The Journal of Emergency Medicine, Vol. 49, No. 4, pp. 523–529, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.04.001
Administration of Emergency Medicine MANAGING LAW ENFORCEMENT PRESENCE IN THE EMERGENCY DEPARTMENT: HIGHLIGHTING THE NEED FOR NEW POLICY RECOMMENDATIONS Morsal R. Tahouni, MD,*† Emory Liscord, MD,* and Hani Mowafi, MD, MPH‡ *Department of Emergency Medicine, Boston Medical Center, †Boston University School of Medicine, Boston, Massachusetts, and ‡Yale School of Medicine, New Haven, Connecticut Reprint Address: Morsal R. Tahouni, MD, Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118
, Abstract—Background: The Emergency Department (ED) is the portal of entry to the health care system for a large percentage of patients. This is especially true for victims and perpetrators of interpersonal violence. Frequently, law enforcement personnel (LEP) accompany patients to the ED or seek access to patients during their ED stay or subsequent hospitalization. The time-sensitive nature of both emergency care and criminal investigation motivates both health care personnel and LEP, and can lead to potential conflicts of interest regarding access to patients in the ED. Objectives: We hope to examine the relationship among patients, providers, and LEP in the ED, and the potential impact these interactions have on patient care. This article presents a review of the relevant literature and policy consideration as well as provides guidance on the development of such policies for EDs. Discussion: Hospitals, EDs, and trauma resuscitation rooms are highly regulated environments, but LEP largely fall outside the ethical and institutional guidelines of health care institutions. Many potential areas of conflict exist when LEP are present in the ED that can have detrimental effects on patient care, provider liability, and LEP efficacy. Patients’ perceptions of collaboration between ED personnel and LEP can compromise emergency patient care. Conclusion: There is a need for hospital policies to govern interactions among patients, emergency health care providers, and LEP in the ED. Ó 2015 Elsevier Inc.
jurisdictions; emergency medicine (EM); ethics; chain of custody (COC); Trauma Informed Care (TIC)
INTRODUCTION Just over two years ago, the City of Boston was shocked by the heinous terror attack on one of it’s premier large public events - the Boston Marathon. The bombing at the finish line killed three people and left hundreds more grievously wounded. The subsequent manhunt resulted in two more deaths including a police officer and one of the suspects. These events that gripped our national attention raised serious questions for politicians, policymakers, and health personnel. For many healthcare providers these traumatic events also illustrated the tensions posed by the presence of law enforcement personnel (LEP) in acute healthcare settings. Such interactions occur every day in less dramatic (but for patients similarly traumatic) fashion. The younger suspect in the case, 19-year-old Dzhokhar Tsarnaev, was critically injured and initially unable to speak due to a gunshot wound to the throat when he was taken into custody. As he lay sedated, LEP remained at his bedside, waiting to interrogate him. LEP were eventually allowed to question Tsarnaev for a total of 16 hours over the course of 3 days, before he was arraigned and read his Miranda rights under the direction of Judge Marianne Bowler. The preMiranda interrogation was allowed under the ‘‘public
, Keywords—police; law enforcement personnel (LEP); Emergency Department (ED); privacy; evidence collection;
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safety exception’’ to the Miranda ruling established by the case New York v. Quarles in 1980, which allows LEP to pursue questioning of a suspect when there is concern of imminent danger to officers or the public (1). Although there is much dispute over the extension of the public safety exception in terror cases, this case highlights important policy considerations for health care providers—specifically, Emergency Department (ED) personnel—dealing with more routine cases of criminal suspects under their care. Patients presenting to the ED are often not well known to the provider caring for them. This lack of familiarity necessitates close collaboration with a wide variety of actors to gather information about a patient’s health status and the events that led to their presentation to the ED (2). Such sources of information may include a patient’s family, neighbors, primary doctor, emergency medical services personnel, nursing home staff, and even bystander reports. In theory, all parties involved are working with the motivation to improve the health of the patient and assist in their care. In this regard, all actors in the network have similar and overlapping interests. Frequently, LEP are part of this information network, however, they have a different set of responsibilities and are not accountable to either the same ethical restrictions as health care providers or to hospital administration. Their primary interests lie in protecting public safety, not patient privacy. The presence of LEP in the ED presents a unique conflict of interest for patients, health care providers, and hospitals. It is important to recognize these different motivations when considering how to develop a policy response to govern this interaction between medical and law enforcement personnel. Few health care institutions have clear guidelines regarding LEP presence in the ED. Under the Health Insurance Portability and Accountability Act, all covered entities, including health care providers and facilities, must adhere to strictly governed procedures about what health information may be shared, how, and with whom (2–7). Furthermore, ethical norms guiding health care providers and LEP differ in some important aspects. The goal of this article is to examine the ethical and legal ramifications of LEP in the ED, and to illustrate the need for a hospital-wide policy to govern the role of LEP in the ED. Finally, this article concludes with specific recommendations regarding the development of such policies. Law Enforcement and the Emergency Department The ED is the primary point of entry into the health care system for those affected by a variety of crimes, including episodes of domestic abuse, sexual assault, and gangrelated violence (8). Frequently, victims of violence are
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accompanied to the ED by LEP as part of a prehospital emergency response. The primary objective of LEP is to rapidly initiate investigation of a crime by collecting information regarding the mechanism of injury and the role of the patient in the incident, as well as the patient’s prognosis (5). The accuracy of such information degrades with time (9). For this reason, many jurisdictions allow LEP presence for rapid acquisition of information related to potential criminal activity. Although LEP presence in the ED has long-standing historical precedents, in only very rare instances is this presence governed by the law or hospital policy. It is a practice most often implicitly allowed rather than prescribed by law, and the position of professional societies point to adherence to local laws that many times are lacking (10). Complicating matters are the varied interpersonal relationships that exist between emergency medicine (EM) providers and LEP. This includes the collegial camaraderie between EM providers and all first responders, or may even be of a more personal nature. For the proper function of the ED, its providers, and for the community as a whole, it is vital that these relationships be kept in good standing. However, providers must be careful never to do so to the detriment of their patients and the care they provide. Patients may be unable (or unwilling) to speak with LEP during their initial evaluation, causing LEP to sometimes turn to ED staff to obtain the information they require (11,12). Hospital personnel are frequently caught between the desire, as a health care provider, to focus on patient care, and the desire to avoid obstructing a police investigation. This conflict is further intensified as the presence of LEP in the ED can impact the quality of care provided. Patients may perceive that their health care team is collaborating with LEP, which can result in withholding information that is vital to their diagnosis and care. Alternatively, patients may feel implicit pressure to cooperate with LEP (even if they feel it is against their interest) if they perceive that their care will be dependent on such cooperation. Such conflicts can place emergency physicians in an untenable situation. There are times when patients’ personal health information must be shared with authorities without a patient’s specific approval – for example, in the case of mandated reporting of domestic, child, or elder abuse; or of certain disease entities that must be reported to public health authorities (3–5). In these exceptional instances, physicians are required by law to subordinate patient confidentiality for a defined public good—when the importance of relaying confidential patient information outweighs the ethical obligation of maintaining patient privacy (4–7). Legislation clearly delineates in what instances such violations need take place, what types of information are reported, to whom this information may be
