Working Collaboratively with Law Enforcement at Trauma Patient’s Bedside
January 1, 2023 7 minutes read
Trauma patients and law enforcement might arrive together, raising multiple ethical issues — and a potential conflict with clinicians. “We need to figure out how to work collaboratively with law enforcement during acute trauma resuscitations,” says Leah Carey Tatebe, MD, associate professor of surgery at Northwestern Medicine.
The American Association for the Surgery of Trauma’s prevention committee offers recommendations to build ethical interactions between clinicians and law enforcement in the trauma bay.1 While some clinicians say law enforcement should never be present on trauma units, others think law enforcement needs unfettered access.
“The answer is probably somewhere in the middle,” says Tatebe, lead author of the guidance.
The overarching goal is for clinicians to understand the priorities of law enforcement, and vice versa. “We cannot just presume that ‘It’s our house, our rules,’ and that law enforcement needs to do what we say. That is not true. We still have to abide by the laws of our state and our hospital policies,” Tatebe says.
There are some cases in which law enforcement oversteps patient autonomy, such as questions over probable cause to search the patient’s belongings. In other cases, clinicians are in the wrong by refusing to follow instructions of law enforcement. “We need to work together to keep the patient, and the community at large, at the center of what we do,” Tatebe asserts.
Good hospital policies can prevent conflict by outlining best practices for interactions for situations that happen regularly, such as requested blood draws on trauma patients. Tatebe says leaders must train staff on those policies and keep the guidelines close at hand for easy access.
Prevention is the best approach. Ideally, clinicians and law enforcement can work things out before conflict occurs. Ethicists are well suited for this role. “Using bioethics as a universal language for guiding principles within the hospital is a good way for clinicians to express what our priorities are, and to start that conversation,” Tatebe says.
Tatebe and colleagues recommended designating a trauma navigator who can advocate for what is best for the patient. That person could be a social worker or trauma injury prevention specialist, serving as a go-to resource to clarify policies and local laws. “This is ideal, instead of expecting nurses, medical trainees, and everybody coming through the unit to understand what’s going on,” Tatebe says.
Ethicists also can help educate clinicians and local law enforcement on the ethical implications of cases. Ideally, ethicists would lead a group discussion, airing the various perspectives of emergency physicians, patient advocates, law enforcement, and patients. “That would be a really great way to start that conversation and get rid of a lot of myths or stereotypes people may have,” Tatebe offers.
Adult patients with decision-making capacity should be handling their own medical decisions, regardless of whether they are involved with law enforcement, says Elizabeth Lanphier, PhD, MS, assistant professor in the Ethics Center at Cincinnati Children’s Hospital Medical Center. When tricky questions arise about patients involved with law enforcement, it is important to coordinate with hospital legal counsel. “Ethical duties may not align with legal liabilities and obligations,” Lanphier warns.
Neither medical staff nor ethicists should be interpreting laws, warrants, or interfacing with law enforcement on their own. “This should be something that involves either legal counsel or hospital security, or both, depending on a hospital’s own policies for engagement with law enforcement,” Lanphier suggests.
Mostly, clinicians and law enforcement officers are supportive of each other’s work. “However, this is not always the case,” says Pamela J. Grace, RN, PhD, FAAN, associate professor emeritus at Boston College.
In one highly publicized episode, a nurse was arrested for defending an unconscious patient’s right to privacy.2 In that case, a patient was the lead suspect in a hit-and-run accident, but was not under arrest or the subject of a warrant. The nurse was following the hospital’s policy. The troubling case, says Grace, “highlighted the fact that healthcare professionals and law enforcement officers have different service goals. The reason healthcare professions and their members exist is to provide a good.” (Editor’s Note: For more information about that nurse’s arrest, please read this report from the November 2017 edition of our sister publication, Healthcare Risk Management.)
For healthcare providers, the priority is to uphold the rights and dignity of a patient. For law enforcement, the priority is protecting the public from harm and maintaining order. There also is a power imbalance between armed police officers and healthcare providers. “It can be very intimidating to be given an ultimatum by someone who has the power to harm one and is used to exercising intimidation to get desired results, regardless of the ethical proscriptions against achieving the result in the manner directed,” Grace says.
Frequent, ongoing education of both law enforcement and healthcare staff is important. Ethicists can play a role in these collaborations by understanding the police chain of command in their locale, learning more about how officers are trained, and by acting as liaisons between the hospital and law enforcement. However, not all institutions are equipped with robust ethics services, nor are all adequately staffed.3 “Thus, ethicists may see this as beyond their capacity to address,” Grace acknowledges.
