Caring for the Dangerous Patient
Caring for the Dangerous Patient
Despite the longstanding expectation that the confidentiality of private patient information should be guarded at all costs, there has been a steady movement toward defining situations when the provider is required by law to report to appropriate authorities all suspected physical or mental danger to the patient or to others. In addition, virtually all states require a health care provider to report specific injuries and wounds (gunshots, animal bites, stab wounds), suspected child abuse, elder abuse, and/or vulnerable adult abuse to appropriate law enforcement agencies.
NPs may find the following points helpful to consider when caring for patients who threaten to harm themselves or others.
Advice to Nurse Practitioners
Despite the longstanding expectation that the confidentiality of private patient information should be guarded at all costs, there has been a steady movement toward defining situations when the provider is required by law to report to appropriate authorities all suspected physical or mental danger to the patient or to others. In addition, virtually all states require a health care provider to report specific injuries and wounds (gunshots, animal bites, stab wounds), suspected child abuse, elder abuse, and/or vulnerable adult abuse to appropriate law enforcement agencies.
NPs may find the following points helpful to consider when caring for patients who threaten to harm themselves or others.
Most states mandate that providers report some types of threats or potential harm. Some have limited reporting requirements to specific professionals, such as psychiatrists, psychologists, and mental health professionals. Others are more general and use the term health care provider, which in a growing number of states may include NPs. Consequently, NPs must be fully aware of the provisions of their current state laws in this regard to determine what actions are required regarding a duty to warn or a duty to protect.
New laws are emerging in response to current societal needs. New legislation and new court decisions may change the duty to warn or duty to protect requirements imposed on the NP.
Careful assessment of whether a patient presents an imminent threat of danger to himself or others includes any or all of these criteria:
Has the patient made any specific threats to cause self-harm or communicated a potential intent to harm others?
Has the patient identified a specific individual or target?
Has the individual identified a plan to implement the threat?
Has the patient identified a means (such as possession of a firearm or learning about how to construct a bomb) that could make the plan a reality?
If the patient speaks about self-harm or harming others, NPs should initiate the process to have him or her voluntarily or involuntarily admitted as an inpatient for further psychiatric workup.
If the patient does not fully meet the criteria for involuntary commitment, but the NP is still concerned, he or she should urge the patient to voluntarily commit himself to inpatient treatment.
If an NP is concerned that the patient presents an immediate and realistic threat to himself, others, or a provider, he or she should plan and prepare for his or her safety first. In this situation, the legal standard for "duty to warn" does not take priority over clinicians protecting themselves. They should keep in mind that providers are the closet first victim. Therefore, they need to have a policy and plan of action in their facility that includes signaling an emergency and protecting themselves and their staff or coworkers.
NPs should carefully document the advice they give the patient. If the patient refuses to follow advice, document the patient's refusal along with any reasons the person gives for not following that advice.
If an NP feels the patient is unfit to drive a car or ride on public transportation because of obvious balance issues or slurred speech (appears impaired), he or she should try to get consent for a toxicology screen for drugs or alcohol.
If an NP is unsure about what course of action to take with a difficult situation or patient presentation, he or she should seek a consultation with another provider who specializes in this type of condition. Sometimes the consultation should be with a mental health practitioner and sometimes with an attorney who specializes in the activities of concern.
NPs should carefully consider the ethical obligation to prevent harm (non-malfeasance) whenever possible. The prevention of injury not only protects the intended victim but also may help protect the patient from significant legal responsibilities if he or she carries out the violent act. This fact remains true regardless of where an NP practices in the US.
NPs should consider obtaining advice from the state board of nursing, legal counsel at the workplace, and the Occupational Health and Safety Administration (OSHA) in drafting a policy and procedure manual that addresses their rights and responsibilities when considering a potentially violent patient and their duty to protect or warn others.
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