Discussing Firearms with Emergency Department Patients: Why, Who, Where, When, and What
July 1, 2016 42 minutes read
AUTHORS
Megan L. Ranney, MD, MPH, Assistant Professor, Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, RI.
Marian E. Betz, MD, MPH, Associate Professor, Department of Emergency Medicine, University of Colorado School of Medicine, Denver.
PEER REVIEWER
Steven M. Winograd, MD, FACEP, Core Faculty and Assistant Clinical Professor of Emergency Medicine, NYiTCOM, St. Barnabas Hospital, Bronx, NY, Albert Einstein Affiliate Residency in Emergency Medicine.
Statement of Financial Disclosure
To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Dr. Farel (CME question reviewer) owns stock in Johnson & Johnson. Dr. Stapczynski (editor) owns stock in Pfizer, Johnson & Johnson, Walgreens Boots Alliance Inc., GlaxoSmithKline, Bristol Myers Squibb, and AxoGen. Dr. Ranney (author) is a medical advisor with equity options for Study Cue LLC. Dr. Schneider (editor), Ms. Fessler (nurse planner), Dr. Betz (author), Dr. Winograd (peer reviewer), Ms. Mark (executive editor), Ms. Coplin (executive editor), and Mr. Landenberger (editorial and continuing education director) report no financial relationships with companies related to the field of study covered by this CME activity.
There are few more polarizing words in the United States than “firearms.” Even the mention of the word immediately evokes emotions, either pro or con. This article is not about the firearm debate. It is about the safety of our patients. As physicians, we provide information to our patients about how to safely use automobiles (seat belts) and when not to use them (impaired drivers). This article describes how to have that difficult discussion about firearms, and when to take extra steps to safeguard the guns we own.
— Sandra M. Schneider, MD, Editor
Introduction
In the United States, on average 92 people die from firearms every day.1 In our heterogeneous population, the question of how to prevent firearm deaths remains a politically charged and contentious one. Approximately one-third of American adults report owning at least one firearm, and ownership rates vary among states from approximately 5% to more than 60%;2 similar rates of ownership (15-40%) are reported by physicians.3,4 The Second Amendment to the U.S. Constitution states “the right of the People to keep and bear arms shall not be infringed.” In light of recent mass shootings, there are some who call for limits on firearm ownership and usage.
The larger political debate has considered the role of healthcare providers — including emergency physicians (EPs) — in preventing firearm injuries or deaths. The impact of firearm safety screening and counseling by providers remains unclear, but firearm safety screening and counseling may encourage safer home firearm storage and may reduce the risk of death.5 Screening typically involves asking “at-risk” patients — those deemed to be at higher than average risk for firearm injury — about their access to firearms. Counseling typically involves the physician or other healthcare professional discussing ways to mitigate risk of firearm injury (such as locked storage or temporary storage out of the home) with the patient and his or her family. In most states and most scenarios, firearm screening and counseling does not mean the EP contacts law enforcement to remove or confiscate firearms. Although some states have considered or enacted laws attempting to limit provider discussions, there is currently no federal or state prohibition on providers asking about firearms when it is relevant to the health or safety of the patient or others.6
Generally, the three categories when discussions about firearm access could be appropriate in the emergency department (ED) setting include: risk of intentional harm to self (i.e., risk of suicide); risk of intentional harm by or to others (i.e., homicide, including intimate partner and other interpersonal violence); and risk of unintentional harm to self or others (i.e., “accidental” injury in a child or cognitively impaired person).
This article explores questions around physician firearm safety counseling — including why EPs might do it, who might benefit, where and when to consider it, and what such counseling should include (along with what resources exist for EPs and for patients). We conclude with a discussion of relevant legal and ethical issues.
Why?
EPs should consider screening and counseling at-risk patients about firearm access both because of the incidence of firearm injury and death in the United States and because physicians, in collaboration with patients and their families, may prevent some of these injuries and deaths.
In 2014, the United States had 33,599 firearm deaths, and U.S. EDs treated 81,034 non-fatal firearm injuries.1 Two-thirds of firearm deaths were due to suicide (21,334 deaths in 2014, representing 51% of all suicides that year); the remainder were homicides (11,409 deaths, peer and partner violence, representing 70% of all homicides), unintentional or “accidental” (586 deaths), and “undetermined intent” (270 deaths; see Figure 1).”7 The rate of firearm homicide has decreased slightly during the past few decades, but the overall rate of firearm death remains largely unchanged because suicide rates have increased.8 (See Figure 1.) Only poisonings (including the much-discussed opioid epidemic) and motor vehicle collisions were responsible for a similar injury mortality burden in 2014.1 (See Figure 2.)
