DEALING WITH DIFFICULT SITUATIONS

DOMESTIC ABUSE as appropriate. Midwifery services should be advised of

The Home Office revised the definition of domestic abuse in women who have been assaulted during pregnancy.
2013 as If the patient gives consent, referral to partner agencies,
follows: including the police and domestic abuse advocacy services,
may help to reduce repeat victimization. Research has
- Any incident or pattern of incidents of controlling,
indicated a significant reduction in risk, following referral to
coercive or threatening behavior, violence or abuse
an Independent Domestic Violence Advocate (IDVA).
between those aged 16 or over who are, or have been,
intimate partners or family members regardless of gender It is important that health staff contribute to local multi-agency
or sexuality. The abuse can encompass, but is not limited partnerships to tackle domestic abuse such as the Multi-
to: Agency Risk Assessment Conference (MARAC) and/or
Multi-Agency Safeguarding Hub (MASH).
• psychological
• physical
A vulnerable adult is someone ‘who is or may be in need of
• sexual
community care services by reason of mental or other
• financial disability, age or illness; and who is or may be unable to take
• emotional care of him or herself, or unable to protect him or herself
Controlling Behavior against significant harm or exploitation’.
- is a range of acts designed to make a person
subordinate and/or dependent by isolating them from There are many forms of abuse, including:
sources of support, exploiting their resources and • physical—including hitting, misuse of medication,
capacities for personal gain, depriving them of the and restraint;
means needed for independence, resistance and • sexual—including sexual assault and rape;
escape and regulating their everyday behavior. • psychological—including emotional abuse,
Coercive Behavior humiliation, and threats to harm;
- is an act or a pattern of acts of assault, threats, • financial or material—including fraud, theft, and
humiliation and intimidation or other abuse that is misappropriation of benefits;
used to harm, punish, or frighten their victim. • acts of omission or neglect—including ignoring
Note that this definition includes so-called ‘honour’-based physical or medical needs, delays in seeking care,
violence, female genital mutilation (FGM), and forced and failure to provide care or seek help;
marriage, and is clear that victims are not confined to one • discrimination—including racist, sexual, or
gender or ethnic group. disability-based comments

Health professionals are often the first point of contact for END ABUSE: a guide to intervention
people who have experienced domestic abuse, and they should • Empowerment. Enable people to know what their
be trained to give an appropriate response. The use of routine choices are—the choices need to be feasible and
enquiry about domestic abuse remains controversial. EDs practical (information should be made available and
should at least have a policy that promotes targeted screening known to staff in advance).
within a safe, confidential, and supportive environment. • Neglect is as much a form of abuse as a violent act.
Following disclosure of domestic abuse, clinicians should This may be the only sign; when identified, it
reassure the individual and seek to make it easier for them to requires action.
talk about their experiences by taking a non-judgmental • Documentation. Careful documentation, if there is
stance. Assessment of risk to the patient and their children injury and/or illness, is essential for future reference
should be undertaken. The Coordinated Action Against if legal action is to be taken.
Domestic Abuse (CAADA) Domestic Abuse, Stalking and Remember to document the patient’s own words.
Honour-Based Violence (DASH) Risk Identification Checklist • Advocacy. In the case of a vulnerable elderly person
(RIC) is a nationally recognized tool for assessing risk related who is either physically or mentally incapacitated and
to domestic abuse, including so-called ‘honour’-based is unable to speak for themselves, you may have to
violence. act as their advocate.
Staff should not encourage patients to leave their abusive • Be aware of the organizations that can assist and
partner, as only the individual will know when it is safe to do have to hand information that can be given to the
so. However, help should be given with safety planning, and victim (this may need to be done discreetly).
clinicians can facilitate access to a refuge if the patient • Understanding. Part of the intervention is to help the
requests it. When domestic abuse is disclosed, clinicians victim understand that abuse is a crime, that they are
should consider whether adult or child safeguarding factors a victim (it is not their fault), and that help is
exist and follow local Adult and Child Safeguarding policies available.
• Social services. Early involvement of social services
is essential when abuse is identified.
 DEALING WITH DIFFICULT SITUATIONS
• Education of staff in the recognition of elder abuse should be kept. They may need to be contacted for
and the sensitive steps to be taken when identified is witness statements at a later date.
fundamental.