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disclosed, and the manner in which such disclosures must be made. Legislation, however, is often less clear when it comes to sharing confidential information with LEP in cases of interpersonal violence. The absence of clear legislative guidelines leaves health care providers and institutions with ethical and legal uncertainty. DISCUSSION Policy Considerations For an institution to develop a coherent policy governing the interaction among LEP, patients, and providers, it is necessary that hospital policymakers take into account several key ethical and legal considerations, including patient confidentiality; the impact of LEP presence on the delivery of patient care; legislation regarding mandatory reporting of certain suspected crimes or conditions; and custodial chains of evidence. Confidentiality and Mandated Reporting Emergency medicine (EM) physicians, like all medical practitioners, are required to adhere to a strict set of ethical principles that uphold the integrity of the physician–patient relationship (3,4,13). Once a patient enters a clinical care setting, there is an expectation of privacy and confidentiality (3,4). It is this expectation that allows physicians to address deeply personal issues in an effort to better understand a patient’s illness or injury. Such an expectation may be heightened when the patient is severely injured or is an alleged victim or perpetrator of violence. In these instances, patients may be taken to a resuscitation room, where they are completely undressed to rapidly diagnose potentially life-threatening injuries. Due to the intimate and timesensitive nature of the examination, hospitals have strict regulations regarding what equipment and personnel are allowed into these rooms during resuscitative efforts. An exception is frequently made for LEP who may ask to be present, not only during the initial patient encounter, but during resuscitative efforts as well. The presence of LEP may challenge a physician’s ability to honor a patient’s confidentiality, which in turn may undermine the trust a patient has in the provider. Such a breakdown of trust can drastically affect care. A patient may be less inclined to disclose pertinent information regarding their injury or illness for fear of legal repercussions (14). To avoid potentially negative effects, EM providers should take steps to inform the patient of LEP involvement early in the course of treatment, even prior to arrival of the authorities if possible. Failure to do so can seriously jeopardize the trust necessary for the development of a therapeutic relationship between patient and provider.
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Furthermore, EM staff often encounter situations where they are legally obligated to report a concern regarding patient or public safety to legal or public health authorities (4,7). Although the majority of these cases are reported to non-law-enforcement governmental organizations, such as local public health departments or departments of protective services, cases involving violent crimes are often reported to law enforcement agencies directly (4,6). Each jurisdiction varies with regard to what constitutes a reportable case and, within that case, what specific information should be provided to LEP. The onus is on the EM provider to verify the legality of a request for patient information, preferably through a court order (4,10). This may vary from state to state, with some states simply requiring a subpoena for release of confidential patient information, whereas others may require a court order or warrant. If there is any doubt, the provider should first confer with the hospital’s legal counsel prior to discussing a case with law enforcement. In most cases, health care providers are responsible only for reporting the case itself (including diagnosis and prognosis). Rarely should EM personnel provide LEP with information regarding the patient’s personal account of the incident. Nor is it the provider’s responsibility (or right) to report the likely mechanism of injury unless otherwise mandated by local laws. The provider must be aware of their role as a fiduciary of the patient, not as an agent of law enforcement. Their only legal and ethical responsibility in such situations, outside of those mandated by law, is in providing for the care and safety of the patient. The sharing of such information with LEP constitutes a breach of patient confidentiality. It may also complicate future evidence collection and legal proceedings, especially if there is a discrepancy among physician documentation, patient recollection, and law enforcement findings. Impact of LEP on Perceptions of Care Studies have shown that many patients may have a negative perception regarding law enforcement institutions (14–16). The perception of collaboration between providers and LEP may lead a patient to question their provider’s motives (16). This situation can jeopardize the ability of the staff to provide effective care for the patient. The presence of LEP may have effects that go beyond diminished trust and compromised care. Patients, especially victims of violence, may view LEP presence as a presumption of guilt. This notion is not an entirely unfounded fear, because research suggests that even some emergency physicians believe victims of violence are largely responsible for their own injuries (17).
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A recent study by Schwartz et al. illustrates the impact of LEP presence on patient perception (16). In this study, researchers examined the experiences of young, black male victims of violence in a large urban hospital setting. The authors found that poor delineation between health care staff and LEP led to increased mistrust of health care providers and health care institutions as a whole (16). Another study, by Hacker et al., found that, among immigrant patient populations in Massachusetts, fear of collaboration among health care providers, local law enforcement, and Immigration and Customs Enforcement led to decreased health care services utilization (15). Furthermore, a study among homeless youth in Los Angeles listed discrimination by LEP as a barrier to accessing health care (18). Although there are no studies to date that empirically quantify the relationship between LEP presence in the ED and health care outcomes, the above literature suggests that LEP presence in the ED may have a negative impact on a patient’s trust and utilization of emergency services. From an ethical standpoint it is reasonable for EM staff to limit LEP presence in the ED when possible and permissible by local laws. Limiting LEP presence would help to maintain patient confidentiality, engender trust between the patient and her/his provider, and protect the integrity of the physician–patient relationship. Evidence Collection During the course of regular care, it is common for ED staff to take temporary possession of patient property. Hospital staff may maintain possession of these articles until the patient has finished receiving care, or until such time that a person appointed by the patient may take possession of their property. Most health care institutions have strict regulations regarding how a patient’s property is collected, stored, and relinquished. Similar but more stringent procedures guide how criminal evidence is collected, stored, and transferred. Such procedures create a chain of evidence, or chain of custody (COC). The purpose of COC is to avoid tampering and the appearance of tampering with evidence through the demonstration of a clear, welldocumented trail that connects evidence presented in a criminal case to the individuals involved (19). Although hospital regulations are designed to protect patients’ property while they are under treatment, those regulations often fail to clearly delineate how a patient’s personal property should be managed when dealing with LEP. Some EDs may hand over patient property to LEP once requested, without further consideration or consent on the part of the patient. Although this is done in an effort to cooperate, this act has many far-reaching implications for an EM provider and patient (11,12). By taking