Figure 1. Age-adjusted Firearm Death Rates, by Gender and Race/Ethnicity (US, 1999-2014)1
Homicide includes legal intervention deaths.
Figure 2. Deaths, by Mechanism and Year (US, 1999-2014)1
MVC = motor vehicle collision
Although non-fatal firearm injuries are more common than fatal injuries, firearm injuries are more likely to be lethal than injuries from other mechanisms.9,10 For instance, a suicide attempt with a firearm has a case fatality rate of 90%, compared to 10% for all other methods combined.11-13 In 2014, for every 100 firearm assaults presenting to the ED for care, there were 19 deaths; this rate is higher than for other penetrating trauma (1.3 deaths/100 ED visits) or blunt force assault (< 1 death/10,000 ED visits).1 Among youth ≤ 19 years old, those injured by firearms have significantly higher rates of serious injury, major surgery, and in-hospital mortality compared to other mechanisms of injury.14
Non-fatal firearm-related injuries also have significant negative consequences for patients, families, and society. They are associated with high rates of physical disability and mental illness, among both victims and bystanders.15-19 They increase risk of future violent victimization and death, crime perpetration, and recurrent firearm injuries.20-22 They are expensive to society: Approximately $1.2 billion is spent on firearm-injury-related acute medical care each year, with another $47 billion from work-loss costs.10,23
In addition to the large burden of injury from firearm suicide, peer violence, partner violence, and unintentional injuries, concerns over mass shootings have focused attention on firearm screening and counseling in the ED. Increasingly, EPs are being asked to evaluate patients for risk of harm against self or others, which includes risk of harm through firearms. Psychiatric evaluations are the most rapidly increasing category of ED visits.24 ED visits by children for mental health evaluations are increasing at a faster rate than visits for other chronic care conditions.25 In addition, many patients with mental health problems present in the ED with non-psychiatric chief complaints. Although the vast majority of patients with acute mental illness are not violent,26 EPs must consider how best to evaluate, care for, and arrange follow-up for patients who are at risk of suicide or who pose a serious danger of violence to others.
Despite the attention paid to mass violence, it is relatively rare, with only 298 cases and 1,479 victims since 2006,27 and 154 hospital-based shootings over a decade.28 Nonetheless, so-called “active shooter incidents” are increasing in frequency, and firearms are used in more than three-quarters of mass killings (incidents during which four or more people are killed).27 As EPs are the front line of treatment for mass shootings in our communities and our hospitals, we are dedicating increasing time and resources to preparing for these tragic scenarios.29,30 Additionally, prior legal decisions suggest that we, as physicians, may be held responsible if a patient murders someone after discharge from our care.31
Therefore, it is critical for us to understand who, where, and when to screen for firearm access — and to know what counseling is appropriate for a positive answer.
Physician screening and counseling can be effective in reducing multiple forms of injury,32-35 including the risk of firearm injury and death. As will be discussed below, evidence exists that physician-led interventions increase rates of safe storage of firearms,36 decrease weapon carriage among victims of violent assault,37 and decrease access to firearms among suicidal patients.38,39
Although EPs can help prevent firearm injury,3,40 although the American College of Emergency Physicians encourages firearm injury prevention,41 and although a growing body of evidence supports the importance of screening and counseling,42 only a minority of emergency physicians currently screen high-risk patients for firearm injury risk.40,43 (Other specialties, including pediatricians, family practitioners, and psychiatrists, have a similar low rate of screening.44-46)
Who?
Firearm injury occurs across the lifespan and across demographic groups, with variation in injury rates and patterns among states. (See Figure 3.) Young African-American males have the highest mortality rate from firearm injury.10 In absolute terms, however, most firearm deaths occur among older white men, with suicide being the leading cause of firearm death.10,47 (See Figures 4 and 5.)
Figure 3. Firearm Death Rates,* by State, for (a) Suicide and (b) Homicide per 100,000 Population (US, 2004-2010)1
*Crude death rates (all ages, races, ethnicities, and both sexes). Maps Produced by the Statistics, Programming & Economics Branch, National Center for Injury Prevention & Control, CDC. Data Sources: NCHS National Vital Statistics System for numbers of deaths; U.S. Census Bureau for population estimates.
