DEALING WITH DIFFICULT SITUATIONS
DOMESTIC ABUSE
The Home Office revised the definition of domestic abuse in
2013 as
follows:
- Any incident or pattern of incidents of controlling,
coercive or threatening behavior, violence or abuse
between those aged 16 or over who are, or have been,
intimate partners or family members regardless of gender
or sexuality. The abuse can encompass, but is not limited
to:
• psychological
• physical
• sexual
• financial
• emotional
Controlling Behavior
- is a range of acts designed to make a person
subordinate and/or dependent by isolating them from
sources of support, exploiting their resources and
capacities for personal gain, depriving them of the
means needed for independence, resistance and
escape and regulating their everyday behavior.
Coercive Behavior
- is an act or a pattern of acts of assault, threats,
humiliation and intimidation or other abuse that is
used to harm, punish, or frighten their victim.
Note that this definition includes so-called ‘honour’-based
violence, female genital mutilation (FGM), and forced
marriage, and is clear that victims are not confined to one
gender or ethnic group.
Health professionals are often the first point of contact for
people who have experienced domestic abuse, and they should
be trained to give an appropriate response. The use of routine
enquiry about domestic abuse remains controversial. EDs
should at least have a policy that promotes targeted screening
within a safe, confidential, and supportive environment.
Following disclosure of domestic abuse, clinicians should
reassure the individual and seek to make it easier for them to
talk about their experiences by taking a non-judgmental
stance. Assessment of risk to the patient and their children
should be undertaken. The Coordinated Action Against
Domestic Abuse (CAADA) Domestic Abuse, Stalking and
Honour-Based Violence (DASH) Risk Identification Checklist
(RIC) is a nationally recognized tool for assessing risk related
to domestic abuse, including so-called ‘honour’-based
violence.
Staff should not encourage patients to leave their abusive
partner, as only the individual will know when it is safe to do
so. However, help should be given with safety planning, and
clinicians can facilitate access to a refuge if the patient
requests it. When domestic abuse is disclosed, clinicians
should consider whether adult or child safeguarding factors
exist and follow local Adult and Child Safeguarding policies
as appropriate. Midwifery services should be advised of
women who have been assaulted during pregnancy.
If the patient gives consent, referral to partner agencies,
including the police and domestic abuse advocacy services,
may help to reduce repeat victimization. Research has
indicated a significant reduction in risk, following referral to
an Independent Domestic Violence Advocate (IDVA).
It is important that health staff contribute to local multi-agency
partnerships to tackle domestic abuse such as the Multi-
Agency Risk Assessment Conference (MARAC) and/or
Multi-Agency Safeguarding Hub (MASH).
A vulnerable adult is someone ‘who is or may be in need of
community care services by reason of mental or other
disability, age or illness; and who is or may be unable to take
care of him or herself, or unable to protect him or herself
against significant harm or exploitation’.
There are many forms of abuse, including:
• physical—including hitting, misuse of medication,
and restraint;
• sexual—including sexual assault and rape;
• psychological—including emotional abuse,
humiliation, and threats to harm;
• financial or material—including fraud, theft, and
misappropriation of benefits;
• acts of omission or neglect—including ignoring
physical or medical needs, delays in seeking care,
and failure to provide care or seek help;
• discrimination—including racist, sexual, or
disability-based comments
END ABUSE: a guide to intervention
• Empowerment. Enable people to know what their
choices are—the choices need to be feasible and
practical (information should be made available and
known to staff in advance).
• Neglect is as much a form of abuse as a violent act.
This may be the only sign; when identified, it
requires action.
• Documentation. Careful documentation, if there is
injury and/or illness, is essential for future reference
if legal action is to be taken.
Remember to document the patient’s own words.
• Advocacy. In the case of a vulnerable elderly person
who is either physically or mentally incapacitated and
is unable to speak for themselves, you may have to
act as their advocate.
• Be aware of the organizations that can assist and
have to hand information that can be given to the
victim (this may need to be done discreetly).
• Understanding. Part of the intervention is to help the
victim understand that abuse is a crime, that they are
a victim (it is not their fault), and that help is
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
and the sensitive steps to be taken when identified is
fundamental.
