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Forensic Nursing Process: An Evaluation of Forensic Patients in the Clinical
Environment
By Barbara Goll-McGee RN, MSN; Sherry Couto, RN, BSN;
John Ferrandi; Kelly Jankowski, RN, BSN; Patricia Lawlor, RN, BSN; Ines
Luciani-McGillvray, RN, BSN, CEN, SANE; and Maryellen Robertson, RN, BSN, CNRN
Clinical forensic nursing has come
of age as a means of coping with the resultant increased complexity of nursing
practice, society and the law. A living forensic population, "survivors of
criminalor liability-related injuries that result in an investigation by a legal
agency"1 is being recognized by healthcare professionals in varied clinical
practice environments, especially in the emergency department (ED). In fact,
personnel frequently interface with forensic cases and therefore have the
greatest potential for evaluating the associated forensic elements."2 The
Clinical Forensic Nursing Committee at Massachusetts General Hospital (MGH) is
spearheading a method of identifying its forensic patient population and
managing its medico-legal needs. This article will present actual cases
involving clinical forensic patients and suggests, for emergency nurses without
formal training, loose guidelines for addressing their needs within a forensic
nursing framework.
The Framework
Identification of a living forensic patient population is paramount. Pasqualone suggests "27 forensic categories" resulting from the "use of
weapons, interpersonal violence, sharp and blunt force trauma, police custody
deaths, abuse and neglect of the child, elder or disabled, hate crimes, sudden
and unexpected deaths, occupational and environmental hazards, sexual assault, and substance abuse."3
Violence against self, natural or man-made disasters and/or terrorist attacks
are also considered. Once a forensic patient is recognized, four overlapping
clinical practice issues are addressed. These are physical evidence collection, non-physical evidence collection,
meticulous documentation and crisis intervention.
Mund defines physical evidence as "anything that has been used, left,
removed, altered or contaminated during the commission of a crime by either the
suspect or victim."4 The ability to recognize evidence acknowledges that it
has relevance and may come in varying forms and sizes. "In many situations,
important information... which may not be required for patient care is nonetheless vital to later
investigation" and requires the patient’s consent "to ensure that
collection of the evidence will not amount to an illegal search (or perhaps malpractice)."5
Proper collection of evidence is imperative to avoid the compromise of its
integrity. "Preservation of evidence in the clinical setting requires
planning, attention to detail, and the guidance of agency policies and procedures."6
Non-physical evidence collection suggests the use of an index of suspicion
"to uncover the how and why of their mechanisms of injury."7 This effort
involves an assessment of psychosocial history, separating the injuries from the
story and asking hard questions. It looks for inconsistencies in clinical
presentations.
"Thorough, objective documentation of ED evaluation and treatment of
patients who present with complaints suggesting potential litigation and/or
criminal activity is critical."5 Meticulous documentation provides evidence
that "something is done or not done, exists or doesn’t exist, it provides
evidence for the client, protection for the nurse and testimony for the court."7
"Effective crisis intervention requires finding the right resources for the
client."8 It may be extended to include an interface with multi-disciplines in
communicating patient conditions, formulating advance directives, guiding
end-of-life decision making, pursuing anatomical gifts, notifying death,
reporting abuse and neglect, dangerousness assessment and protecting patient
confidentiality. According to Hoff, a critical level of assessment asks, "Is there an
obvious or potential threat to life, either the life of the individual in crisis
or the lives of others?" "Has the person been abused?" And "What are the risks of suicide, assault, and homicide?"8
All of the aforementioned clinical practice issues are considered, but not
always pursued. Many of the following case studies incorporate ethical and other
dilemmas, which are thought-provoking, but are not addressed due to the length
constraints of this article.
Case Studies
Two male United States customs agents escorted a 23-year-old female "mule"
into the ED after having been tipped off that she had been transporting illegal
drugs into the country. Her vital signs on admission were within normal limits;
however, the threat of overdose remained. A gynecological examination was
performed and revealed an intra-vaginal, 850-gram, condom and plastic wrapped
package of a white powdery substance suspected to be cocaine. A physician
collected the package and gave it to the customs agent who was present in the
exam room and properly maintained the evidence.
Blood work including serum electrolytes, a complete blood count (CBC),
bleeding times (PT/PTT), blood bank sample (BBS), toxicology screen, and
pregnancy test (hcg) was drawn and sent to the laboratory. Radiological exam
(X-ray) of the kidneys, ureters and bladder, revealed the presence of
approximately 20 to 30 intraabdominal pouches. The patient reported ingesting
these at the suggestion of her boyfriend who offered her $3,500. The patient was
given a medication used for intestinal diagnostics to evacuate bowel contents.
Subsequent trips to the bathroom required the emergency nurse and customs
presence for the collection of these pouches as evidence. The patient was under
constant guard without the use of physical restraints.
This patient presents as a living forensic patient because she is a survivor
of a criminal related activity, ingestion and transport of illegal drugs that
will result in an investigation by the United States Customs Department.
Physical evidence consists of the package and pouches of the white powdery
substance suspected to be cocaine. Also, one may consider the X-rays showing the intra-abdominal pouches as
photo-documentation evidence. A toxicology screen may show presence of illegal drugs or drug metabolites, but may be
inadmissable because the patient has not given consent to this laboratory test
that is a medical necessity. The chain of custody for laboratory specimens and
X-rays within the hospital may also come under scrutiny.