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custody of a patient’s property and then relaying that property to LEP, hospital staff have unknowingly entered into the COC. Lack of established procedures for doing so cannot only endanger the integrity of the COC itself, but possibly the rights of the patient as well. Federal and local statutes are deliberately very clear regarding how, when, and by whom evidence can be collected in police investigations. Such laws protect a person’s constitutional right against unlawful search and seizure during the process of evidence collection. Although LEP would be able to collect patient property directly by invoking ‘‘probable cause,’’ the procedures are less clear when the health care personnel have taken intermediate possession of the property. In a recent case, United States of America vs. Tony Neely, the judge found that the defendant had a right to suppress evidence collected during the hospitalization that was later used to convict the patient of armed robbery (20). Similarly, a case heard in the Massachusetts Court of Appeals found that evidence collected during hospitalization, namely clothing, was inadmissible in a criminal case because LEP did not follow evidentiary procedure when obtaining the evidence. Specifically, the opinion found that ‘‘a defendant retain [s] a possessory interest in [his] clothing, regardless of his status as a hospital patient’’ (21). Both courts concluded that hospital possession of the patient’s property disrupted the COC and ultimately lead to a clear violation of the patient’s civil rights. The question of whether a warrant is required in cases where the hospital has taken possession of property, and a patient is unable or unwillingly to give consent, is one that has yet to be addressed by the courts. One exception worth noting is when the patient’s property is either itself illegal (e.g., illicit substances) or prohibited by hospital policy (weapons). In the latter case, hospital public safety personnel should handle these items in accordance with hospital policy. The protocol for illegal property is more problematic. By handing illegal items over to LEP, the care provider is again inserting himself into the COC, as well as possibly implicating their patient in criminal activity. To avoid this dilemma, some institutions dispose of such materials in a nonrecoverable manner. However, the exact legal implications of doing so have yet to be defined. Limitations to Ethical and Legal Considerations Use of force by LEP. In rare instances, patients deemed to be at risk of harming themselves or others might be restrained for safety. On occasion, LEP are present in the ED when such restraint takes place. There is a paucity of literature addressing the role of LEP in the restraining of patients not already in police custody. At most
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institutions, public safety personnel who are employed, trained, and regulated by the hospital are primarily responsible for restraining a patient. The guiding principles that allow health care staff to restrain a patient differ significantly from those that support LEP. This is because a hospital is ultimately responsible for any complication that arises as a result of a patient being restrained, and therefore it is reasonable to assert that restraining a patient be handled only by hospital-authorized personnel. Although LEP involvement in such a circumstance may be motivated by a broader duty to protect the public at large, it has yet to be determined what their participation means for the hospital from a legal standpoint. Involving an outside party in the process of restraint may lead to excessive force being applied, consequently placing the patient at risk of injury. If an injury occurs during this process, the issue of legal responsibility becomes difficult to ascertain, especially if the injury occurred as a result of LEP action on hospital property. Exceptions. By United States (US) legal standards, once a person is convicted of a crime and incarcerated, certain rights are suspended. These include, but are not limited to, the right of privacy, and some decisions regarding autonomy. These standards extend to when an incarcerated person becomes a patient in the ED. In most jurisdictions, LEP accompanying the patient are legally bound to keep the incarcerated patient within visual contact and physical proximity. In such a situation, patient confidentiality is very difficult, if not impossible, to maintain. The same may apply to individuals whose arrest is pending for alleged criminal activity. Although LEP may use their discretion in deciding when to arrest a suspect, often waiting until that person has finished receiving medical care, they are fully within their legal right to place a patient under custody during medical treatment. This is especially true if the patient is considered a high flight risk or presents an immediate danger to public safety. EM providers should do their best to maintain patients’ rights, while still allowing LEP to perform their lawful duties. Conflicts may be mitigated by making the patient aware beforehand of LEP presence and engaging LEP in a discussion about the respective obligations of health care providers and LEP. RECOMMENDATIONS Using the above principles as a guide, the following framework is suggested for institutions attempting to develop their own policy on LEP activities within the ED and the hospital. A sample policy on LEP in the clinical environment is provided for review in the Appendix. The first step in the creation of a hospital policy governing activities of LEP in the clinical environment is
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to identify all the stakeholders who would be affected by such involvement. The list of stakeholders should include representatives from all clinical departments primarily involved in direct patient care, representatives from nursing leadership, patient advocates or community members, hospital public safety officials, hospital legal and risk management, as well as leaders from local law enforcement. Emphasis should be placed on the role of public safety personnel in drafting and implementing such policy given that many have backgrounds in law enforcement, as well as an understanding of patient rights and hospital practice. Secondly, for patients being treated for traumatic injury, the policy should specifically focus on the tenets of Trauma Informed Care (TIC). TIC is a multidimensional approach that entails a practitioner acknowledging a patient’s history of violent trauma and understanding how this may shape a patient’s current experience in the health care setting (21). As previously mentioned, a patient’s preconceived negative view regarding LEP may shape their experience in the ED. For ED personnel to provide TIC, it is essential that this be recognized. There is a wealth of literature that suggests this model of care is essential when providing effective care to victims of violent injury (22,23). Thirdly, the policy should spell out clear guidelines about when LEP may have access to the patient, their belongings, or personal information. The policy should identify a primary liaison between ED staff and LEP who has a thorough understanding of the issues. Public safety personnel may be best suited for this role for the aforementioned reasons. Furthermore, the policy should outline an algorithm for evidence collection. It is best for EM providers to minimize their role in evidence collection. Logistically, this would mean avoiding collection of personal property unless the patient gives explicit permission to do so, with further consent required if the property is to be given to LEP. If the patient is unable to give consent, then the property should be given to next of kin as is appropriate. In the extreme case where the patient is unable to give consent, and no next of kin is available, then hospital staff should collect and maintain patient property in accordance with strict policies that comply with laws defining evidence collection, while still respecting the patient’s civil rights. In these cases, LEP may require a warrant to obtain the property from hospital staff. This process should draw on personnel from local jurisdictions to help with honoring local laws. Many jurisdictions have specific individuals who are tasked with helping institutions understand their role in the community. Collaboration with local jurisdictions will help broaden understanding between hospital personnel and LEP with regard to patient care and safety.
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Lastly, the policy should address how its recommendations are to be enforced and what, if any, consequences will arise if there is a lapse in adherence. CONCLUSION The present literature suggests that, without appropriate guidelines, LEP presence in the ED may negatively impact the delivery of quality care and have legal ramifications for health care institutions. The ungoverned nature of LEP presence in the ED can further result in ethical dilemmas for health care providers. For these reasons, we advocate for the establishment of policies to govern the role of LEP in the ED. Drafting this policy requires a multidisciplinary approach that involves all stakeholders from patients to hospital staff to law enforcement officials. The resultant policy should honor the tenets of TIC; address when LEP should have access to patients, as well as their property and personal health information; and identify an individual who will serve as a liaison between ED staff and LEP. Such policies are necessary for safe, effective, and ethical treatment of patients and will help to reduce the risk of negative consequences associated with LEP presence in the ED. Acknowledgments—Special thanks to Mrs. Kathleen Shea for her administrative assistance.