RESUSCITATION, DEATH, AND COMMUNICATING
SEXUAL ASSAULT BAD NEWS
- When caring for a patient who discloses sexual assault, Witnessed resuscitation
clinicians should ascertain whether a vulnerable adult, - Exposure to resuscitation scenes in television dramas
child, or domestic abuse is a factor, and follow local adult appears to have had a role in preparing relatives for
and child safeguarding policy and/or domestic abuse what they might witness. Some clinicians are still
guidelines, as appropriate. uncomfortable with the concept of relatives being
- Following sexual assault, victims have three main care present, whilst resuscitation is being carried out.
needs:  forensic, medical, and psychosocial. Unless Experience from practice suggests that relatives are
medical problems take precedence, forensic examination focusing on their loved one, and not on what is going
should be performed as early as possible, if consent has on around them. They often express gratitude and
been given to do so. reassurance that it appears that all which could be
• If the patient gives consent, they may be referred done was done. Preparation and support of the
to the police, who will coordinate forensic and legal relatives are fundamentally important.
actions. Whether or not the police are involved, - This should include the following:
patients can be referred to a Sexual Assault Referral • information about their loved one’s
Centre (SARC), which will provide support and appearance;
services (including forensic medical examination) • a brief description and explanation of the
following sexual assault. equipment, lines, and tubes attached to the
• If medical needs predominate, ED staff should patient;
optimize the preservation of forensic evidence • brief information about the team;
during care provision. Helpful advice regarding • reassurance that they can leave the room at
preservation of forensic evidence may be gained any time;
from http://www.careandevidence.org. • an individual member of staff to stay with
• Urgent consultation with a specialist in them and support them at all times
genitourinary medicine (GUM) should be The team also requires briefing and support before the
undertaken to discuss the risks associated with relatives come in. It can be stressful and emotionally
bloodborne viruses and other sexually acquired challenging to experience the raw grief that is often expressed
illness. Pregnancy testing and post-coital in these circumstances. Senior experienced staff are essential
contraception should be offered where in this situation for both the family and the team.
appropriate. Arrangements should be made for Bereavement care can be very demanding and time-
follow-up screening by GUM staff. consuming. Support mechanisms should be in place for staff
• Independent Sexual Violence Advisors who have been involved in bereavement support. The hospital
(ISVAs) offer information, advice, and support chaplaincy team can provide support for relatives, loved ones,
to victims of sexual offences. ED clinicians and staff involved in these situations.
should familiarize themselves with how to
contact their local ISVA service.
• Referral for counselling via the patient’s GP or Sudden death Dealing with sudden death is common in the
a voluntary agency may be required. The Rape ED. It is a sad and traumatic event for the family and loved
Crisis service provides face-to-face and ones of those involved. Even in circumstances where the death
telephone counselling by qualified and trained was expected, when the actual death occurs, it can still seem
volunteers sudden and traumatic. Nurses have a key role in breaking bad
news and caring for the family and loved ones.

FORENSIC ISSUES
Breaking bad news This is a key skill that requires
- Patients may attend the ED as a result of an incident preparation and experience. The person to break the bad news
in which criminal proceedings may ensue. should be the person who has established the greatest rapport
Preservation of evidence is of utmost importance. with the family or loved ones (and who has the greatest
Care should be taken not to dispose of anything that experience of breaking bad news). This could be either a nurse
could constitute evidence. Careful documentation of or a doctor. It is advisable to have two professional staff
facts is important. Each department should have an present who are able to break the news, provide comfort, and,
agreed process for preservation of evidence and a where possible, answer questions. One person should be the
sufficient supply of materials necessary for the link person and spend time with the family. Breaking bad
storage of the evidence. A careful record of all news is not an exact science—every situation and
personnel interacting or involved with the case
 DEALING WITH DIFFICULT SITUATIONS
circumstance is different, requiring rapid assessment and emotional crisis, evidence suggests that many relatives
decision-making about the most appropriate approach and gain some comfort from knowing that others might benefit
language to use. from the organs or tissues of their loved one. Recent
The language used should be clear and unambiguous. awareness campaigns about the importance of organ
Euphemisms, such as ‘we lost him’ or ‘he has passed over’ or donation have resulted in some families raising the subject
‘he has gone to a better place’, should not be used. Phrases, of donation when bad news is broken, but this cannot be
such as ‘has died’ or ‘is dead’, should be used. It is not relied upon. There are three different types of donations: 
uncommon to have to repeat these words in the first few donation after brainstem death (DBD), donation after
sentences. In situations where you are preparing relatives or circulatory death (DCD), and tissue donation. Local
loved ones for a poor outlook, again clear language should be policies and procedures will determine how these
used. It is better to be ‘up front’ with individuals and give the processes are enacted. NICE has issued a short clinical
worst possible outcome, as well as the most optimistic one— guideline on organ donation.