Figure 4. Absolute Number of Firearm Deaths, by Age and Race/Ethnicity, for (a) Males and (b) Females (US, 2014)1
Figure 5. Firearm Deaths, by Age and Intent (US, 2014)1
Firearm access is a major risk factor for death from suicide, partner violence, and homicide across the life cycle, and access to unsecured firearms increases youth risk of unintentional death. Longitudinal,48 case-control,49-52 and cross-sectional studies53-55 show that personal ownership or household exposure to firearms is a risk factor for death. Indeed, firearm access in the home is one of the strongest and most well-established risk factors for suicide for all household members.56-59 Approximately one-third of Americans report owning a firearm, with higher rates of ownership in rural, Southern, and Western states.60-62
Of course, most Americans who own or have access to a firearm will not be injured. And in some communities, most ED patients, EPs, and their staff likely own firearms. Therefore, it is important to consider what demographic characteristics, medical history, or other risk factors put a patient at higher risk of firearm injury or death. (See Table 1.)
Table 1. Who To Ask
Category of Risk of Firearm Injury or Death |
Sample Patient Populations |
|
Intentional harm to self |
|
|
Intentional harm by or to others |
|
|
Unintentional harm to self |
|
Risk of Intentional Harm to Self. Firearms account for more than 50% of the 21,000 yearly suicide deaths in the United States.1 Firearm suicide rates are highest in the intermountain and rural states, for both adults and for youth (see Figure 3),10 with a strong and consistent correlation between home firearm access and risk of death by suicide.63 Among youth who die by firearm suicide, 82% used a family member’s gun.64
Reducing access to firearms (and other highly lethal methods) for those patients at high risk for suicide can save lives63,65 because: many suicide attempts are impulsive,66 with only minutes between decision and action; attempts often occur within a short-lived crisis;67 and the lethality of the method affects chance of survival, with up to 90% of firearm attempts resulting in death.68 Of note, of those who survive a suicide attempt, less than 10% go on to eventually die from suicide.69-71 Therefore, reducing access to lethal means may reduce risk of suicide death.65
Risk factors for suicide are both static and dynamic, with variable interactions and significance for different individuals. In the United States, groups of particular concern for suicide include middle-aged and older adults, particularly white men and Native Americans. (See Figures 4 and 5.) A history of mental illness, particularly depression or prior suicide attempt, is a strong risk factor.72 Additional risk factors for firearm suicide for EPs to consider include: alcohol or substance abuse, adolescence, older age, chronic illness, chronic pain, and social stressors including recent incarceration and being separated, divorced, or widowed (rather than married).72
The most obvious cases for firearm screening in the ED are when an ED patient expresses suicidal ideation or intent or is in the ED for a suicide attempt. But some patients, including those with the risk factors above, may not reveal their thoughts of suicide unless directly asked. It is important to remember that asking about suicidal thoughts — or about firearms as a suicide method — will not induce patients to attempt suicide.73-75
Risk of Intentional Harm By or To Others. Assault. Although only approximately one-third of firearm deaths are due to homicide, its impact is disproportionate in certain communities and demographic groups. Firearm homicide is the leading cause of death for black males ages 15-34 years. Black and Hispanic males have the highest relative firearm homicide rates across their lifespan (compared with females, or with males of other races and ethnicities; Figure 4). Firearm injury tends to concentrate in urban areas, particularly those marked by poverty, high availability of alcohol, and high levels of vandalism.76-79 However, most firearm injuries occur outside of these geographic clusters.80 (See Figure 3.)
Although a history of severe mental illness doubles the risk of perpetrating violence, it does so primarily in the context of co-existing substance use or misuse, including alcohol misuse.81,82 Indeed, substance use is an even more significant risk factor, both on a lifetime basis (e.g., having a history of substance misuse, dependence, or addiction) and on a moment-by-moment basis (e.g., most assault perpetrators and victims report using substances in the time period immediately prior to the injury).83-85
Having an ED visit for an assault also increases the chances of future assault-related injury, and particularly firearm-related injury. Hospitalization for assault injuries also seems to be associated with access to firearms.86 A Washington study showed that a firearm-related hospitalization increased the risk of future firearm death by more than 300%.19 A two-year prospective cohort study showed that high-risk youth visiting urban EDs for assault injuries had a 40% higher risk of subsequent firearm violence (aggression or victimization) versus the comparison group.87
In the ED, the most important indication for screening for risk of peer firearm injury is a prior history of violent injury, whether blunt or penetrating, and a history of or current substance or alcohol use.