REFERENCES 1. Benoit C. The ‘‘Public Safety’’ exception of Miranda. FBI Law Enforcement Bulletin (2011). Available at: http://www.fbi.gov/stats -services/publications/law-enforcement-bulletin/february2011/lega l_digest. Accessed June 5, 2014. 2. Pines JM, Asplin BR. Systems Approach Conference Panelists. Conference proceedings—improving the quality and efficiency of emergency care across the continuum: a systems approach. Acad Emerg Med 2011;18:655–61. 3. American Medical Association (AMA), AMA Council on Ethical and Judicial Affairs. Report 6-I-07, amendment to Opinion E-8.032, ‘‘Conflicts of Interest: Health Facility Ownership by a Physician’’. Chicago, IL: American Medical Association; 2007. Available at: http://www.ama.assn.org/resources/doc/ethics/ceja6i07.pdf. Accessed June 19, 2014. 4. American Medical Association (AMA). AMA policy H-315.983: Patient privacy and confidentiality. Available at: http://www.amaassn.org/resources/doc/PolicyFinder/policyfiles/HnE/H-315.983.H TM. Accessed June 15, 2014.
5. Moskop JC, Marco CA, Larkin GL, et al. From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine—part II: challenges in the emergency department. Ann Emerg Med 2005; 45:60–7. 6. U.S. Department of Health & Human Services. When does the Privacy Rule allow covered entities to disclose protected health information to law enforcement officials? Available at: http://www.hhs. gov/ocr/privacy/hipaa/faq/disclosures_for_law_enforcement_purp oses/505.html. Accessed June 25, 2014. 7. U.S. Department of Health & Human Services. Disclosures for public health activities: OCR HIPAA Privacy 45 CFR 164.512 (b) December 3, 2002. Revised April 3, 2003. Available at: http:// www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/pub lichealth.html. Accessed April 29, 2014. 8. Cunningham R, Knox L, Fein J, et al. Before and after the trauma bay: the prevention of violent injury among youth. Ann Emerg Med 2009;53:490–500. 9. Cutler BL. A sample of witness, crime, and perpetrator characteristics affecting eyewitness identification accuracy. Cardozo Public Law Policy Ethics J 2006;4:327. 10. American College of Emergency Physicians (ACEP). Law enforcement information gathering in the emergency department. Policy statement. Ann Emerg Med 2010;56:80. 11. De Leeuw M, Jacobs W. Forensic emergency medicine: old wine in new barrels. Eur J Emerg Med 2010;17:186–91. 12. Wiler JL, Bailey H, Madsen TE. The need for emergency medicine resident training in forensic medicine. Ann Emerg Med 2007;50: 733–8. 13. American Medical Association (AMA). AMA policy H-275.937 Patient/physician relationship and medical licensing boards. Available at: https://www.ama-assn.org/ssl3/ecomm/PolicyFinderForm. pl?site=www.ama-assn.org&;uri=/resources/html/PolicyFinder/po licyfiles/HnE/H-275.937.HTM. Accessed June 15, 2014. 14. Liebschutz J, Schwartz S, Hoyte J, et al. A chasm between injury and care: experiences of black male victims of violence. J Trauma 2010;69:1372–8. 15. Hacker K, Chu J, Leung C, et al. The impact of immigration and customs enforcement on immigrant health: perceptions of immigrants in Everett, Massachusetts, USA. Soc Sci Med 2011;73:586–94. 16. Schwartz S, Hoyte J, James T, Conoscenti L, Johnson RM, Liebschutz J. Challenges to engaging black male victims of community violence in healthcare research: lessons learned from two studies. Psychol Trauma 2010;2:54–62. 17. Peak JD, Johns MD, Shepherd JP. Attitudes towards assault patients. Arch Emerg Med 1991;8:286–7. 18. Hudson AL, Nyamathi A, Greengold B, et al. Health-seeking challenges among homeless youth. Nurs Res 2010;59:212–8. 19. Giannelli P. Chain of custody and the handling of real evidence. Am Crim Law Rev 1983;20:527–68. 20. United States of America vs Tony Neely, 345 F.3d 366. United States Court of Appeals Fifth Circuit 2003. 21. Commonwealth vs Dwayne M Williams, Jr., 76 Mass. App. Ct. 489; 923 N.E.2d Appeals Court of Massachusetts 2010. 22. Harris M, Fallot RD. Envisioning a trauma-informed service system: a vital paradigm shift. New Dir Ment Health Serv 2001;89:3–22. 23. Corbin TJ, Rich JA, Bloom SL, Delgado D, Rich LJ, Wilson AS. Developing a trauma-informed, emergency department-based intervention for victims of urban violence. J Trauma Dissociation 2011; 12:510–25.
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APPENDIX: SAMPLE POLICY Law Enforcement Presence Guidelines Purpose: To provide guidelines regarding law enforcement personnel (LEP) presence during patient evaluation. Policy Statement: Patient confidentiality is an ethical cornerstone of patient care and of hospital policy. It allows staff physicians to provide quality care in a setting of mutual trust and respect. When confidentiality is violated, it compromises the ability of the hospital staff to evaluate and care for the patient. The presence of LEP during patient evaluation and treatment has a potential to create either a perceived or a real breach of patient confidentiality and may lead to impairment of evaluation or treatment. Therefore, LEP should be asked to wait outside of patient care areas, including trauma rooms, during and following emergency department (ED) evaluations until such time as their presence is deemed appropriate by both the hospital staff and the patient. Application: This policy pertains to patients in the ED who do not arrive in police custody. Responsibility: Trauma team Registered Nurse (RN), ED Attending, Surgical Attending, Public Safety. Procedure: 1. During a patient evaluation, all LEP with the exception of Public Safety staff will be asked to wait outside the patient care area. 2. Once the patient has been fully evaluated and stabilized by the treating team, health care staff can readdress the issue of law enforcement presence, and make the patient aware of a likely interview. If the patient refuses law enforcement contact, LEP should be made aware by the ED attending,
3.
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but shall still be allowed to speak with the patient when appropriate. In cases wherein the patient is suspected by law enforcement of illicit activity, law enforcement will be cleared to interview and if need be, detain the patient once full evaluation and treatment of the patient is complete, or at the discretion of the ED attending. Aside from the below, personal property of the patient obtained during examination shall remain in the custody of the patient until LEP obtain a written warrant for the procurement of such property or the patient gives permission for the property to be transferred to the custody of LEP. a. Any items prohibited by hospital policy (e.g., weapons) discovered during routine evaluation of a patient shall be provided to hospital security personnel if LEP are not present. If LEP are present, hospital staff should transfer such items to their custody. b. If, for any reason, the patient is unable to maintain custody of their personal property or provide consent for transfer of property (such as incapacitation, or critical health status), the property will be kept with the patient. LEP must follow legal channels to procure patient property in this situation. If LEP fail to comply with this policy after repeated discussion, this is to be considered behavior that has the potential to interfere with patient care, and should be managed by the Public Safety Office. Per hospital policy, LEP will be allowed to remain in full view of the patient in such cases wherein the patient is previously in the custody of lawenforcement.
