custody hearings. Translation Services Professional interpreters or translators who are trained in maintaining patient confidentiality should be used whenever possible if a language barrier is evident in a clinical encounter involving IPV. Otherwise, there is a risk of compromising the quality of the information being translated and can put the survivor in danger or lead to a missed opportunity for intervention. Providers should never use accompanying persons (i.e., friends, relatives, children) as interpreters.
The person chosen could actually be the perpetrator or they could inadvertently breach confidentiality by speaking about the conversation with others. Additionally, if the translator is a member of the survivor’s community, shame or stigma may prevent the survivor from disclosing the abuse. Remote telephone interpretation services are an appropriate alternative when an in-person interpreter is from the survivor’s small community or is not available. Regardless of language, providers need to avoid assuming literacy. Just because a patient can speak a language does not mean they can read or write it, and vice versa. Intervention Strategies The USPSTF, in a systematic review of the literature, found “adequate” evidence that effective IPV interventions that provide or refer patients to ongoing support services can reduce violence, abuse, and physical or mental harms for women of reproductive age. 1 Evidence from randomized trials support various interventions including counseling, home visits, information cards, referrals to community services, and mentoring support. Depending on the type of intervention, these services may be provided by clinicians, nurses, social workers, non-clinician mentors, or community workers. Counseling generally includes information on safety behaviors and community resources.
In addition to counseling, home visits may include emotional support, education on problem-solving strategies, and parenting support. 1 Health care providers should bear in mind four guiding principles of intervention when addressing IPV with their patients: 33 Patient Safety Patient assessment, documentation, safety planning, communication, intervention, and follow- up must be conducted with utmost concern for the immediate and long-term safety of the survivor and their dependent children. The clinician should ask, “Is what I am asking/doing/recommending going to help my patient become safer, or at least not place the patient at risk for further harm?” Survivor Empowerment Abused individuals have often been denied their freedom to make informed, independent choices about their (and their children’s) lives. Facilitating the patient’s ability to make their own choices is key to restoring a sense of purpose and well-being for survivors of IPV, and can facilitate a patient’s readiness to take proactive steps to end the violence.
94
Powered by FlippingBook