Intimate Partner Violence (IPV). Women who are killed are most likely to die at the hands of an intimate partner (“domestic violence”) and are most likely to be killed by a gun. More than half of female homicides are perpetrated by partners, and more than half of these involve a firearm.88 A firearm in the home increases a woman’s risk of death five-fold,89 and is such an important risk factor that a partner’s access to a firearm is a question in the well-validated “Danger Assessment” for risk of death from partner violence (https://www.dangerassessment.org/). The perpetrators of non-fatal firearm injuries of women are also most likely to be romantic partners.90
In the ED, any patient with a history of partner violence should be screened for firearm access, both on the part of the partner and the patient.
Mass Violence. Due to the small number of mass violence firearm deaths, and lack of research, it is difficult to clearly identify risk factors. Some studies suggest that as many as one-quarter of perpetrators of homicide-suicide had been seen by a physician within a month of the crime,91 and high-profile mass shooters may have been evaluated in EDs prior to their crime.92 Some forensic psychologists have developed so-called “behavioral typologies” to help identify eventual perpetrators of mass violence.93 The combination of access to means (including high-powered firearms) in combination with the presence of impulsive anger, paranoia, and delusions of persecution may be enough to warrant a higher level of concern. However, only an extremely small proportion of people with these behavioral risk factors and access to firearms will actually commit acts of mass violence.94,95
Further research and guidance in this area is needed. For the time being, best practice would suggest that an EP should consider screening any patient with active psychosis or paranoid delusions for firearm access.
Risk of Unintentional Harm to Self or Others. Most unintentional, or “accidental,” firearm injuries and deaths occur among youth (ages 2-24 years); most unintentional deaths are due to being unintentionally shot by a friend or family member, and rarely due to being shot by an adult.96 Living in a household with a firearm that is stored loaded, unlocked, and with easy access to ammunition has repeatedly been shown to be the strongest risk factor for unintentional firearm injury.57,97
Although screening all parents of pediatric patients for firearm access is not currently feasible in the ED, EPs may consider discussing firearm safety along with other safety information when time permits.
Where?
EDs are an important but underutilized setting for preventing injury and death, including those from firearms. EDs provide access to traditionally hard-to-reach populations, including uninsured or underinsured patients, those without a primary care physician, and youth not regularly attending school.98,99 The ED is already encouraged to screen for suicidality and for partner violence in all high-risk patients.100,101
Risk factors for all types of firearm injury — suicidality, intimate partner violence, and assault victimization — are more common among ED patients than in the general American population.102 Up to 6-10% of ED patients have had recent suicidal thoughts,103-105 and many people who die by suicide are seen by a healthcare provider within one year of their death (more than one-third are seen within one week of death).106,107 Among all ED patients, 20-40% report having been a victim of intimate partner violence,108,109 and almost 40% of women who are seen in the ED for an assault were injured by their partner.110,111 Approximately 30-50% of a random sample of ED patients report past-year physical assaults by a peer.112,113
However, most EPs do not ask about firearm ownership, even among the highest risk patients. For example, according to two studies, firearm ownership or access is documented in 0-3% of pediatric ED psychiatric evaluations.114,115 In another recent study, 45% of adult suicidal patients who were discharged home had no medical record documentation of questioning about access to firearms or other lethal means; yet 13% of these patients reported to study staff that they had firearm access at home.43
There are many reasons why EPs may not ask high-risk patients about firearms, including lack of time,116 concerns about patients’ willingness to answer,3 and lack of physician comfort with the topic.117 EPs may believe that asking about firearm access should or will be done by a psychiatrist or other mental health professional,118 but psychiatrists and psychologists appear equally unlikely to ask patients about firearm access.46,119
Some physicians fear that patients will be upset by being asked about firearms, but there is little evidence that patients are offended by respectful questioning about firearms and other personal issues.42,120 Interestingly, physicians who own firearms may be particularly likely to screen and counsel on firearm safety.121 These physicians also may be more likely to be perceived by patients as trustworthy or as experts in firearm discussions.121
Unlike with discussions of motorcycle helmet use or child safety locks, physicians fear having a similar discussion about firearms. The only existing law that limits physician questions about firearm discussions is in Florida. This law states that healthcare providers “should refrain” from asking patients about firearms; however, it allows exceptions when relevant “to the patient’s medical care or safety, or the safety of others.”122 Laws in Montana, Missouri, and Minnesota also prohibit some aspects of recording or collecting information about firearms, but not in emergency situations.123-126 Multiple medical organizations are currently challenging these laws as causing undue interference in the doctor-patient relationship.127,128 However, it is important for EPs to know that it is currently permissible to ask about a patient’s firearm access in the context of an acute medical concern, even in these states.