http://dx.doi.org/10.1016/j.jemermed.2015.04.001
Administration of Emergency Medicine MANAGING LAW ENFORCEMENT PRESENCE IN THE EMERGENCY DEPARTMENT: HIGHLIGHTING THE NEED FOR NEW POLICY RECOMMENDATIONS Morsal R. Tahouni, MD,*† Emory Liscord, MD,* and Hani Mowafi, MD, MPH‡ *Department of Emergency Medicine, Boston Medical Center, †Boston University School of Medicine, Boston, Massachusetts, and ‡Yale School of Medicine, New Haven, Connecticut Reprint Address: Morsal R. Tahouni, MD, Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118
, Abstract—Background: The Emergency Department (ED) is the portal of entry to the health care system for a large percentage of patients. This is especially true for victims and perpetrators of interpersonal violence. Frequently, law enforcement personnel (LEP) accompany patients to the ED or seek access to patients during their ED stay or subsequent hospitalization. The time-sensitive nature of both emergency care and criminal investigation motivates both health care personnel and LEP, and can lead to potential conflicts of interest regarding access to patients in the ED. Objectives: We hope to examine the relationship among patients, providers, and LEP in the ED, and the potential impact these interactions have on patient care. This article presents a review of the relevant literature and policy consideration as well as provides guidance on the development of such policies for EDs. Discussion: Hospitals, EDs, and trauma resuscitation rooms are highly regulated environments, but LEP largely fall outside the ethical and institutional guidelines of health care institutions. Many potential areas of conflict exist when LEP are present in the ED that can have detrimental effects on patient care, provider liability, and LEP efficacy. Patients’ perceptions of collaboration between ED personnel and LEP can compromise emergency patient care. Conclusion: There is a need for hospital policies to govern interactions among patients, emergency health care providers, and LEP in the ED. Ó 2015 Elsevier Inc.
jurisdictions; emergency medicine (EM); ethics; chain of custody (COC); Trauma Informed Care (TIC)
INTRODUCTION Just over two years ago, the City of Boston was shocked by the heinous terror attack on one of it’s premier large public events - the Boston Marathon. The bombing at the finish line killed three people and left hundreds more grievously wounded. The subsequent manhunt resulted in two more deaths including a police officer and one of the suspects. These events that gripped our national attention raised serious questions for politicians, policymakers, and health personnel. For many healthcare providers these traumatic events also illustrated the tensions posed by the presence of law enforcement personnel (LEP) in acute healthcare settings. Such interactions occur every day in less dramatic (but for patients similarly traumatic) fashion. The younger suspect in the case, 19-year-old Dzhokhar Tsarnaev, was critically injured and initially unable to speak due to a gunshot wound to the throat when he was taken into custody. As he lay sedated, LEP remained at his bedside, waiting to interrogate him. LEP were eventually allowed to question Tsarnaev for a total of 16 hours over the course of 3 days, before he was arraigned and read his Miranda rights under the direction of Judge Marianne Bowler. The preMiranda interrogation was allowed under the ‘‘public
, Keywords—police; law enforcement personnel (LEP); Emergency Department (ED); privacy; evidence collection;
RECEIVED: 1 October 2014; FINAL SUBMISSION RECEIVED: 30 March 2015; ACCEPTED: 7 April 2015 523
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safety exception’’ to the Miranda ruling established by the case New York v. Quarles in 1980, which allows LEP to pursue questioning of a suspect when there is concern of imminent danger to officers or the public (1). Although there is much dispute over the extension of the public safety exception in terror cases, this case highlights important policy considerations for health care providers—specifically, Emergency Department (ED) personnel—dealing with more routine cases of criminal suspects under their care. Patients presenting to the ED are often not well known to the provider caring for them. This lack of familiarity necessitates close collaboration with a wide variety of actors to gather information about a patient’s health status and the events that led to their presentation to the ED (2). Such sources of information may include a patient’s family, neighbors, primary doctor, emergency medical services personnel, nursing home staff, and even bystander reports. In theory, all parties involved are working with the motivation to improve the health of the patient and assist in their care. In this regard, all actors in the network have similar and overlapping interests. Frequently, LEP are part of this information network, however, they have a different set of responsibilities and are not accountable to either the same ethical restrictions as health care providers or to hospital administration. Their primary interests lie in protecting public safety, not patient privacy. The presence of LEP in the ED presents a unique conflict of interest for patients, health care providers, and hospitals. It is important to recognize these different motivations when considering how to develop a policy response to govern this interaction between medical and law enforcement personnel. Few health care institutions have clear guidelines regarding LEP presence in the ED. Under the Health Insurance Portability and Accountability Act, all covered entities, including health care providers and facilities, must adhere to strictly governed procedures about what health information may be shared, how, and with whom (2–7). Furthermore, ethical norms guiding health care providers and LEP differ in some important aspects. The goal of this article is to examine the ethical and legal ramifications of LEP in the ED, and to illustrate the need for a hospital-wide policy to govern the role of LEP in the ED. Finally, this article concludes with specific recommendations regarding the development of such policies. Law Enforcement and the Emergency Department The ED is the primary point of entry into the health care system for those affected by a variety of crimes, including episodes of domestic abuse, sexual assault, and gangrelated violence (8). Frequently, victims of violence are
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accompanied to the ED by LEP as part of a prehospital emergency response. The primary objective of LEP is to rapidly initiate investigation of a crime by collecting information regarding the mechanism of injury and the role of the patient in the incident, as well as the patient’s prognosis (5). The accuracy of such information degrades with time (9). For this reason, many jurisdictions allow LEP presence for rapid acquisition of information related to potential criminal activity. Although LEP presence in the ED has long-standing historical precedents, in only very rare instances is this presence governed by the law or hospital policy. It is a practice most often implicitly allowed rather than prescribed by law, and the position of professional societies point to adherence to local laws that many times are lacking (10). Complicating matters are the varied interpersonal relationships that exist between emergency medicine (EM) providers and LEP. This includes the collegial camaraderie between EM providers and all first responders, or may even be of a more personal nature. For the proper function of the ED, its providers, and for the community as a whole, it is vital that these relationships be kept in good standing. However, providers must be careful never to do so to the detriment of their patients and the care they provide. Patients may be unable (or unwilling) to speak with LEP during their initial evaluation, causing LEP to sometimes turn to ED staff to obtain the information they require (11,12). Hospital personnel are frequently caught between the desire, as a health care provider, to focus on patient care, and the desire to avoid obstructing a police investigation. This conflict is further intensified as the presence of LEP in the ED can impact the quality of care provided. Patients may perceive that their health care team is collaborating with LEP, which can result in withholding information that is vital to their diagnosis and care. Alternatively, patients may feel implicit pressure to cooperate with LEP (even if they feel it is against their interest) if they perceive that their care will be dependent on such cooperation. Such conflicts can place emergency physicians in an untenable situation. There are times when patients’ personal health information must be shared with authorities without a patient’s specific approval – for example, in the case of mandated reporting of domestic, child, or elder abuse; or of certain disease entities that must be reported to public health authorities (3–5). In these exceptional instances, physicians are required by law to subordinate patient confidentiality for a defined public good—when the importance of relaying confidential patient information outweighs the ethical obligation of maintaining patient privacy (4–7). Legislation clearly delineates in what instances such violations need take place, what types of information are reported, to whom this information may be