In an emergency situation involving law enforcement, an ethics consult is not always possible. “But certainly, consulting an ethicist after the fact would be helpful, to think about how a situation might be addressed in the future,” Grace offers.
Healthcare workers may worry about their personal and staff safety when law enforcement brings in a patient, says Kathleen M. Akgün, MD, MS, co-author of recent ethical guidance for clinicians when police are at the bedside.4 Clinicians may be unsure if it is their business to ask about a patients’ detention status, or unsure of their duties when asked to procure patient samples that are not otherwise clinically warranted.
Akgün and colleagues offered these examples of scripting when caring for incarcerated patients: “It seems to me this patient is not a threat. If you agree, would you please step outside while I provide care?” or “This seems unconventional to search the visitors’ belongings. Help me think about why this is indicated for them, and whether we can reassess.”
Clinicians do not always realize they have the right to push back against law enforcement requests to restrain the patient, to be present in treatment rooms, or search belongings. “This leaves them uncertain about how to advocate for patients’ autonomy, privacy, and dignity,” says Akgün, chair of the ethics and conflict of interest committee at the American Thoracic Society.
For example, clinicians might assume law enforcement is required to be in the patient room during clinical care at all times. Without clarification, clinicians may unnecessarily discuss private health information in the presence of law enforcement. While seeking clarification, determine the necessity of physical restraints, particularly in light of the evidence of harms associated with their unnecessary use.5,6 “Clinical teams should remember that shackling an incapacitated or comatose patient is simply inhumane and should not be acceptable in clinical care,” Akgün says.
Akgün and colleagues suggested clinicians state, “We avoid routine use of physical or chemical restraints for patients, and their use can lead to greater harm in most cases.” Similarly, clinicians can push back against questionable searches conducted on surrogates and other patient visitors. “A growing group of healthcare workers addressing these issues, including intensivists, nurses, and ethicists, maintain that the clinical room cannot ethically function as an extension of law enforcement, and must practice with the least intrusions of law enforcement as possible,” Akgün says. Other recommendations include the following:
• Care teams must remember their ethical obligation is to the patient first, and that they are entitled to ask for clarifications of law enforcement. Akgün suggests stating: “We are here to care for our patient and protect their privacy and dignity. I am wondering if you would please wait outside the room while we tend to their healthcare needs?”
If the law enforcement personnel do not agree, the clinician could respond: “It might be best for our legal counsel to contact your supervisor to assure we are all on the same page.”
• Clinicians should set expectations about clinical information sharing with law enforcement right away. Declare their intention to practice with the least intrusive law enforcement presence required.
• Clinicians should seek ethicists’ input if there is disagreement between the team and the law enforcement personnel. Without that support, clinical teams may be asked to provide care in a way that is unethical and unjust. “In addition to the damage this causes the patient, this presents risk of moral injury to the healthcare teams,” Akgün stresses.
• Ethicists should counsel clinical teams to advocate for patient autonomy, beneficence, justice, and non-maleficence. “Ethicists should get involved if clinical teams are asked to care for their patients in a way that violates these principles,” Akgün urges.
REFERENCES
1. Tatebe LC, Kaufman EJ, Nappi T, et al. Walk the line: An ethical framework for interactions with law enforcement in trauma care environments. J Trauma Acute Care Surg 2022; Oct 18. doi: 10.1097/TA.0000000000003810. [Online ahead of print].
2. Olsen DP, Brous E. The ethical and legal implications of a nurse’s arrest in Utah. Am J Nurs 2018;118:47-53.
3. Fox E, Danis M, Tarzian AJ, et al. Ethics consultation in U.S. hospitals: A national follow-up study. Am J Bioeth 2022;22:5-18.
4. Griffith MF, O’Brien JK, Sergew A, et al. Profiling, privacy, and protection: Ethical guidance when police are present at bedside. Ann Am Thorac Soc 2022;19:890-894.
5. Evans D, Wood J, Lambert L. Patient injury and physical restraint devices: A systematic review. J Adv Nurs 2003;41:274-282.
6. House KT, Kelley S, Sontag DN, King LP. Ending restraint of incarcerated individuals giving birth. AMA J Ethics 2021;23:E364-E368
Trauma patients and law enforcement might arrive together, raising multiple ethical issues — and a potential conflict with clinicians. While some clinicians say law enforcement should never be present on trauma units, others think law enforcement needs unfettered access. The answer likely is somewhere in the middle.
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