SEXUAL ASSAULT
- When caring for a patient who discloses sexual assault,
clinicians should ascertain whether a vulnerable adult,
child, or domestic abuse is a factor, and follow local adult
and child safeguarding policy and/or domestic abuse
guidelines, as appropriate.
- Following sexual assault, victims have three main care
needs:  forensic, medical, and psychosocial. Unless
medical problems take precedence, forensic examination
should be performed as early as possible, if consent has
been given to do so.
• If the patient gives consent, they may be referred
to the police, who will coordinate forensic and legal
actions. Whether or not the police are involved,
patients can be referred to a Sexual Assault Referral
Centre (SARC), which will provide support and
services (including forensic medical examination)
following sexual assault.
• If medical needs predominate, ED staff should
optimize the preservation of forensic evidence
during care provision. Helpful advice regarding
preservation of forensic evidence may be gained
from http://www.careandevidence.org.
• Urgent consultation with a specialist in
genitourinary medicine (GUM) should be
undertaken to discuss the risks associated with
bloodborne viruses and other sexually acquired
illness. Pregnancy testing and post-coital
contraception should be offered where
appropriate. Arrangements should be made for
follow-up screening by GUM staff.
• Independent Sexual Violence Advisors
(ISVAs) offer information, advice, and support
to victims of sexual offences. ED clinicians
should familiarize themselves with how to
contact their local ISVA service.
• Referral for counselling via the patient’s GP or
a voluntary agency may be required. The Rape
Crisis service provides face-to-face and
telephone counselling by qualified and trained
volunteers
FORENSIC ISSUES
- Patients may attend the ED as a result of an incident
in which criminal proceedings may ensue.
Preservation of evidence is of utmost importance.
Care should be taken not to dispose of anything that
could constitute evidence. Careful documentation of
facts is important. Each department should have an
agreed process for preservation of evidence and a
sufficient supply of materials necessary for the
storage of the evidence. A careful record of all
personnel interacting or involved with the case
should be kept. They may need to be contacted for
witness statements at a later date.
RESUSCITATION, DEATH, AND COMMUNICATING
BAD NEWS
Witnessed resuscitation
- Exposure to resuscitation scenes in television dramas
appears to have had a role in preparing relatives for
what they might witness. Some clinicians are still
uncomfortable with the concept of relatives being
present, whilst resuscitation is being carried out.
Experience from practice suggests that relatives are
focusing on their loved one, and not on what is going
on around them. They often express gratitude and
reassurance that it appears that all which could be
done was done. Preparation and support of the
relatives are fundamentally important.
- This should include the following:
• information about their loved one’s
appearance;
• a brief description and explanation of the
equipment, lines, and tubes attached to the
patient;
• brief information about the team;
• reassurance that they can leave the room at
any time;
• an individual member of staff to stay with
them and support them at all times
The team also requires briefing and support before the
relatives come in. It can be stressful and emotionally
challenging to experience the raw grief that is often expressed
in these circumstances. Senior experienced staff are essential
in this situation for both the family and the team.
Bereavement care can be very demanding and time-
consuming. Support mechanisms should be in place for staff
who have been involved in bereavement support. The hospital
chaplaincy team can provide support for relatives, loved ones,
and staff involved in these situations.
Sudden death Dealing with sudden death is common in the
ED. It is a sad and traumatic event for the family and loved
ones of those involved. Even in circumstances where the death
was expected, when the actual death occurs, it can still seem
sudden and traumatic. Nurses have a key role in breaking bad
news and caring for the family and loved ones.
Breaking bad news This is a key skill that requires
preparation and experience. The person to break the bad news
should be the person who has established the greatest rapport
with the family or loved ones (and who has the greatest
experience of breaking bad news). This could be either a nurse
or a doctor. It is advisable to have two professional staff
present who are able to break the news, provide comfort, and,
where possible, answer questions. One person should be the
link person and spend time with the family. Breaking bad
news is not an exact science—every situation and
 DEALING WITH DIFFICULT SITUATIONS
circumstance is different, requiring rapid assessment and
decision-making about the most appropriate approach and
language to use.
The language used should be clear and unambiguous.
