Domestic violence

Domestic abuse is very common and can be physical, sexual or emotional. Consequences may include traumatic injury and death, and victims are more likely to suffer from chronic illness and mental health problems.

Aims of the station

• Be reassuring and non-judgemental
• Don’t be afraid to ask about abuse
• Assess risk to patient and others around them (e.g. their children)
• Don’t assume the patient wants to leave their partner immediately, just offer advice and support

Before raising the issue

• Develop a good rapport with the patient and make them feel comfortable
• Mention confidentiality
• Speak to them alone and in privacy

When raising the issue

• Use an open question to allow them to explain the situation: ‘Tell me about things at home’, ‘Do you feel scared/safe at home?’, ‘I’m worried someone may have hurt you’, ‘I’m worried you may not be safe at home’, ‘Does your partner’s behaviour upset you?’
• Establish the details of the abuse
  • Type(s) of abuse:
    • Physical: ‘Has your partner ever hurt you?’
    • Sexual: ‘Does your partner ever pressured you into sexual activities against your will?’
    • Emotional: ‘How does your partner make you feel?’
  • Perpetrator: who, relationship to patient
  • Others involved (e.g. children, vunerable adults)
  • Pattern: timing of abuse/violence, substance misuse
  • Timeframe
  • Coping: coping strategies, have they ever tried to do something about it?
• Explore their social situation/domestic environment
  • Household residents
  • Family unit
  • Weapons
  • Occupation
• Tips
  • Try to be supportive, give them time to talk and offer tissues if they get upset
  • Be relaxed and compassionate with the patient
  • Don’t pressure them into telling you, but they may need to be asked several times before opening up

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Risk assessment

• NEVER FORGET RISK!
  • To patient:
    • From partner: are they in current danger, what would happen if they go home now
    • Risk of self-harm: their mood, have they ever considered harming theirself, any suicidal thoughts
  • To others
    • Children
    • Vulnerable adults

Management

• Be non-judgemental and try to establish the patient’s concerns
• Allow them to guide the consultation
• Acknowledge and reassure
  • Acknowledge their situation and how difficult it must have been to disclose
  • Reassure patient it is not their fault and that no one should be treated that way
• Explain about sources of support
  • Establish if they have any friends/family who could support them
  • Counselling/support and helplines (e.g. national domestic violence helpline, WomensAid.org.uk) – give a leaflet
  • Refuge is available if they cannot go home
• Offer referrals (and explain how they can help)
  • Police
  • Local domestic abuse service
  • Counselling/support services
  • Social services must be informed if children or vulnerable adults are involved/at risk
  • NB: if the victim is an adult with capacity, you can only refer them if they consent (unless a child or vulnerable adult is involved).
• Encourage the patient to talk about it and seek help

Conclusion

• Again acknowledge how difficult it must be for them
• Formulate a plan together
• Arrange follow-up and advise them they can come to see you at any time