As with other sensitive topics, these questions and discussions are ideally conducted in patient rooms or other private spaces.
When and What?
Regardless of why, with whom, or where discussions about firearms occur with patients, they should take the form of respectful, nonjudgmental education about the individual’s risk of firearm injury or death, including ways to mitigate that risk. The language used by providers during screening and counseling is important.129 Expert consensus recommends leading into the question “Do you own or have access to a gun?” with an explanation of why you are asking. It is critically important to begin this conversation as one would any other injury prevention conversation with recognition of the patient’s condition. So, for instance, one might say: “I am concerned about your safety. I ask all of my depressed patients about these safety concerns. Do you have a plan for how you would hurt yourself? Do you own or have access to a gun?”
Borrowing from concepts of shared decision-making and motivational interviewing, the physician can then show empathy, educate about risks, and engage in discussion. When having this discussion, be aware that words like “confiscation,” “restriction,” “removal,” or similar terms may be concerning or offensive to patients130 and are best avoided. In most cases, providers can provide assurance that the goal is to work with patients (and often their family members) to reduce the threat of injury or death, without involvement of law enforcement or other agencies and without permanent removal of firearms. Specifically, these discussions aim to engage patients and family members in decisions about safer firearm storage options. (See Table 2.) Choice of storage method likely will depend on the clinical scenario, as well as cost and acceptability. For example, a person who owns a firearm mostly for self-protection may not be interested in using a cable or trigger lock (as these preclude instant use), but may be open to a rapid-access, code-operated bedside lock box.
Table 2. Firearm Safe Storage Options
Expanded and adapted from materials from Project ChildSafe,135 Means Matter,161 New Hampshire Firearm Safety Coalition,162 Law Center to Prevent Gun Violence,163 and the National Rifle Association.131-133
Information and recommendations about safe storage are also available from large firearm organizations like the National Rifle Association (NRA) and National Shooting Sports Foundation (NSSF), and providers can refer patients to these organizations and their materials as appropriate. The NRA “Gun Safety Rules” include the recommendation to “store guns so they are not accessible to unauthorized persons” and “always keep the gun unloaded until ready to use.”131 The NRA also offers a description of available locking devices132 and recommends that parents educate children about firearms133 but does not specifically suggest that all guns always be stored locked. The NSSF recommends storing firearms unloaded and locked, with ammunition stored separately and locked,134 with specific suggestions about options for locked storage of firearms kept loaded for personal protection and additional guidance for parents through its “Project ChildSafe.”135 The NSSF also specifies that if a household member is “at risk,” the gun owner should ensure that firearms are inaccessible to that person, either through offsite storage or effective locking. “At risk” people are defined by the NSSF as “those with symptoms or history of treatment for mental illness, increasing patterns of alcohol/substance abuse, isolation or violent behaviors, or recent experience with a major life event — such as divorce, job loss, or financial trouble. It also can be someone who you, the firearm’s owner, have good reason to believe is likely to do harm to himself or others.”134
As outlined above, there are three clinical situations in which it would be important for an ED provider to ask a patient about firearm access: risk of intentional harm to self (i.e., risk of suicide); risk of intentional harm by or to others (i.e., homicide, including intimate partner and other interpersonal violence); and risk of unintentional harm to self (i.e., “accidental” injury in a child or cognitively impaired person). Written educational materials for patients can be helpful in all of the above scenarios; examples of available resources are listed in Table 3.
Specific recommendation for screening and risk mitigation also may depend on the scenario.