but be realistic. You should be prepared for a wide variety of - This guideline applies to practice in England, Wales, and
reactions. These are also culturally dependent. Reactions can Northern Ireland, and recommends that hospital staff
include anger, denial, crying, shouting, wailing, laughing, initiate discussions with a Specialist Nurse for Organ
violent outbursts, self-flagellation, and collapse, to name just a Donation (SN-OD) when one of the following criteria
few. In the case of sudden death in children, parents have been is met:
known to attempt to take their dead child home with them. A o an intention to use brainstem death tests to
checklist of information and key contacts can be useful in a confirm death;
bereavement situation. No matter how many times you have o an intention to withdraw life-sustaining treatment in
broken bad news, it is always stressful and emotionally patients with a life-threatening or life-limiting
challenging. The checklist should ensure that you have condition which will, or is expected to, result in
relevant contact numbers for follow-up, that correct circulatory death;
documentation is given, and that the GP is informed. The o admission of a patient with very severe brain injury
necessary arrangements should be made to inform medical (defined as a Glasgow Coma Scale (GCS) score of
records, in order to ensure that inappropriate letters or 3–4 with at least one absent brainstem reflex) that
appointments are not sent to the person who has recently died. cannot be attributed to the effects of sedation.
Organs that may be retrieved from DBD donors include the
 Remember to offer the support of spiritual leaders heart and lungs, liver, kidneys, pancreas, and small bowel.
from the patient’s faith through either the family’s DCD donors can donate the liver, kidneys, pancreas, lung, and
contacts or the hospital chaplaincy team. tissue. Tissues that can be donated include eyes, heart valves,
Keepsakes It can be helpful to offer ‘keepsakes’ to relatives skin, and skeletal tissue (bone, tendon, and ligaments). Tissues
and loved ones. For adults, a lock of hair from the deceased, can be donated up to 24–48h after death.
thoughtfully presented, can be offered. For children, a book of Absolute contraindications to organ donation are:
keepsakes can be provided, including foot and hand prints, • age 85y or above;
locks of hair, and photographs (with the consent of the • any cancer with evidence of spread outside the affected
coroner). organ (including lymph nodes) within 3y of donation
Environment Providing a quiet area for breaking bad news is (however, localized prostate, thyroid, in situ cervical,
important. The area should ideally be close to the resuscitation and non-melanotic skin cancers are acceptable);
room, but with sufficient audio/visual separation. Making this • melanoma (except completely excised Stage 1 cancers);
area welcoming and comfortable is important. The provision • choriocarcinoma;
of a visiting room is highly desirable. The room should • active hematological malignancy (myeloma,
accommodate the deceased individual in comfortable lymphoma, leukemia);
surroundings without the equipment found in the clinical area. • definite, probable, or possible cases of human
This area should allow the loved ones to spend time saying transmissible spongiform encephalopathy (TSE),
goodbye in an unhurried manner. Ideally, this room should be including Creutzfeldt–Jakob disease (CJD) and variant
close to the relatives’ room and the resuscitation room, but not CJD, individuals whose blood relatives have had
in a busy thoroughfare. familial CJD, or other neurodegenerative diseases
associated with infectious agents;
 TISSUE AND ORGAN DONATION • TB—active and untreated;
• West Nile virus (WNV) infection;
- There is a shortage of organs for donation in the UK. As a • human immunodeficiency virus (HIV) disease (but not
result, sadly, patients are dying, whilst waiting for a HIV infection).
transplant. When faced with a sudden or imminent death,
consideration should be given to raising the issue of organ
or tissue donation (always check that there are no absolute
contraindications first). Although staff are sometimes
concerned about raising this issue at a time of major