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Domestic Violence

Discussion in 'General Issues and Discussion Forum' started by Mark Russell, Jun 15, 2016.

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    You have a husband and wife as patients. Both late seventies and married for 50+ years. She is a nervous type but in a nice way, excitable and can't stop talking when she finds the confidence. He is ex army and very much the dominant partner in the relationship although when they attend together, he rarely says much or intervenes/interrupts his wife. Of late you have seen them separately, initially the husband, who his own is more loquacious - especially about his wife. He tells you she is an alcoholic and rarely out of bed before afternoon and he clearly is disgusted at her behaviour. You quickly realise the relationship isn't what you first assumed.

    You then see the wife for a course of treatment. Her behaviour is consistent with previous and when you mention her husband, she speaks warmly of him and gives no hint of any problem. When asked, she says she has up to a bottle of wine each evening, all seems good. However, during a subsequent visit you notice a bruise on her leg that looks like it has been squeezed by a hand - and when you mention it she breaks down. She explains her husband regularly beats her - with a leather strap and wooden stick. There are other bruises on her back and stomach.

    Once she has composed herself she insists you don't inform anyone. You suggest her GP or the police but she steadfastly refuses. She is clearly terrified of her husband, but even more so of the consequences of disclosure - and she thinks she can "manage" the situation by keeping out his way - and self medicating with alcohol to cope.

    There are other complications in their circumstances. Although the husband has always had a dominant personality, it appears the violence has been restricted to the last nine years. They have one son who is also ex-forces. He has served in Iraq and Afghanistan but was caught up in an IED and ambush and has severe PTSD and is prone to violent outbursts too. He lives in the UK and now runs a prostitute ring as well as being a significant drug dealer. His mother had visited him a decade ago and he had borrowed a sizeable sum of money - but she had a breakdown during the visit and was hospitalised for several weeks. She has declined any further treatment and does not visit her GP. The husband refuses to accept the situation and will not speak to the son. His wife thinks if she speaks to anyone, her life will implode. Despite your best efforts, she refuses to seek help and insists that you do not break her confidence under any circumstance.

    What do you do?
  2. mgates01

    mgates01 Active Member

    Hi Mark - you pose a interesting moral vs ethical dilema. Not an easy scenario by any means.

    My feeling is that you have a duty of care to the patient you are treating and an obligation to respect their confidentiality, and you potentally need to be guided with that in mind. I work within the NHS so often the response is governed by the protocols most NHS Trust / Boards would have in place. There are a number of other clear criteria you would need to bear in mind,

    • [/Domestic abuse or violence is a crime and should be reported to the policeLIST]

      • Police take domestic violence seriously and UK law allows them to prosecute the abuser even if the person being abused does not wish to pursue the abuser

        • [Medical staff are not under any legal obligation to report an instance of intimate partner violence. For Doctors and other health care professionals, reporting abuse to the police should only be done with the abused person?s knowledge and consent./LIST]

          It is clear form your scenario that both these individuals are in need of specialised help

          My feeling taking all these things into consideration are that you should set boundaries with the patient that communicates concern and try and convince the patient that there are more specialised services that can help. Your aim should be to facilitate a referral to such services. Ultimately only the abused person can assess the danger and relative risk of reporting the violence verses not reporting the violence to the authorities.

          Not an easy situation (and one you may not be entirely comfortable with particularly if you see the level of abuse escalating).
          The fact that the patient has opened up to you and admitted this abuse may indicate an opportunity for you as a practitioner to try and convince the patient to take the next step of talking to an individual (or agency) that could offer them more specialised advice.
  3. Greg Fyfe

    Greg Fyfe Active Member

    Hi Mark,

    What would I do? probably what I'm doing now and look for information on the internet.

    Like Michael I think where the boundaries are defined , both personal and professional is pretty important. If your not required to mandatory report domestic violence, the challenge is to provide the best care/advocacy you can and not stray beyond an appropriate professional and personal boundary.

    It may be you have to consider , at some point, that you need to report this in order to keep the person safe.

    I had a quick look on line and this link has a comprehensive UK resource some of which relates to the kind of scenario you've described.


    There may be some useful pointers in there for what is a complex issue.

  4. timharmey

    timharmey Active Member

    In good old NHS you have to try and work out if the patient has capacity( which is a whole book on its own ) , if they do not, you are duty bound to contact the " Safe guarding team " who will take it from there, I am not sure about outsuide the NHS , I think councils/social services have " safe guarding" departments .If they do have capacity then its up to them , not a very nice position to be put in and not one I would relish but in a way it is similair to child abuse / animal mis treatment/ Your neighbours fighting next door

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