The International Association of Forensic Nurses (IAFN) defines the duties of the forensic nurse as “integrat[ing] forensic and nursing sciences in the assessment and care of populations affected by physical, psychological, or social violence or trauma. Privacy, respect, and dignity characterize the services that the forensic nurse provides to those affected by crime, trauma, and intentional harm. In addition, the forensic nurse strongly advocates for minimum standards of assessment, collection of specimens for forensic analysis, and reporting of crime.”
These services are straightforward when the patient is awake, aware, and able to participate in his or her own healthcare decisions. The nurse can present potential procedures and receive the patient’s input and authorization. When a patient is comatose, however, things become trickier. Decisions must be made without the patient’s input, and some of these decisions have ethical and legal ramifications.
Understanding how to make the right decisions in these circumstances, and how to be an effective liaison with law enforcement when necessary, is a matter of education. Duquesne University’s online MSN in Forensic Nursing program offers one path to this essential knowledge. Also offering Post-Master’s Certificate programs to meet the needs of all healthcare providers, Duquesne’s online master’s in nursing can prepare forensic nursing candidates for the challenges inherent in the profession.
The Key Issues
Nurses have two key issues to juggle when an unconscious trauma victim arrives for medical care. The first is the notion of informed consent, which in nursing terminology is the basic right of patients to make decisions about their own medical care. According to a recent article in the Open Journal of Nursing, “The process of seeking informed consent is a routine part of patient care. It is the basis for our understanding and respect for individual rights. Informed consent originates from the legal and ethical right the patient has to direct what happens to her/his body and from the ethical duty of the provider to involve the patient in her/his health care.”
An unconscious patient, of course, cannot provide informed consent. In life-threatening situations, virtually all healthcare providers fall back on the concept of implied consent. Legal Dictionary defines implied consent as “the assumption that a person has given permission for an action, which is inferred from his or her actions, rather than expressly or explicitly provided.” In other words, if an unconscious person shows up at a hospital, medical personnel can reasonably assume that the person would consent to be treated.
But what about non-life-threatening situations? This is where the second issue—time urgency—comes into play. Imagine that a comatose victim shows up at an emergency room. He or she is not in danger of dying. Based on the person’s condition, however, it is obvious or strongly suspected that a violent crime has occurred. To investigate this crime, forensic nurses must collect evidence as soon as possible, because physical evidence can break down in a matter of days or even hours.
Performing a coma physical exam to collect this evidence would fall to the forensic nurse. In the case of suspected sexual assault, such collection might include invasive procedures such as vaginal, anal, penile, and oral swabs; the removal of hair and clothing; and the collection of material on the skin, under the fingernails, or elsewhere on the body. A patient has every right to refuse these procedures, and indeed might refuse them if he or she were conscious. Although the forensic nurse has a duty to collect evidence, this duty is secondary to the patient’s consent—and the nurse has no way of knowing for sure what the patient would prefer.
Making the Decision
Making the right decision in this circumstance is not merely a matter of doing what is right. There are legal implications as well. If the forensic nurse collects evidence, but the patient later wakes up and feels abused and traumatized, then the nurse can be charged with the crime of battery.
To avoid this outcome, forensic nurses can do a few things. First and foremost is to confer with the patient’s legal guardian or next of kin, if available. “Next of kin or legal guardians provide consent based on their knowledge of what the patient would want to the extent it can be determined. If the patient’s preferences are unknown, the patient’s best interests are considered,” explains the Open Journal of Nursing.
Next, forensic nurses should consider any laws pertaining to their individual place of practice. Laws vary widely from region to region, and the forensic nurse has the responsibility to understand and abide by these rules. For example, in Maine, collecting evidence from a comatose patient is legal as long as the evidence is not used until the patient wakes up and decides what to do with it. The British Columbia Network in Canada, on the other hand, takes the position that such an exam is “an invasive, non-medical procedure that would submit a person to a demeaning procedure that may victimize the individual even further.” A nurse practicing in this area would not collect evidence from a comatose patient, no matter how compelling the situation might seem.
In most areas, the issue is not so cut and dried. The laws are vague, and forensic nurses must use their best judgment. In doing so, they can refer to a number of professional guidelines. For example, in the United States, the Violence Against Women Act (VAWA) recognizes the importance of a sexual assault evidentiary examination, emphasizing that it allows choice for the victim—a choice that will disappear if the evidence is allowed to degrade. The Emergency Nurses Association (ENA) discusses the importance of evidence collection, although not specifying issues around the unconscious patient. And the American College of Obstetrics and Gynecology recognizes the medical-legal needs of the sexual assault patient, asserting that forensic nurses must be aware of policy requirements and laws in their own states when collecting evidence.
Many hospitals and medical centers have developed their own guidelines for the treatment of comatose patients, and these guidelines will be helpful to forensic nurses as well. By staying informed and keeping the patient’s welfare as their top priority, forensic nurses can fulfill their duties while staying within their legal limits.
About Duquesne University’s Online MSN in Forensic Nursing
As a leader in online nursing education, Duquesne University has helped RNs learn the skills, strategies, and practices necessary to become forensic nurses. Duquesne’s Forensic Nursing MSN coursework is presented entirely online, so students can maintain their careers and personal responsibilities while pursuing their educational goals.
For more information, contact Duquesne University today.
Definition of forensic nursing – International Association of Forensic Nurses
The key issues – Open Journal of Nursing
Implied consent definition – Legal Dictionary
Evidence procedure for sexual assault – SAFEta.org
Making the decision – Open Journal of Nursing
Professional guidelines – Open Journal of Nursing