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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Mandated Reporters: Do RNs report at higher rates than PCPs?
Without evidence, physicians must rely on anecdotal experiences and perceptions
Realities of reporting abuse
Intuition and harm reduction in reporting elder abuse
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Julie M. Parent, Preston, CT, USA RN, BSN/ Public Health& Community Nursing
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Dear Authors: It is unsettling, although not surprising, that primary care physicians have a low rate of reporting suspected elder abuse or neglect. It will be interesting to find what, if any, statistics or original research studies exist to date that demnostrate reporting levels among RNs, especially those who are involved in public health and community health nursing. The risk of alienating the family and patient is high; however, the alternative risk of suspecting neglect or abuse and avoiding the intervention is much higher. This is not merely a litigation risk, as most, if not all, mandated reporters are protected from litigation, providing they made such a referral "in good faith." Laws vary from state to state, of course; however it is doubtful that a health care professional could be sucessfully sued for filing a report of child or elder abuse. It is a concern that this might become a barrier to intervention, as the concerned health care professional has an obligation to the patient first. In such circumstances, it is a good practice to involve any reasonable familiy members and other memebers of the health care team to a family conference to discuss the concerns of the health care professional. In many circumstances, families (or other practitioners) are aware of abuse or neglect, and an intervention, however threatening initially, may ultimately be a relief. The referral by a professional takes the onus of reporting abuse or neglect away from the family, if they are aware of such abuse and have not intervened thus far, and in doing so places it on the reporter. Needless to say, such families where abuse is a long-standing issue, are generally dysfunctional, and a sincere, helpful, non-threatening intervention is often a welcome avenue they might otherwise never explore. This is a topic that deserves much study. There exists the need to make such interventions helpful, not hurtful, for the elderly. This can done in a manner so as to preserve the sometimes tenuous relationships our elderly citizens maintain with their healthcare providers. Thank you for a provocative research analysis. Sincerely Yours, Julie M. Parent, RN, BSN Connecticut, USA Competing interests: None declared |
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Carmel B Dyer, Houston, Texas Academic physician
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Drs. Rodriguez, Wallace, Woolf and Mangione are to be congratulated on their fine work. They have scientifically examined the attitudes of primary care physicians towards the reporting of elder mistreatment. The findings of Rodriguez et al nicely illustrate the experiences of members of our elder abuse response team, the Texas Elder Abuse and Mistreatment Institute and that seen in our paper of the views of geriatricians on identifying elder mistreatment. (1) Physicians’ fear of negative impact on rapport is a real one; perhaps the families will completely isolate the victim/patient if he or she is reported to an agency. However once reported the hope is that the investigating agency will address the concerns. Failure to report due to a favorable relationship with family members may result in mistaking the perpetrator for a worried caregiver, a frequent scenario in domestic violence cases. Failure to report due to concern about Adult Protective Service (APS)interventions was a concern to the physicians in our study; however there is little evidence to inform that opinion as there has not been a study of APS interventions in over thirty years. In many if not most states, anyone making a report in good faith is exempt from liability. The paradoxes presented in this work are the result of a lack of data to inform health care providers. This article underscores the real truth; that is without evidence, physicians must rely on anecdotal experiences and perceptions. The federal government mandates that all states have some agency to protect seniors. Elder abuse is a risk factor for death and the numbers of US reports increased by 20% from 2000 to 2004.(2,3) The state protective service agencies do not have research units to guide their processes; instead they do what they think will help seniors, and they do it often with very limited budgets. At this point in time, until rigorous research is funded and conducted, APS intervention is the best that we have. Interested physicians who form collaborative relationships with APS agencies find their interactions with APS workers fruitful and beneficial to patients. It is probably the understanding of each other’s limitations and the mingling of medical care and social service resources that make the collaborations work. (4) Kudos to the authors for focusing on this critical issue. (1)Harrell R, Toronjo C, Pavlik VN, Hyman DJ, McLaughlin J, Dyer CB: How geriatricians identify elder abuse and neglect. Am J of Med Sci, 323(1):34-38, 2002. (2) Lachs Ms, Williams CS, O'Brian S, et al. Mortality of elder mistreatment. J Am Med Assoc. 1998;280(5):428-432. (3) The 2004 Survey of State Adult Protective Services: Abuse of Adults 60 Years of Age and Older. Washington DC: National Center on Elder Abuse, 2006. (Accessed on July 24, 2006 at http://www.apsnetwork.org/Resources/docs/AbuseAdults60.pdf ) (4)Brandl B, Dyer CB, Heisler CJ, Otto J, Stiegel L, Thomas R: Elder Abuse Detection and Intervention: A Collaborative Approach. 2006 Springer. Competing interests: None declared |
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Therese M Zink, Minneapolis MN Physician, UMN
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Accolades to Dr. Rodriquez et. al. for this important work. He confirms what we found in interviews and focus groups conducted with 44 providers about managing older women with domestic violence.(1) Providers don’t want to ask about things for which they don’t have good solutions or resources that work. Similar issues occur in child abuse. (2) Some communities have good support, many do not. The ratchet is now tighter due to current public policies and budget cuts. The social network is limited in what they can provide. This should be a wake up call to policy makers as we move into the next election cycle. 1. Zink T, Regan S, Goldenhar L, Pabst S. Intimate Partner Violence: Physicians’ Experiences with Women over 55. Journal of the American Board of Family Practice. 2004; 17:332-40. 2. Zink T, Kamine D, Musk L, Sill M, Field V, Putnam F. What Are Physicians’ Reporting Requirements For Children Who Witness Domestic Violence (DV)? Clinical Pediatrics. 2004;43(5): 449-460. Competing interests: None declared |
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Daniel Pound, San Francisco, CA UCSF Department of Family and Community Medicine
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Although physicians in practice encounter the contradictions inherent in suspected elder abuse, many physicians lack a forum for raising their own concerns about reporting abuse. I commend Dr. Rodriguez and his colleagues for their analysis, in particular as they described the extent to which physicians’s own biases may be subconscious. Their article will stimulate further research broadly into the realm of elder abuse reporting, and it will also stimulate physician readers to reflect on their own individual processing of paradoxes in reporting suspected abuse. Quotes from physicians who participated in the study make me curious to know more about two areas. Did awareness of the paradox between rapport and disclosure influence the extent to which physicians elicited more details after patients made indirect references about possible abuse? While direct allegations of physical abuse from cognitively intact patients can be clear cut, many elderly patients at risk for abuse unfortunately lack the memory or expressive language to describe abusive situations, requiring more intuition on the part of health care providers to recognize signs of abuse. How did participating physicians exercise intuition to interpret the history of cognitively impaired patients? I was most surprised by the finding that physicians considered their own risk for incurring lawsuits as a potential barrier to reporting. Educational programs may address this fear by reporting the legal precedents granting immunity to physicians who acted in good faith when reporting suspected abuse. Physicians quoted in the article expressed a model of harm reduction in their approach to assessing and reporting abuse. Often the same principle of harm reduction is carried forward by adult protective services after a report is filed, focusing as much on case management and recruitment of social services as on incrimination of a suspected abuser. Educational programs that give feedback to primary care physicians about outcomes of reported cases may help to encourage participation in the reporting process. Competing interests: None declared |
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