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disclosed, and the manner in which such disclosures must be made. Legislation, however, is often less clear when it comes to sharing confidential information with LEP in cases of interpersonal violence. The absence of clear legislative guidelines leaves health care providers and institutions with ethical and legal uncertainty. DISCUSSION Policy Considerations For an institution to develop a coherent policy governing the interaction among LEP, patients, and providers, it is necessary that hospital policymakers take into account several key ethical and legal considerations, including patient confidentiality; the impact of LEP presence on the delivery of patient care; legislation regarding mandatory reporting of certain suspected crimes or conditions; and custodial chains of evidence. Confidentiality and Mandated Reporting Emergency medicine (EM) physicians, like all medical practitioners, are required to adhere to a strict set of ethical principles that uphold the integrity of the physician–patient relationship (3,4,13). Once a patient enters a clinical care setting, there is an expectation of privacy and confidentiality (3,4). It is this expectation that allows physicians to address deeply personal issues in an effort to better understand a patient’s illness or injury. Such an expectation may be heightened when the patient is severely injured or is an alleged victim or perpetrator of violence. In these instances, patients may be taken to a resuscitation room, where they are completely undressed to rapidly diagnose potentially life-threatening injuries. Due to the intimate and timesensitive nature of the examination, hospitals have strict regulations regarding what equipment and personnel are allowed into these rooms during resuscitative efforts. An exception is frequently made for LEP who may ask to be present, not only during the initial patient encounter, but during resuscitative efforts as well. The presence of LEP may challenge a physician’s ability to honor a patient’s confidentiality, which in turn may undermine the trust a patient has in the provider. Such a breakdown of trust can drastically affect care. A patient may be less inclined to disclose pertinent information regarding their injury or illness for fear of legal repercussions (14). To avoid potentially negative effects, EM providers should take steps to inform the patient of LEP involvement early in the course of treatment, even prior to arrival of the authorities if possible. Failure to do so can seriously jeopardize the trust necessary for the development of a therapeutic relationship between patient and provider.
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Furthermore, EM staff often encounter situations where they are legally obligated to report a concern regarding patient or public safety to legal or public health authorities (4,7). Although the majority of these cases are reported to non-law-enforcement governmental organizations, such as local public health departments or departments of protective services, cases involving violent crimes are often reported to law enforcement agencies directly (4,6). Each jurisdiction varies with regard to what constitutes a reportable case and, within that case, what specific information should be provided to LEP. The onus is on the EM provider to verify the legality of a request for patient information, preferably through a court order (4,10). This may vary from state to state, with some states simply requiring a subpoena for release of confidential patient information, whereas others may require a court order or warrant. If there is any doubt, the provider should first confer with the hospital’s legal counsel prior to discussing a case with law enforcement. In most cases, health care providers are responsible only for reporting the case itself (including diagnosis and prognosis). Rarely should EM personnel provide LEP with information regarding the patient’s personal account of the incident. Nor is it the provider’s responsibility (or right) to report the likely mechanism of injury unless otherwise mandated by local laws. The provider must be aware of their role as a fiduciary of the patient, not as an agent of law enforcement. Their only legal and ethical responsibility in such situations, outside of those mandated by law, is in providing for the care and safety of the patient. The sharing of such information with LEP constitutes a breach of patient confidentiality. It may also complicate future evidence collection and legal proceedings, especially if there is a discrepancy among physician documentation, patient recollection, and law enforcement findings. Impact of LEP on Perceptions of Care Studies have shown that many patients may have a negative perception regarding law enforcement institutions (14–16). The perception of collaboration between providers and LEP may lead a patient to question their provider’s motives (16). This situation can jeopardize the ability of the staff to provide effective care for the patient. The presence of LEP may have effects that go beyond diminished trust and compromised care. Patients, especially victims of violence, may view LEP presence as a presumption of guilt. This notion is not an entirely unfounded fear, because research suggests that even some emergency physicians believe victims of violence are largely responsible for their own injuries (17).
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A recent study by Schwartz et al. illustrates the impact of LEP presence on patient perception (16). In this study, researchers examined the experiences of young, black male victims of violence in a large urban hospital setting. The authors found that poor delineation between health care staff and LEP led to increased mistrust of health care providers and health care institutions as a whole (16). Another study, by Hacker et al., found that, among immigrant patient populations in Massachusetts, fear of collaboration among health care providers, local law enforcement, and Immigration and Customs Enforcement led to decreased health care services utilization (15). Furthermore, a study among homeless youth in Los Angeles listed discrimination by LEP as a barrier to accessing health care (18). Although there are no studies to date that empirically quantify the relationship between LEP presence in the ED and health care outcomes, the above literature suggests that LEP presence in the ED may have a negative impact on a patient’s trust and utilization of emergency services. From an ethical standpoint it is reasonable for EM staff to limit LEP presence in the ED when possible and permissible by local laws. Limiting LEP presence would help to maintain patient confidentiality, engender trust between the patient and her/his provider, and protect the integrity of the physician–patient relationship. Evidence Collection During the course of regular care, it is common for ED staff to take temporary possession of patient property. Hospital staff may maintain possession of these articles until the patient has finished receiving care, or until such time that a person appointed by the patient may take possession of their property. Most health care institutions have strict regulations regarding how a patient’s property is collected, stored, and relinquished. Similar but more stringent procedures guide how criminal evidence is collected, stored, and transferred. Such procedures create a chain of evidence, or chain of custody (COC). The purpose of COC is to avoid tampering and the appearance of tampering with evidence through the demonstration of a clear, welldocumented trail that connects evidence presented in a criminal case to the individuals involved (19). Although hospital regulations are designed to protect patients’ property while they are under treatment, those regulations often fail to clearly delineate how a patient’s personal property should be managed when dealing with LEP. Some EDs may hand over patient property to LEP once requested, without further consideration or consent on the part of the patient. Although this is done in an effort to cooperate, this act has many far-reaching implications for an EM provider and patient (11,12). By taking