Euphemisms, such as ‘we lost him’ or ‘he has passed over’ or
‘he has gone to a better place’, should not be used. Phrases,
such as ‘has died’ or ‘is dead’, should be used. It is not
uncommon to have to repeat these words in the first few
sentences. In situations where you are preparing relatives or
loved ones for a poor outlook, again clear language should be
used. It is better to be ‘up front’ with individuals and give the
worst possible outcome, as well as the most optimistic one—
but be realistic. You should be prepared for a wide variety of
reactions. These are also culturally dependent. Reactions can
include anger, denial, crying, shouting, wailing, laughing,
violent outbursts, self-flagellation, and collapse, to name just a
few. In the case of sudden death in children, parents have been
known to attempt to take their dead child home with them. A
checklist of information and key contacts can be useful in a
bereavement situation. No matter how many times you have
broken bad news, it is always stressful and emotionally
challenging. The checklist should ensure that you have
relevant contact numbers for follow-up, that correct
documentation is given, and that the GP is informed. The
necessary arrangements should be made to inform medical
records, in order to ensure that inappropriate letters or
appointments are not sent to the person who has recently died.
 Remember to offer the support of spiritual leaders
from the patient’s faith through either the family’s
contacts or the hospital chaplaincy team.
Keepsakes It can be helpful to offer ‘keepsakes’ to relatives
and loved ones. For adults, a lock of hair from the deceased,
thoughtfully presented, can be offered. For children, a book of
keepsakes can be provided, including foot and hand prints,
locks of hair, and photographs (with the consent of the
coroner).
Environment Providing a quiet area for breaking bad news is
important. The area should ideally be close to the resuscitation
room, but with sufficient audio/visual separation. Making this
area welcoming and comfortable is important. The provision
of a visiting room is highly desirable. The room should
accommodate the deceased individual in comfortable
surroundings without the equipment found in the clinical area.
This area should allow the loved ones to spend time saying
goodbye in an unhurried manner. Ideally, this room should be
close to the relatives’ room and the resuscitation room, but not
in a busy thoroughfare.
 TISSUE AND ORGAN DONATION
- There is a shortage of organs for donation in the UK. As a
result, sadly, patients are dying, whilst waiting for a
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
emotional crisis, evidence suggests that many relatives
gain some comfort from knowing that others might benefit
from the organs or tissues of their loved one. Recent
awareness campaigns about the importance of organ
donation have resulted in some families raising the subject
of donation when bad news is broken, but this cannot be
relied upon. There are three different types of donations: 
donation after brainstem death (DBD), donation after
circulatory death (DCD), and tissue donation. Local
policies and procedures will determine how these
processes are enacted. NICE has issued a short clinical
guideline on organ donation.
- This guideline applies to practice in England, Wales, and
Northern Ireland, and recommends that hospital staff
initiate discussions with a Specialist Nurse for Organ
Donation (SN-OD) when one of the following criteria
is met:
o an intention to use brainstem death tests to
confirm death;
o an intention to withdraw life-sustaining treatment in
patients with a life-threatening or life-limiting
condition which will, or is expected to, result in
circulatory death;
o admission of a patient with very severe brain injury
(defined as a Glasgow Coma Scale (GCS) score of
3–4 with at least one absent brainstem reflex) that
cannot be attributed to the effects of sedation.
Organs that may be retrieved from DBD donors include the
heart and lungs, liver, kidneys, pancreas, and small bowel.
DCD donors can donate the liver, kidneys, pancreas, lung, and
tissue. Tissues that can be donated include eyes, heart valves,
skin, and skeletal tissue (bone, tendon, and ligaments). Tissues
can be donated up to 24–48h after death.
Absolute contraindications to organ donation are:
• age 85y or above;
• any cancer with evidence of spread outside the affected
organ (including lymph nodes) within 3y of donation
(however, localized prostate, thyroid, in situ cervical,
and non-melanotic skin cancers are acceptable);
• melanoma (except completely excised Stage 1 cancers);
• choriocarcinoma;
• active hematological malignancy (myeloma,
lymphoma, leukemia);
• definite, probable, or possible cases of human
transmissible spongiform encephalopathy (TSE),
including Creutzfeldt–Jakob disease (CJD) and variant
CJD, individuals whose blood relatives have had
familial CJD, or other neurodegenerative diseases
associated with infectious agents;
• TB—active and untreated;
• West Nile virus (WNV) infection;
• human immunodeficiency virus (HIV) disease (but not
HIV infection).