Risk of Intentional Harm to Self. Regardless of how suicide risk is identified, all patients at risk of intentional self-harm should be asked about access to firearms and other lethal means.72,136 This question can be integrated into questioning about a suicidal individual’s thoughts, intent, and plan. For example, an EP might ask a patient: “What kind of suicidal thoughts have you been having? Do you have any intention of acting on those thoughts? Do you have a plan for how you would kill yourself? Do you have access to firearms?” If the patient discloses a particular non-firearm plan, the EP should also ask about access to that method; for example, if a patient is planning on overdosing on a medication, the EP should ask about access to that medication. However, all suicidal patients should be screened for firearm access, regardless of their plan, because of the impulsivity of suicide attempts and the high lethality of firearm attempts.66
For patients at acute risk of suicide, the goal of screening for firearm access and subsequent “lethal means counseling” is to ensure the at-risk individual does not have access to firearms (or other lethal means of suicide) until the risk of self-harm has abated. One option to reduce access is locked storage within the home (such that the at-risk person does not have access to the key or code); numerous types of storage devices exist (see Table 2), and patients and families should be encouraged to choose the one they are most likely to use. Out-of-home firearm storage, even temporarily, is another way to limit a suicidal patient’s access. Some gun stores or ranges, as well as law enforcement agencies, may temporarily store guns, so providers could inquire about resources in their locale of practice. For patients with chronic elevated risk of suicide, the safest long-term option to reduce risk of death is to permanently remove firearms from the home, but this type of counseling would likely occur within an established patient-provider relationship (and not in an ED).
Lethal means counseling is a recommended component of discharge planning for all ED patients evaluated for suicide risk and then discharged home.72,136 Assessing firearm access is also important for ED patients being admitted for suicidal ideation or attempts, as it can help a family make the home safer for when the patient is eventually discharged. Firearm access itself also might affect decisions about patient disposition; for example, a provider may lean toward hospitalization for a patient with high suicide risk who is also unwilling to reduce firearm access.
Risk of Intentional Harm By or To Others. Assault. Identification of patients at elevated, acute risk of homicide (as a perpetrator or victim) is difficult. Patients who explicitly mention homicidal ideation clearly merit further evaluation and questioning, and it may be permissible to disclose this threat to the police (if a patient does not meet criteria for involuntary psychiatric hold). Providers may want to assess firearm access in patients with other risk factors for future violence.
It is easier to identify patients at near-term risk of firearm injury. Those presenting with an acute injury from physical assault, whether as a victim or a perpetrator, are at the highest risk of future firearm death. For these patients, it is important to provide a “safety check,” which may include specific questions about firearms, or may include more general questions about risk of future assault-related injury. One such screen, developed by the Children’s Hospital of Pennsylvania, includes four questions: “Do you know who the person is who hurt you? Do you think that the conflict that caused this incident is over? Do you plan to hurt anyone because of what happened today? Do you think that your friends or family will hurt anyone because of what happened today?”137
For those screening positive for risk of future injury, EPs have a few options. When possible, such as in large trauma centers, the provider may consider linking the patient to a social worker or a violence intervention program (VIP). Many studies have shown that by addressing assault-injured patients’ psychosocial needs — such as substance dependence, mental health issues (particularly post-traumatic stress disorder), and lack of access to jobs — the trajectory of violence can be changed.138 For instance, one study found that youth who received a hospital-based peer intervention program soon after a violent injury were 70% less likely to be arrested for any offense and 60% less likely to have criminal involvement when compared with violently injured youth who did not receive the intervention.139 One study of stepped psychiatric care, ranging from brief motivational interviews to in-depth multi-session cognitive behavioral therapy, reduced rates of weapon carriage in traumatically injured youth during the year after the injury.140 These VIPs repeatedly have been shown to be cost-effective, with a brief motivational interviewing intervention estimated to cost just $17.06 per violent event averted, and a similar intervention estimated to save $82,765 to $4,055,873 in healthcare, criminal justice, and lost productivity costs for 90 violently injured patients over five years.141,142 These interventions also may be reimbursable under the Affordable Care Act.143
Providers working in less-resourced settings could consider what community resources are available. Many communities have non-hospital-based VIPs. Other community programs, such as Boys’ and Girls’ Clubs, also may be effective at reducing violence recidivism.144
Finally, all providers can consider engaging patients in brief motivational interviews, similar to the “screening and brief intervention” strategy used for alcohol and substance use. This involves validating a patient’s experience; reviewing patterns of behavior; connecting these patterns to their current ED visit; providing normative data; developing discrepancies between a patient’s goals and their current patterns; providing resources; and restating and reflecting a patient’s goals and next steps.137
Intimate Partner Violence. Patients identified as victims or perpetrators of IPV should always be asked about the presence of firearms in the home and about any recent threats or escalation of violence. In these situations, the preamble to the question about firearm access may include a statement such as, “My primary concern is about the safety of you [and your children]. Because of that, I want to ask a few more questions.” The question to ask can be taken directly from Danger Assessment, a standard tool for assessing risk of death from partner violence: “Does your partner own a gun?”
