Forensic Nursing Process: An Evaluation of Forensic Patients in the Clinical Environment

By Barbara Goll-McGee RN, MSN; Sherry Couto, RN, BSN; John Ferrandi; Kelly Jankowski, RN, BSN; Patricia Lawlor, RN, BSN; Ines Luciani-McGillvray, RN, BSN, CEN, SANE; and Maryellen Robertson, RN, BSN, CNRN

Clinical forensic nursing has come of age as a means of coping with the resultant increased complexity of nursing practice, society and the law. A living forensic population, "survivors of criminalor liability-related injuries that result in an investigation by a legal agency"¹ is being recognized by healthcare professionals in varied clinical practice environments, especially in the emergency department (ED). In fact, personnel frequently interface with forensic cases and therefore have the greatest potential for evaluating the associated forensic elements."² The Clinical Forensic Nursing Committee at Massachusetts General Hospital (MGH) is spearheading a method of identifying its forensic patient population and managing its medico-legal needs. This article will present actual cases involving clinical forensic patients and suggests, for emergency nurses without formal training, loose guidelines for addressing their needs within a forensic nursing framework.

The Framework

Identification of a living forensic patient population is paramount. Pasqualone suggests "27 forensic categories" resulting from the "use of weapons, interpersonal violence, sharp and blunt force trauma, police custody deaths, abuse and neglect of the child, elder or disabled, hate crimes, sudden and unexpected deaths, occupational and environmental hazards, sexual assault, and substance abuse."³

Violence against self, natural or man-made disasters and/or terrorist attacks are also considered. Once a forensic patient is recognized, four overlapping clinical practice issues are addressed. These are physical evidence collection, non-physical evidence collection, meticulous documentation and crisis intervention.

Mund defines physical evidence as "anything that has been used, left, removed, altered or contaminated during the commission of a crime by either the suspect or victim."4 The ability to recognize evidence acknowledges that it has relevance and may come in varying forms and sizes. "In many situations, important information... which may not be required for patient care is nonetheless vital to later investigation" and requires the patient’s consent "to ensure that collection of the evidence will not amount to an illegal search (or perhaps malpractice)."⁵

Proper collection of evidence is imperative to avoid the compromise of its integrity. "Preservation of evidence in the clinical setting requires planning, attention to detail, and the guidance of agency policies and procedures."⁶

Non-physical evidence collection suggests the use of an index of suspicion "to uncover the how and why of their mechanisms of injury."⁷ This effort involves an assessment of psychosocial history, separating the injuries from the story and asking hard questions. It looks for inconsistencies in clinical presentations.

"Thorough, objective documentation of ED evaluation and treatment of patients who present with complaints suggesting potential litigation and/or criminal activity is critical."5 Meticulous documentation provides evidence that "something is done or not done, exists or doesn’t exist, it provides evidence for the client, protection for the nurse and testimony for the court."⁷

"Effective crisis intervention requires finding the right resources for the client."8 It may be extended to include an interface with multi-disciplines in communicating patient conditions, formulating advance directives, guiding end-of-life decision making, pursuing anatomical gifts, notifying death, reporting abuse and neglect, dangerousness assessment and protecting patient confidentiality. According to Hoff, a critical level of assessment asks, "Is there an obvious or potential threat to life, either the life of the individual in crisis or the lives of others?" "Has the person been abused?" And "What are the risks of suicide, assault, and homicide?"⁸

All of the aforementioned clinical practice issues are considered, but not always pursued. Many of the following case studies incorporate ethical and other dilemmas, which are thought-provoking, but are not addressed due to the length constraints of this article.

Case Studies

Two male United States customs agents escorted a 23-year-old female "mule" into the ED after having been tipped off that she had been transporting illegal drugs into the country. Her vital signs on admission were within normal limits; however, the threat of overdose remained. A gynecological examination was performed and revealed an intra-vaginal, 850-gram, condom and plastic wrapped package of a white powdery substance suspected to be cocaine. A physician collected the package and gave it to the customs agent who was present in the exam room and properly maintained the evidence.

Blood work including serum electrolytes, a complete blood count (CBC), bleeding times (PT/PTT), blood bank sample (BBS), toxicology screen, and pregnancy test (hcg) was drawn and sent to the laboratory. Radiological exam (X-ray) of the kidneys, ureters and bladder, revealed the presence of approximately 20 to 30 intraabdominal pouches. The patient reported ingesting these at the suggestion of her boyfriend who offered her $3,500. The patient was given a medication used for intestinal diagnostics to evacuate bowel contents. Subsequent trips to the bathroom required the emergency nurse and customs presence for the collection of these pouches as evidence. The patient was under constant guard without the use of physical restraints.

This patient presents as a living forensic patient because she is a survivor of a criminal related activity, ingestion and transport of illegal drugs that will result in an investigation by the United States Customs Department. Physical evidence consists of the package and pouches of the white powdery substance suspected to be cocaine. Also, one may consider the X-rays showing the intra-abdominal pouches as photo-documentation evidence. A toxicology screen may show presence of illegal drugs or drug metabolites, but may be inadmissable because the patient has not given consent to this laboratory test that is a medical necessity. The chain of custody for laboratory specimens and X-rays within the hospital may also come under scrutiny.

