- Domestic violence and abuse (DVA), perpetrated by one (or multiple) adult family members against another can be physical, emotional, sexual and/or financial. Often characterised by coercion, it may be present (but hidden) in a family over decades. DVA against women is more common and more severe than DVA against men, although older men are more vulnerable than younger men.
- Risk factors for DVA include social isolation, frail health, and increased dependence on another for care. These factors are invariably present during chronic, life limiting conditions and at end of life (EOL)
- Health and Care Services of EOL care are often completely unaware of the hidden history of abuse in a family
- The COVID-19 pandemic will cause an increase in mortality, with an increase in deaths at home from the complications of COVID-19, either by choice or necessity, if hospitals do not have the capacity to deal with all critically ill patients.
- Managing DVA experienced by dying patients that is invisible to the GP, community nurses and palliative care teams will become more problematic as the capacity of clinicians is stretched in the pandemic, with a potentially greater direct caring role for spouses and other family members, including the administration of medications, potentially including opioids.
- Recognition of DVA in EOL care has a different rationale from its recognition in other clinical contexts, where there are a wider range of options for the victim. Moreover, during the pandemic, face-to-face support from a DVA support worker is not feasible and phone or video contact may not be appropriate. Nevertheless, it is crucial that clinicians providing EOL care recognise DVA when it is present and aim to give the patient the opportunity to disclose what has been happening to them.
- Good communication will be needed between health and care teams, for example, between primary care and palliative care teams, to share concerns about DVA in an EOL care situation. This could be via the patient electronic medical record, or via phone call.
Recommendations
o Be aware and mindful of controlling or coercive behaviour of any family members
o As part of initial assessment of the patient, always find some time to speak to them on their own
o Consider asking if they are afraid of anyone in their family or if anyone has been hurting them
o Depending on the nature of the disclosure (which should be communicated confidentially to colleagues, but not to abuser, because of the risk of abuse escalation),
next steps include:
? Further one-to-one conversation with patient
? Avoid giving family members control over medication
? If the abuser is one family member (e.g. spouse), discuss with another family member
? If abuse is severe and the risk is high and ongoing, consider if it is possible moving to a safe care space, for example hospice or hospital care.
? If the abused person is the carer or family member, offer referral or link to the local DVA agency
? Safe and timely information sharing is crucial so that professionals involved are empowered to keep the abused person safe as well as ensuring that their actions and decisions do not put the person further at risk of harm. It is important that any concerns about DVA are recorded safely on the patient electronic medical record (Guidance on recording of domestic violence and abuse information in general practice medical records, RCGP Adult Safeguarding Toolkit).
If you have not had specific training about managing DVA (and even if you have) disclosure of abuse in EOL care can be challenging. Key sources of support are your practice or organisation safeguarding lead, Named GPs for Safeguarding (or equivalents) and your local safeguarding professionals such as Designated Professionals. Another key source will be an advocate or support worker in your local DVA agency. If your practice is IRIS-trained, that will be your advocate educator. If you are not an IRIS practice or do not know how to contact your local agency, please ring your national Domestic Violence Helpline that will give you initial guidance and signpost you to your local agency.
o National 24 hour helpline – 0808 2000 247