Kevin Mego, Steven Siegel

A female patient arrived at the ER with a left arm injury sustained from a fall. The patient was professionally trained at this ER and familiar with the nurse in charge. An x-ray indicated a plaster cast should be applied, however after careful analysis of the recorded history and the x-rays it was suspected that the fracture was not from a fall but rather from a direct blow. When questioned, the patient proceeded to disclose to the nurse that the injury was from intimate partner violence (IPV) when her husband was drunk and threw her down the stairs. The patient also injured the right side of her chest causing painful inspiration. Her husband is a healthcare professional who had training in the same ER. The patient’s two young children were present during the commotion. The patient informed the nurse that she does not wish to document the mechanism of injury and does not want it disclosed to the attending physician. Patient also refused examination or treatment of the other injuries from the incident (Jenkins, 2005).

Ethics consultation was sought on whether or not to honor the patient’s request for non-disclosure in the chart and to the attending physician of the cause of the injury.

I recommend that the nurse encourage the patient for permission to disclose to the attending physician and medical records.

Beneficence requires us to act in a way that benefits others; preventing or removing harms and therefore promoting good (Yeo, Michael et al. 2010). The patient identifies two goals: avoid the risk of harm to her children, not risk her husband’s career by involving police. Autonomy means self determination, the right to make independent decisions concerning one’s own life and well-being ( Yeo et al., 2010). In this case the patient’s decision is to not disclose the information about the IPV, even if it means further harm is possible. The patient is aware of potential consequences of her decision to disclose the IPV to the nurse, however she is limiting her benefit by insisting on keeping the information from the attending physician. Is this decision truly a reflection of her character? Autonomy as authenticity explains that for a person to express true autonomy their decisions must be a reflection of who they are as a person, it must be consistent with her character. Autonomy as moral reflection explains how a patient understands the values that are important to them and makes choices consistent with those values. Confidentiality in health care is important to establish or maintain confidence and trust in the relationship between patient and provider (Kirk, 2015). To what extent must confidentiality be kept when the responsibility of a healthcare professional is the well being of the patient and her children? 

If we follow the patient’s autonomy in her decision, we are not removing harm rather we are allowing it. Following her wishes exposes her to further violence and distress, even not acting on it reinforces the physical abuse. In order for beneficence to be expressed we must break the vicious cycle of abuse and remove exposure to harm. Harm not only causes physical abuse to the patient but also subjects the children to an abusive environment which can be detrimental to their health to the point of developing psychological, emotional and behavioral problems.

Following the incident, the patient was under a great deal of emotional stress and pain which can cause her to behave “out of character”. Therefore, her decision may not be a true reflection of her identity but rather that of distress; it was not based on moral reflection. The patient freely disclosed the information of the nature of her injury to the nurse, this can be perceived as seeking help not only for herself but for her children. It can be inferred that the patient did not critically examine her values when making the decision to not disclose, otherwise she would not subject her children to both the current abuse and future risk of harm.

Nonmaleficence entails doing no harm to the patient. Her decision to not disclose directly contradicts this principle. There is a strong likelihood of future injuries without disclosure and proper documentation of the events. By not informing the attending physician, examination or treatment of the injuries sustained during the incident is not feasible. By acting on her wishes we would be allowing her injuries to worsen as examination and treatment would not occur.

Disclosure of IPV without the patient’s permission could be considered a violation of her confidentiality. This can in turn erode the patient’s trust in the ER department as a whole. The patient’s pursuit of confidentiality is also due to her desire to keep her husband’s career, however it may contradict her goal of protecting her children. Disclosing IPV or pressing charges with the police can lead to her husband losing his job. If information is disclosed social services might become involved and separate the family. What is certain is that if she does not disclose IPV her children may experience physical and emotional effects of violence which is in direct contradiction to the patient’s goal of protecting her children.

There is a greater likelihood of harm inconsistent with the patient’s goals if she were to insist on confidentiality from her attending physician and medical records.  Disclosing the IPV has greater benefit consistent with the patient’s goal of keeping her children safe. In this case, maintaining the privacy that the patient requests involves generating a risk to her life.

Confidentiality serves to increase trust between patient and provider and is not meant to “keep secrets”. How can a patient confidently trust a nurse with their health care if they prevent the attending physician from knowing all of the available facts about the case? In this case, the patient could have made the choice to not reveal aspects of her history regarding IPV, but she made a decision to disclose the information to the nurse. The nurse did not force the patient to disclose that specific information. The purpose of confidentiality is to maintain trust in order to honor patient’s integrity and respect their personhood in order to optimize clinical outcomes and prevent avoidable harm (Kirk, 2015). Documenting IPV and respectfully encouraging the patient to allow disclosure to the attending physician help to accomplish these goals.

By respecting the patient’s wishes to not disclose to the attending physician we may be respecting her decision, however we may also expose her and her children to further violence (Gremellion and Kanof, 1996). This future risk of IPV directly contradicts her goal of avoiding harm to her children. The perception of the staff was that by disclosing to the nurse the nature of the event, she is seeking help to avoid risk of future harm to her children. The patient prioritizes protecting her children from harm. She indicates this by sending her children to their grandmother in order to protect them. However, her action to not disclose the IPV to the attending physician is not consistent with her goal. Following the patient’s wishes in this situation, whilst demonstrating respect for her autonomy, may expose them to further violence. Based on the principles of autonomy, beneficence, and confidentiality I recommend that the patient disclose the information to her attending physician and medical record.

References:

Gremellion, D., Kanof, E., 1996. Overcoming barriers to physician involvement in identifying and referring victims of domestic violence. Annals of Emergency Medicine 27 (6), 769–773.

Jenkin, A, Millward, J. (2006).  A moral dilemma in the emergency room: Confidentiality and domestic violence . Accident and Emergency Nursing, 14(1), 38-42.

Kirk, TW. (2015).  Confidentiality .  In N Cherny, M Fallon, S Kaasa, R Portenoy, & D Currow (eds.). Oxford Textbook of Palliative Medicine. (5th ed.) New York/London: Oxford University Press, pp. 279-284.

Yeo, Michael et al. (2010). Beneficence . In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 103-116.

Yeo, M et al. (2010). Autonomy  [selections]. In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 91-97, 103-109.