The counseling and referral options for IPV victims at risk of homicide differ from those for peer violence victims. The most important thing is to validate a patient’s experience and avoid offering prescriptive solutions.145 Research studies show that EPs often fail to acknowledge a patient’s disclosure of IPV.146 Once a patient’s positive response has been acknowledged, we can offer resources, including a referral to local domestic violence services or a call to the National Domestic Violence Hotline (which often has local volunteers who can visit an ED; Table 3). These resources will be able to assist the EP to help ensure the patient’s safety, and will have greater knowledge of local laws about how to minimize a perpetrator’s firearm access.147
Table 3. Examples of Available Resources for Patients and Providers
Resource |
Source |
|
General (applicable to all types of firearm injuries and deaths) |
|
|
Patient handout |
Firearms Responsibility in the Home (National Shooting Sports Foundation) www.nssf.org/safety/lit/FRITH.pdf |
|
General information |
Center for Gun Policy and Research (Johns Hopkins Bloomberg School of Public Health) www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-for-gun-policy-and-research |
|
General information |
Gun Laws & Policies (Law Center to Prevent Gun Violence) http://smartgunlaws.org/gun-policy |
|
General information |
National Network of Hospital-based Violence Intervention Programs http://nnhvip.org |
|
Intentional Self-harm |
|
|
Patient handout |
When a family member is suicidal: Firearm storage options (New Hampshire Firearm Safety Coalition) www.theconnectprogram.org/sites/default/files/site-content/firearm_storage_options.pdf |
|
Patient resource |
National Suicide Prevention Lifeline (1-800-273-8255, also web chat) www.suicidepreventionlifeline.org |
|
Provider training |
Counseling on Access to Lethal Means: CALM (Suicide Prevention Resource Center) http://training.sprc.org/ |
|
General information |
Means Matter, Harvard School of Public Health http://www.hsph.harvard.edu/means-matter |
|
Intentional harm to or by others |
|
|
Patient resource |
National Domestic Violence Hotline (1-800-799-7233, also web chat) www.thehotline.org |
|
Provider training and tools |
The Danger Assessment www.dangerassessment.org |
|
Provider information |
State hotlines & coalitions (Feminist Majority Foundation) www.feminist.org/911/crisis_state.html |
|
Provider information |
California’s Gun Violence Restraining Order (Law Center to Prevent Gun Violence) http://smartgunlaws.org/californias-new-gun-violence-restraining-order-law |
|
Provider information |
Understanding Intimate Partner Violence (Centers for Disease Control & Prevention) www.cdc.gov/violenceprevention/pdf/ipv-factsheet.pdf |
|
Provider information |
VetoViolence (Centers for Disease Control & Prevention) http://vetoviolence.cdc.gov |
|
Unintentional Self-harm |
|
|
Patient handout |
Pediatrics Patient Page: Keeping Children and Adolescents Safe from Firearms. (Moreno MA. JAMA Pediatr 2015;169:412) http://archpedi.jamanetwork.com/article.aspx?articleid=2214029 |
|
Patient handout |
Parents’ Guide to Home Firearm Safety (University of Michigan Injury Center) www.injurycenter.umich.edu/sites/default/files/documents/firearm_safety_flyer_final_6-3-15.pdf |
|
Patient handouts and videos |
Project ChildSafe (National Shooting Sports Foundation) www.projectchildsafe.org/safety/safety-resources |
|
Patient handouts and provider information |
Where We Stand: Gun Safety (Multiple resources about pediatric firearm injury from the American Academy of Pediatrics) www.healthychildren.org/English/safety-prevention/all-around/Pages/Where-We-Stand-Gun-Safety.aspx |
|
Patient handouts and provider information |
Lok-It-Up (King County Department of Public Health) http://kingcounty.gov/healthservices/health/injury/lokitup.aspx |
Risk of Unintentional Harm to Self or Others. The risk of unintentional self-harm or other-harm from unsecured firearms is elevated in individuals with impaired judgment and cognitive skills. These include those with brain injuries and dementias148 and children and adolescents, as their cognitive skills are still developing.149 Discussing the risk of unintentional harm from firearms in this group may be the most difficult firearm topic in the ED setting, but patient educational materials are available. (See Table 3.)