Non-physical evidence separates the condition from the story. It is what she
says and how she presents. The suggestion that her boyfriend made her do this
raises concerns about the safety of this patient within this relationship and
the cycle of violence within relationships; however, her calm and collected presentation is without physical signs of
abuse. When asked if she feels safe, she says yes. The subjective statements documented on the flowsheet are, "I have a
stomach ache," "I packed the drugs myself," and "My boyfriend made me do
it." The triage nursing diagnosis is "cocaine ingestion" because this is what the patient reports. One time source, agreed upon by the
customs agents and the nursing staff caring for the patient, is used for the
consistent documentation of time. This avoids the obvious variations of time
references. The names and presence of the customs agents are also documented.
Crisis intervention does not consist of a domestic violence resource because
the patient reports that she feels safe. The assessment for suicide or self-harm
risk is low. Patient confidentiality is protected.
A 37-year-old patient was admitted to the ED after an unwitnessed motorcycle
crash. He was awake and responsive with a Glascow coma score of 15. He reports
no past medical history or medicine use. His vital signs were within normal
ranges. Intravenous access (IV) and blood work including electrolytes, CBC,
PT/PTT, BBS and serum toxicology was drawn. Serum toxicology was not medically
indicated and was not sent to the laboratory. During secondary assessment, the
patient was found to have a plastic sandwich bag filled with white pills stuffed
in his underwear. The patient explained that these were for chronic back pain.
The emergency nurse threw the pills in the garbage without documentation. The
patient was discharged after several hours.
This patient is a living forensic patient because he is a survivor of a
motorcycle crash that may be investigated by a legal agency. Physical evidence includes the pills, which are identified as percocet.
These should not be immediately disposed of, but rather secured by police and
security or pharmacy personnel. (Physical evidence can always be discarded if
not relevant, but cannot always be retrieved. This is especially true of exigent
evidence. This is evidence that requires immediate collection or it will be
lost.) Chain of custody should reveal that the emergency nurse discovered the
evidence while undressing, then passed it along. Without mention of the nursing
discovery, the search for evidence may be scrutinized. Non-physical evidence
collection, or an index of suspicion, suggests that in the absence of a medical
history and personal prescription bottle or label, this narcotic may have been
illegally or improperly obtained and affected the judgment of the motorcycle
driver. The emergency nurse does not know if this patient has hit something or
hurt someone else during this accident. Presently, this is an unreported case.
Documentation should include the presence and number of the white pills and
their disposition. There is no crisis intervention in this case.
A 23-year-old man presented to the ED reporting that he had been car-napped
and stabbed. His pants leg was bloodied, but he was in otherwise good condition.
He was rapidly assessed, cleaned and sutured. His clothing was given to him
after being placed in a plastic patient belongings bag and several hours later,
he was discharged wearing hospital sweat pants.
This patient presents as a living forensic patient because he is a survivor
of reported interpersonal violence that may be investigated by local police. The
physical evidence in this case consists of the patient’s clothing. Each piece
of clothing should have been individually collected in paper bags and properly
labeled with a description of the item, the patient’s name and unit number,
the date and time, the collector’s name and title. If the items are wet, law
enforcement personnel should dry them in a secure location.
Chain of custody should be maintained to ensure the integrity of the
evidence. Under no circumstances should a patient’s clinical stability be
compromised for the collection of physical evidence.
Non-physical evidence collection suspends personal judgments, but addresses
the plausibility of the story, the presence and mechanism of injury. By the
patient’s report there is no reason to believe that the explanation for the
injury is false, but the emergency nurse considers that it may not be.
Documentation consists of the subjective statement; "I was carnapped and
stabbed in the leg." Photo documentation of the sharp injury wound, with
documented patient consent, is recommended. Crisis intervention occurs with a referral to appropriate resources such as
police and security.
Conclusion
In accordance with the standards of forensic nursing practice outlined by the
International Association of Forensic Nurses (IAFN), the mission statement of
the MGH Clinical Forensic Nursing Committee includes a commitment to develop,
promote and disseminate information about the science of forensic nursing.
"The forensically trained...nurse recognizes that forensics provides realistic interventions for responding to patient care needs."9
These case studies introduce a fraction of a patient population with
medico-legal needs and suggest a loose approach, an assessment dimension, to
recognizing and meeting these needs.
"The development of protocols for collecting available evidence may assist in assuring that collection is performed appropriately."5
"Intuition research gives the forensically educated nurse permission to
trust and to act upon his or her suspicions."9 "In the duty to document,"
"it is almost as important to keep extraneous material out of the medical
record as it is to be sure to include pertinent information."10
"Becoming familiar with and recognizing the phases of crisis development
can enable healthcare professionals to provide clients with resources that will
keep stressful life events from escalating into crisis episodes."8 As nurses
on the front line begin to ponder the presence of a forensic patient population
they will look to address their needs. As our knowledge base expands,
professionals themselves develop and nursing paradigms shift. Continued
attention to these types of cases and the use of this forensic nursing process
may make "an important contribution to safeguarding the legal rights of
patients and the community"5 and nurture clinical forensic nursing, a
developing nursing specialty, within practice environments.
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