Constance A. Hoyt, MSN, RN
University of California,
Riverside, California, USA
Critical care providers are often confronted with patients who may have been victims of crime, neglect or abuse. Nurses can easily combine their regular patient care duties with some basic forensic practices to help identify and protect these patients.
Nurses in all healthcare settings have an ethical (and indeed, often legal) responsibility to report suspected criminal acts, including neglect and abuse, to the appropriate law enforcement authorities. In support of this, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards establish that: nurses have specific roles and responsibilities in relation to detecting and managing forensic cases; hospitals must establish criteria for identifying and assessing victims of abuse, neglect or exploitation; and all such assessments must be conducted in accordance with legal requirements for collecting and transferring evidence (JCAHO, 2006). Due to the serious nature of illness and injuries associated with violent crime, domestic abuse, neglect, accidents or drug overdose (among other medicolegal cases), the intensive care unit (ICU) often becomes involved in the care and treatment of these victims. Because ICU nurses interact closely and frequently with these patients, they are particularly well poised to serve as liaisons between medical and legal professionals, identifying possible forensic cases and preserving the evidence for law enforcement use.
A Unique Opportunity
Legal responsibilities aside, there are several important reasons for ICU nurse intervention when abuse or neglect is suspected. First, hospitalization places the victim in a controlled environment, where, under the watchful eyes of ICU personnel, victims should be safe from abuse for the duration of their stay. Furthermore, victims may be more willing to talk about their experiences while they are safe in the ICU. Even if the patient is not willing or able to talk, evidence collected upon ICU admission can help build a legal case against the abuser. From a practical standpoint, even if abuse cannot be confirmed, documentation of a nurse’s suspicions and evidence collection (photographs of unusual bruises, for example) can help protect the hospital from liability for the patient’s condition, should questions regarding the care provided arise. The ICU thus has a unique opportunity to apply forensic nursing to everyone’s benefit.
Integrating Forensics in ICU Nursing
A nurse whose primary duties involve the provision of critical care should not be expected to specialize in forensic pathology, which is a discrete medical speciality with its own training program. However, the ICU should make an effort to provide basic forensic training to its nurses and implement policies and procedures that embrace essential forensic practices as an integral part of the standards of care (Lynch, 2006). Training and policies should cover each of the following areas.
Identifying Forensic Patients
Forensic patients include anyone whose condition has medicolegal implications, such as illness or injury resulting in insurance claims, personal liability or criminal charges. ICU nurses may not be the first medical professionals to come into contact with forensic patients, but they are ideally placed to identify and assess these patients, as they are often the first healthcare worker to complete a comprehensive screening and assessment process. Upon patient admission to the ICU, the nurse should conduct or assist the responsible physician with a “head-to-toe” assessment of all body surfaces, taking note of any suspicious conditions, as well as the conspicuous absence of certain findings. Table 1 shows some of the key “red flags” that ICU nurses should be trained to recognize. Nurses who suspect that they may be dealing with a forensic patient, even if the suspicion is no more than a “gut reaction” or hunch, should investigate the situation until their curiosity is satisfied.
Frequently, the nurse is the only person in the right place at the right time to collect certain kinds of evidence. Only initial and periodic inspection of the entire body ensures that most significant medicolegal evidence will be collected. Once a forensic patient has been identified, as part of the initial inspection, the nurse should carefully record the patient’s appearance and condition as a baseline within the medical record, noting particularly any questionable injuries or other signs of neglect or abuse. The nurse should continue to document changes in the patient’s condition over time, taking care to denote forensic observations using terminology that forensic pathologists will recognize, as similar terms are often used differently in critical care and forensic settings. Even the smallest observation may later prove critical.
Nurses should be trained to identify key sources of evidence, such as the victim’s body itself, DNA and other evidence from saliva swabs, shoes, clothing and personal items accompanying the forensic patient to the ICU. They should also be trained to collect and handle evidence properly. Physical evidence, such as clothing or personal belongings, should be stored separately in clean paper or cardboard containers, to allow moisture to evaporate and avoid commingling evidence. In addition, nurses may record any observations they make in words, diagrams and/or photographs to document the patient’s progress over time. All observations should be recorded as soon as possible after contact with the patient, to ensure thoroughness and accuracy.
Chain-of-custody is critical to maintain the integrity of evidence in medicolegal cases. When a nurse collects evidence, he or she must ensure that the container holding the evidence is thoroughly fastened in a manner that will show clearly any tampering by unauthorized persons. The container should be labelled with the patient’s name, date, current time, hospital number, contents and the name of the nurse who collected and bagged the evidence. All forensic evidence should be transferred to law enforcement authorities as soon as possible after collection. At transfer, the date and signatures of the giver and receiver should be written on the container. A duplicate transfer form should be kept with the patient’s record. To protect against tampering or misplacement of evidence, the patient’s belongings should accompany the patient from admission to release or transfer to law enforcement authorities. The patient’s belongings must never be released to next of kin until law enforcement authorities have firmly established that the items have no evidentiary value.
ICU nurses frequently encounter forensic patients. Ethical (and often legal) obligations demand that ICU nurses intervene in possible forensic cases and refer them to the appropriate law enforcement authorities. Training ICU nurses to incorporate forensic examinations into their routine admission procedures may help the ICU to identify forensic patients who may otherwise go undetected and preserve valuable forensic evidence. By learning and performing simple forensic procedures, the ICU nurse can have a lasting impact on the hospital’s ability to fill its medicolegal responsibilities, law enforcement’s ability to pursue justice and the patient’s ability to live a full life free of victimization.