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custody of a patient’s property and then relaying that property to LEP, hospital staff have unknowingly entered into the COC. Lack of established procedures for doing so cannot only endanger the integrity of the COC itself, but possibly the rights of the patient as well. Federal and local statutes are deliberately very clear regarding how, when, and by whom evidence can be collected in police investigations. Such laws protect a person’s constitutional right against unlawful search and seizure during the process of evidence collection. Although LEP would be able to collect patient property directly by invoking ‘‘probable cause,’’ the procedures are less clear when the health care personnel have taken intermediate possession of the property. In a recent case, United States of America vs. Tony Neely, the judge found that the defendant had a right to suppress evidence collected during the hospitalization that was later used to convict the patient of armed robbery (20). Similarly, a case heard in the Massachusetts Court of Appeals found that evidence collected during hospitalization, namely clothing, was inadmissible in a criminal case because LEP did not follow evidentiary procedure when obtaining the evidence. Specifically, the opinion found that ‘‘a defendant retain [s] a possessory interest in [his] clothing, regardless of his status as a hospital patient’’ (21). Both courts concluded that hospital possession of the patient’s property disrupted the COC and ultimately lead to a clear violation of the patient’s civil rights. The question of whether a warrant is required in cases where the hospital has taken possession of property, and a patient is unable or unwillingly to give consent, is one that has yet to be addressed by the courts. One exception worth noting is when the patient’s property is either itself illegal (e.g., illicit substances) or prohibited by hospital policy (weapons). In the latter case, hospital public safety personnel should handle these items in accordance with hospital policy. The protocol for illegal property is more problematic. By handing illegal items over to LEP, the care provider is again inserting himself into the COC, as well as possibly implicating their patient in criminal activity. To avoid this dilemma, some institutions dispose of such materials in a nonrecoverable manner. However, the exact legal implications of doing so have yet to be defined. Limitations to Ethical and Legal Considerations Use of force by LEP. In rare instances, patients deemed to be at risk of harming themselves or others might be restrained for safety. On occasion, LEP are present in the ED when such restraint takes place. There is a paucity of literature addressing the role of LEP in the restraining of patients not already in police custody. At most
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institutions, public safety personnel who are employed, trained, and regulated by the hospital are primarily responsible for restraining a patient. The guiding principles that allow health care staff to restrain a patient differ significantly from those that support LEP. This is because a hospital is ultimately responsible for any complication that arises as a result of a patient being restrained, and therefore it is reasonable to assert that restraining a patient be handled only by hospital-authorized personnel. Although LEP involvement in such a circumstance may be motivated by a broader duty to protect the public at large, it has yet to be determined what their participation means for the hospital from a legal standpoint. Involving an outside party in the process of restraint may lead to excessive force being applied, consequently placing the patient at risk of injury. If an injury occurs during this process, the issue of legal responsibility becomes difficult to ascertain, especially if the injury occurred as a result of LEP action on hospital property. Exceptions. By United States (US) legal standards, once a person is convicted of a crime and incarcerated, certain rights are suspended. These include, but are not limited to, the right of privacy, and some decisions regarding autonomy. These standards extend to when an incarcerated person becomes a patient in the ED. In most jurisdictions, LEP accompanying the patient are legally bound to keep the incarcerated patient within visual contact and physical proximity. In such a situation, patient confidentiality is very difficult, if not impossible, to maintain. The same may apply to individuals whose arrest is pending for alleged criminal activity. Although LEP may use their discretion in deciding when to arrest a suspect, often waiting until that person has finished receiving medical care, they are fully within their legal right to place a patient under custody during medical treatment. This is especially true if the patient is considered a high flight risk or presents an immediate danger to public safety. EM providers should do their best to maintain patients’ rights, while still allowing LEP to perform their lawful duties. Conflicts may be mitigated by making the patient aware beforehand of LEP presence and engaging LEP in a discussion about the respective obligations of health care providers and LEP. RECOMMENDATIONS Using the above principles as a guide, the following framework is suggested for institutions attempting to develop their own policy on LEP activities within the ED and the hospital. A sample policy on LEP in the clinical environment is provided for review in the Appendix. The first step in the creation of a hospital policy governing activities of LEP in the clinical environment is
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to identify all the stakeholders who would be affected by such involvement. The list of stakeholders should include representatives from all clinical departments primarily involved in direct patient care, representatives from nursing leadership, patient advocates or community members, hospital public safety officials, hospital legal and risk management, as well as leaders from local law enforcement. Emphasis should be placed on the role of public safety personnel in drafting and implementing such policy given that many have backgrounds in law enforcement, as well as an understanding of patient rights and hospital practice. Secondly, for patients being treated for traumatic injury, the policy should specifically focus on the tenets of Trauma Informed Care (TIC). TIC is a multidimensional approach that entails a practitioner acknowledging a patient’s history of violent trauma and understanding how this may shape a patient’s current experience in the health care setting (21). As previously mentioned, a patient’s preconceived negative view regarding LEP may shape their experience in the ED. For ED personnel to provide TIC, it is essential that this be recognized. There is a wealth of literature that suggests this model of care is essential when providing effective care to victims of violent injury (22,23). Thirdly, the policy should spell out clear guidelines about when LEP may have access to the patient, their belongings, or personal information. The policy should identify a primary liaison between ED staff and LEP who has a thorough understanding of the issues. Public safety personnel may be best suited for this role for the aforementioned reasons. Furthermore, the policy should outline an algorithm for evidence collection. It is best for EM providers to minimize their role in evidence collection. Logistically, this would mean avoiding collection of personal property unless the patient gives explicit permission to do so, with further consent required if the property is to be given to LEP. If the patient is unable to give consent, then the property should be given to next of kin as is appropriate. In the extreme case where the patient is unable to give consent, and no next of kin is available, then hospital staff should collect and maintain patient property in accordance with strict policies that comply with laws defining evidence collection, while still respecting the patient’s civil rights. In these cases, LEP may require a warrant to obtain the property from hospital staff. This process should draw on personnel from local jurisdictions to help with honoring local laws. Many jurisdictions have specific individuals who are tasked with helping institutions understand their role in the community. Collaboration with local jurisdictions will help broaden understanding between hospital personnel and LEP with regard to patient care and safety.
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Lastly, the policy should address how its recommendations are to be enforced and what, if any, consequences will arise if there is a lapse in adherence. CONCLUSION The present literature suggests that, without appropriate guidelines, LEP presence in the ED may negatively impact the delivery of quality care and have legal ramifications for health care institutions. The ungoverned nature of LEP presence in the ED can further result in ethical dilemmas for health care providers. For these reasons, we advocate for the establishment of policies to govern the role of LEP in the ED. Drafting this policy requires a multidisciplinary approach that involves all stakeholders from patients to hospital staff to law enforcement officials. The resultant policy should honor the tenets of TIC; address when LEP should have access to patients, as well as their property and personal health information; and identify an individual who will serve as a liaison between ED staff and LEP. Such policies are necessary for safe, effective, and ethical treatment of patients and will help to reduce the risk of negative consequences associated with LEP presence in the ED. Acknowledgments—Special thanks to Mrs. Kathleen Shea for her administrative assistance.
