What is the most appropriate action when a patient with scattered bruises and abrasions on their arms and back, presenting with mild epigastric pain, denies domestic violence and requests that it not be reported to authorities?

Managing Suspected Domestic Violence in the Emergency Department

The most appropriate action when encountering a patient with signs of domestic violence who refuses reporting is to educate the patient about violence while respecting their autonomy. 1

Assessment of the Situation

When encountering a patient with physical signs suggestive of abuse (scattered bruises and abrasions) alongside a seemingly unrelated chief complaint (mild epigastric pain), it's critical to:

• Document all physical findings thoroughly, including location and appearance of bruises and abrasions
• Note the discrepancy between the presenting complaint and physical findings
• Assess immediate safety concerns by directly asking if the patient feels safe or has been threatened 2
• Evaluate for other injuries that may require immediate medical attention

Ethical and Legal Considerations

Emergency physicians have an ethical duty to diagnose, treat, and properly refer suspected victims of abuse and neglect 1. However, this duty must be balanced with respect for patient autonomy in cases where reporting is not mandatory by law.

Key considerations include:

• Understanding your state's mandatory reporting laws for domestic violence
• Recognizing that adult patients generally have the right to refuse intervention
• Acknowledging that forcing unwanted reporting may damage the therapeutic relationship and potentially increase danger to the patient

Recommended Approach

1. Provide education about domestic violence 1, 2:

   • Explain the cycle of violence and escalation patterns
   • Discuss health impacts of continued abuse
   • Provide information about available resources

2. Ensure proper medical care:

   • Treat the presenting epigastric pain
   • Document injuries thoroughly with photographs when possible 2
   • Offer appropriate testing and treatment for any injuries

3. Offer resources without forcing action:

   • Provide contact information for domestic violence hotlines
   • Offer social work consultation while the patient is still in the ED
   • Create a safety plan with the patient if they're willing

4. Maintain confidentiality while encouraging disclosure:

   • Reassure the patient about confidentiality (within legal limits)
   • Explain that documentation now may help if they choose to report later
   • Offer follow-up appointments to build trust and provide ongoing support

Common Pitfalls to Avoid

• Forcing unwanted reporting: This can violate patient autonomy and potentially increase danger if the patient returns to an abusive situation after unwanted intervention 3, 4
• Dismissing signs of abuse: Failing to address obvious signs of violence is negligent
• Judgmental attitudes: Questioning why the patient stays or expressing frustration can damage trust
• Inadequate documentation: Poor documentation limits options if the patient later decides to pursue legal action

Follow-up Recommendations

• Schedule a follow-up appointment within 1-2 weeks
• Provide written resources that can be discreetly kept
• Establish a code word system for future communications if the patient is concerned about privacy
• Document your education efforts and the patient's decision in the medical record

By educating the patient about domestic violence while respecting their autonomy, you fulfill your ethical duty as a physician while maintaining the therapeutic relationship that may ultimately lead to the patient seeking help when they are ready.