The American Academy of Pediatrics (AAP) recommends that pediatricians counsel all parents about prevention of firearm injuries;150 this type of “anticipatory guidance,” similar to that used for car seats and smoking, may be appropriate in EDs as well, although patients may be most receptive to it when directly relevant to the reason for visit. Indeed, some studies suggest that providing counseling on multiple injury prevention topics at once may dilute the effectiveness of all topics.151
Counseling to family members of those with impaired cognition or judgment who are at risk of unintentional self-harm (e.g., children, adolescents, and those with brain disorders) typically will focus on in-home secure storage. Given the different time scale of risk — days to weeks for suicide risk vs. years for unintentional injury — out-of-home storage with friends, family, firearm stores, or law enforcement is less likely to be a feasible solution. The AAP recommends that providers educate parents that permanently removing guns from the home is the best option to reduce unintentional firearm “accidents” in children. Although some groups have advocated for firearm safety training for children, studies show that these programs (including NRA’s Eddie Eagle program) are often ineffective in real life.152-154 The safest storage option inside the home is to keep a gun locked up, unloaded, and separate from ammunition.97
Other Considerations
EPs may have medico-legal concerns related to ED-based discussions of firearm safety.
The first concern is over proposed or enacted “gag laws” aimed at preventing healthcare providers from asking or documenting about patients’ firearm access. No true gag law is currently in effect,6 as even Florida’s well-known and controversial law allows for questioning by a provider who “in good faith believes that this information is relevant to the patient’s medical care or safety, or the safety of others” and stipulates that the only information excluded from medical records is that which is “not relevant to the patient’s medical care or safety, or the safety of others.”122 Thus, providers should feel confident that they may question patients about firearms and document these discussions when relevant (as in the scenarios discussed above). Not asking about firearms in relevant situations in fact may raise liability concerns for the provider. As an example, national guidelines now suggest that ED providers conduct lethal means assessments with all suicidal patients,136 and it is conceivable that failure to do so could be grounds for legal action.31
The second concern is that statutes about how best to minimize risk of harm differ greatly between locales. Therefore, each EP should become familiar with local statutes about when and how to handle firearm access by patients at high risk of hurting themselves or others. For instance, in Iowa, anyone served a domestic violence protection order must surrender firearms and ammunition, either to a “qualified person” (as determined by the court) or to a sheriff.155 In many other states, this is limited to a “may” surrender. In Rhode Island, even those convicted of domestic violence misdemeanors may own firearms.156 The strongest level of protection exists in California, where concerned family members or law enforcement officers (but not healthcare providers) may obtain a “Gun Violence Restraining Order” (GVRO).157 A GVRO is designed to be similar to a domestic violence restraining order or a psychiatric hold: A concerned party may ask a judge to deem someone at risk of hurting themselves or others, and then may temporarily remove firearms and ammunition from that person’s possession; the firearms and ammunition are returned after expiration of the GVRO. The efficacy of GVROs has yet to be proven, and these provisions are not currently an option in most U.S. states.
A third concern is how screening and counseling for firearm safety will affect the doctor-patient relationship. Some providers are concerned that encouraging doctors to screen and counsel may dissuade patients who own firearms from seeking medical care, disclosing suicidal ideation, or disclosing psychosis; indeed, a decrease in disclosure of partner violence has been observed in states with mandatory reporting of domestic violence to the police.158 In most states, only court-adjudicated (e.g., involuntary) hospitalizations for mental illness are reported to the national firearm background check system. Of note, time-limited emergency mental health holds (e.g., 72-hour hold, psychiatric hold, M1, 5150, etc., with name variations among states) do not result in the patient being entered into the national background check system or being prohibited from possessing or purchasing firearms. In a few states, such as New York, mental health professionals are required to make a report to a state database if they conclude, using reasonable professional judgment, that the individual is likely to engage in conduct that would result in serious harm to self or others.159 The effect of these laws on either rates of harm to self and others, or on rates of care-seeking, are unknown.160
In response to these three concerns, it is important to reiterate that screening and counseling a patient on firearm safety is optional, and should be performed when a patient fits into one of the three general high-risk categories outlined above. Also, EPs always should be informed and have knowledge of local statutes and resources.
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This article explores questions around physician firearm safety counseling — including why emergency physicians might do it, who might benefit, where and when to consider it, and what such counseling should include (along with what resources exist for emergency physicians and for patients).
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