REFERENCES 1. Benoit C. The ‘‘Public Safety’’ exception of Miranda. FBI Law Enforcement Bulletin (2011). Available at: http://www.fbi.gov/stats -services/publications/law-enforcement-bulletin/february2011/lega l_digest. Accessed June 5, 2014. 2. Pines JM, Asplin BR. Systems Approach Conference Panelists. Conference proceedings—improving the quality and efficiency of emergency care across the continuum: a systems approach. Acad Emerg Med 2011;18:655–61. 3. American Medical Association (AMA), AMA Council on Ethical and Judicial Affairs. Report 6-I-07, amendment to Opinion E-8.032, ‘‘Conflicts of Interest: Health Facility Ownership by a Physician’’. Chicago, IL: American Medical Association; 2007. Available at: http://www.ama.assn.org/resources/doc/ethics/ceja6i07.pdf. Accessed June 19, 2014. 4. American Medical Association (AMA). AMA policy H-315.983: Patient privacy and confidentiality. Available at: http://www.amaassn.org/resources/doc/PolicyFinder/policyfiles/HnE/H-315.983.H TM. Accessed June 15, 2014.
5. Moskop JC, Marco CA, Larkin GL, et al. From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine—part II: challenges in the emergency department. Ann Emerg Med 2005; 45:60–7. 6. U.S. Department of Health & Human Services. When does the Privacy Rule allow covered entities to disclose protected health information to law enforcement officials? Available at: http://www.hhs. gov/ocr/privacy/hipaa/faq/disclosures_for_law_enforcement_purp oses/505.html. Accessed June 25, 2014. 7. U.S. Department of Health & Human Services. Disclosures for public health activities: OCR HIPAA Privacy 45 CFR 164.512 (b) December 3, 2002. Revised April 3, 2003. Available at: http:// www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/pub lichealth.html. Accessed April 29, 2014. 8. Cunningham R, Knox L, Fein J, et al. Before and after the trauma bay: the prevention of violent injury among youth. Ann Emerg Med 2009;53:490–500. 9. Cutler BL. A sample of witness, crime, and perpetrator characteristics affecting eyewitness identification accuracy. Cardozo Public Law Policy Ethics J 2006;4:327. 10. American College of Emergency Physicians (ACEP). Law enforcement information gathering in the emergency department. Policy statement. Ann Emerg Med 2010;56:80. 11. De Leeuw M, Jacobs W. Forensic emergency medicine: old wine in new barrels. Eur J Emerg Med 2010;17:186–91. 12. Wiler JL, Bailey H, Madsen TE. The need for emergency medicine resident training in forensic medicine. Ann Emerg Med 2007;50: 733–8. 13. American Medical Association (AMA). AMA policy H-275.937 Patient/physician relationship and medical licensing boards. Available at: https://www.ama-assn.org/ssl3/ecomm/PolicyFinderForm. pl?site=www.ama-assn.org&;uri=/resources/html/PolicyFinder/po licyfiles/HnE/H-275.937.HTM. Accessed June 15, 2014. 14. Liebschutz J, Schwartz S, Hoyte J, et al. A chasm between injury and care: experiences of black male victims of violence. J Trauma 2010;69:1372–8. 15. Hacker K, Chu J, Leung C, et al. The impact of immigration and customs enforcement on immigrant health: perceptions of immigrants in Everett, Massachusetts, USA. Soc Sci Med 2011;73:586–94. 16. Schwartz S, Hoyte J, James T, Conoscenti L, Johnson RM, Liebschutz J. Challenges to engaging black male victims of community violence in healthcare research: lessons learned from two studies. Psychol Trauma 2010;2:54–62. 17. Peak JD, Johns MD, Shepherd JP. Attitudes towards assault patients. Arch Emerg Med 1991;8:286–7. 18. Hudson AL, Nyamathi A, Greengold B, et al. Health-seeking challenges among homeless youth. Nurs Res 2010;59:212–8. 19. Giannelli P. Chain of custody and the handling of real evidence. Am Crim Law Rev 1983;20:527–68. 20. United States of America vs Tony Neely, 345 F.3d 366. United States Court of Appeals Fifth Circuit 2003. 21. Commonwealth vs Dwayne M Williams, Jr., 76 Mass. App. Ct. 489; 923 N.E.2d Appeals Court of Massachusetts 2010. 22. Harris M, Fallot RD. Envisioning a trauma-informed service system: a vital paradigm shift. New Dir Ment Health Serv 2001;89:3–22. 23. Corbin TJ, Rich JA, Bloom SL, Delgado D, Rich LJ, Wilson AS. Developing a trauma-informed, emergency department-based intervention for victims of urban violence. J Trauma Dissociation 2011; 12:510–25.
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APPENDIX: SAMPLE POLICY Law Enforcement Presence Guidelines Purpose: To provide guidelines regarding law enforcement personnel (LEP) presence during patient evaluation. Policy Statement: Patient confidentiality is an ethical cornerstone of patient care and of hospital policy. It allows staff physicians to provide quality care in a setting of mutual trust and respect. When confidentiality is violated, it compromises the ability of the hospital staff to evaluate and care for the patient. The presence of LEP during patient evaluation and treatment has a potential to create either a perceived or a real breach of patient confidentiality and may lead to impairment of evaluation or treatment. Therefore, LEP should be asked to wait outside of patient care areas, including trauma rooms, during and following emergency department (ED) evaluations until such time as their presence is deemed appropriate by both the hospital staff and the patient. Application: This policy pertains to patients in the ED who do not arrive in police custody. Responsibility: Trauma team Registered Nurse (RN), ED Attending, Surgical Attending, Public Safety. Procedure: 1. During a patient evaluation, all LEP with the exception of Public Safety staff will be asked to wait outside the patient care area. 2. Once the patient has been fully evaluated and stabilized by the treating team, health care staff can readdress the issue of law enforcement presence, and make the patient aware of a likely interview. If the patient refuses law enforcement contact, LEP should be made aware by the ED attending,
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but shall still be allowed to speak with the patient when appropriate. In cases wherein the patient is suspected by law enforcement of illicit activity, law enforcement will be cleared to interview and if need be, detain the patient once full evaluation and treatment of the patient is complete, or at the discretion of the ED attending. Aside from the below, personal property of the patient obtained during examination shall remain in the custody of the patient until LEP obtain a written warrant for the procurement of such property or the patient gives permission for the property to be transferred to the custody of LEP. a. Any items prohibited by hospital policy (e.g., weapons) discovered during routine evaluation of a patient shall be provided to hospital security personnel if LEP are not present. If LEP are present, hospital staff should transfer such items to their custody. b. If, for any reason, the patient is unable to maintain custody of their personal property or provide consent for transfer of property (such as incapacitation, or critical health status), the property will be kept with the patient. LEP must follow legal channels to procure patient property in this situation. If LEP fail to comply with this policy after repeated discussion, this is to be considered behavior that has the potential to interfere with patient care, and should be managed by the Public Safety Office. Per hospital policy, LEP will be allowed to remain in full view of the patient in such cases wherein the patient is previously in the custody of lawenforcement.
