Treating Acute Medical, Traumatic and Psychological Problems

ED providers must first treat and stabilize any acute medical, traumatic, and psychological problems, including bleeding, fracture, dehydration, metabolic abnormalities, infections,
and agitation.

Exacerbations of chronic medical conditions may require management. This is particularly true if the abuser has failed to give the patient proper medications or to provide appropriate care. Hospitalization may be necessary if a patient needs extended treatment.

Ensuring Patient Safety

If an older adult patient is in immediate danger, the ED provider should ensure that the patient does not have contact with the suspected abuser. This may be challenging, particularly if the perpetrator is the healthcare proxy or has power of attorney. But it is critical to maintain the patient’s safety.

Providers should consider involving the hospital administration and legal department to assist with complex issues, including healthcare decision-making and guardianship.

ED security may be necessary to watch and protect a patient or to remove a perpetrator from the ED. When this intervention is necessary, ED providers should consider involving social work, hospital administration and legal, as well as local law enforcement.

Interventional approaches may be more individualized if a patient is not at risk for imminent harm. The ED provider should attempt to contact and coordinate with the patient’s primary care physician to ensure adequate follow-up.

Social workers should provide counseling, safety planning, and appropriate resources to the patient and caregiver. This can include home health services, Meals-on-Wheels, medical transportation services, adult day care, senior centers, substance abuse treatment options, and respite care.

Self-Determination and Evaluation

If a patient experiencing abuse or neglect declines intervention or services, we need to assess his or her capacity to refuse. If the ED provider is unsure about a patient’s decision-making capacity, an evaluation by a psychiatrist may be helpful.

When a victim has the capacity to refuse care or to request discharge, the choice to return to what we might consider as an unsafe environment must still be respected. This quality of self-determination creates a situation that is different than working with child abuse. The situation is similar to the ED management of intimate partner violence among adults.

Even when a patient refuses intervention, the ED provider and social worker should attempt
to offer psychoeducation about violence and abuse, discuss safety planning, suggest appropriate community services, and encourage the older adult to return to the ED whenever he or she desires.

In cases where the victim does not have capacity, ED providers should proceed with treatments that are in the patient’s best interest, including hospitalization when appropriate.