Non-physical evidence separates the condition from the story. It is what she says and how she presents. The suggestion that her boyfriend made her do this raises concerns about the safety of this patient within this relationship and the cycle of violence within relationships; however, her calm and collected presentation is without physical signs of abuse. When asked if she feels safe, she says yes. The subjective statements documented on the flowsheet are, "I have a stomach ache," "I packed the drugs myself," and "My boyfriend made me do it." The triage nursing diagnosis is "cocaine ingestion" because this is what the patient reports. One time source, agreed upon by the customs agents and the nursing staff caring for the patient, is used for the consistent documentation of time. This avoids the obvious variations of time references. The names and presence of the customs agents are also documented.

Crisis intervention does not consist of a domestic violence resource because the patient reports that she feels safe. The assessment for suicide or self-harm risk is low. Patient confidentiality is protected.

A 37-year-old patient was admitted to the ED after an unwitnessed motorcycle crash. He was awake and responsive with a Glascow coma score of 15. He reports no past medical history or medicine use. His vital signs were within normal ranges. Intravenous access (IV) and blood work including electrolytes, CBC, PT/PTT, BBS and serum toxicology was drawn. Serum toxicology was not medically indicated and was not sent to the laboratory. During secondary assessment, the patient was found to have a plastic sandwich bag filled with white pills stuffed in his underwear. The patient explained that these were for chronic back pain. The emergency nurse threw the pills in the garbage without documentation. The patient was discharged after several hours.

This patient is a living forensic patient because he is a survivor of a motorcycle crash that may be investigated by a legal agency. Physical evidence includes the pills, which are identified as percocet. These should not be immediately disposed of, but rather secured by police and security or pharmacy personnel. (Physical evidence can always be discarded if not relevant, but cannot always be retrieved. This is especially true of exigent evidence. This is evidence that requires immediate collection or it will be lost.) Chain of custody should reveal that the emergency nurse discovered the evidence while undressing, then passed it along. Without mention of the nursing discovery, the search for evidence may be scrutinized. Non-physical evidence collection, or an index of suspicion, suggests that in the absence of a medical history and personal prescription bottle or label, this narcotic may have been illegally or improperly obtained and affected the judgment of the motorcycle driver. The emergency nurse does not know if this patient has hit something or hurt someone else during this accident. Presently, this is an unreported case.

Documentation should include the presence and number of the white pills and their disposition. There is no crisis intervention in this case.

A 23-year-old man presented to the ED reporting that he had been car-napped and stabbed. His pants leg was bloodied, but he was in otherwise good condition. He was rapidly assessed, cleaned and sutured. His clothing was given to him after being placed in a plastic patient belongings bag and several hours later, he was discharged wearing hospital sweat pants.

This patient presents as a living forensic patient because he is a survivor of reported interpersonal violence that may be investigated by local police. The physical evidence in this case consists of the patient’s clothing. Each piece of clothing should have been individually collected in paper bags and properly labeled with a description of the item, the patient’s name and unit number, the date and time, the collector’s name and title. If the items are wet, law enforcement personnel should dry them in a secure location.

Chain of custody should be maintained to ensure the integrity of the evidence. Under no circumstances should a patient’s clinical stability be compromised for the collection of physical evidence.

Non-physical evidence collection suspends personal judgments, but addresses the plausibility of the story, the presence and mechanism of injury. By the patient’s report there is no reason to believe that the explanation for the injury is false, but the emergency nurse considers that it may not be.

Documentation consists of the subjective statement; "I was carnapped and stabbed in the leg." Photo documentation of the sharp injury wound, with documented patient consent, is recommended. Crisis intervention occurs with a referral to appropriate resources such as police and security.

Conclusion

In accordance with the standards of forensic nursing practice outlined by the International Association of Forensic Nurses (IAFN), the mission statement of the MGH Clinical Forensic Nursing Committee includes a commitment to develop, promote and disseminate information about the science of forensic nursing.

"The forensically trained...nurse recognizes that forensics provides realistic interventions for responding to patient care needs."⁹ These case studies introduce a fraction of a patient population with medico-legal needs and suggest a loose approach, an assessment dimension, to recognizing and meeting these needs.

"The development of protocols for collecting available evidence may assist in assuring that collection is performed appropriately."⁵ "Intuition research gives the forensically educated nurse permission to trust and to act upon his or her suspicions."⁹ "In the duty to document," "it is almost as important to keep extraneous material out of the medical record as it is to be sure to include pertinent information."¹⁰

"Becoming familiar with and recognizing the phases of crisis development can enable healthcare professionals to provide clients with resources that will keep stressful life events from escalating into crisis episodes."⁸ As nurses on the front line begin to ponder the presence of a forensic patient population they will look to address their needs. As our knowledge base expands, professionals themselves develop and nursing paradigms shift. Continued attention to these types of cases and the use of this forensic nursing process may make "an important contribution to safeguarding the legal rights of patients and the community"⁵ and nurture clinical forensic nursing, a developing nursing specialty, within practice environments.

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