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A patient who is in danger should not be left in the abusive environment. Follow the organization’s policy for removing a pediatric patient from an unsafe home and provide for further examination, treatment, and protection.
A mandated reporter who has reasonable cause to suspect that a child is being abused must immediately make the report in accordance with local, state, and federal laws.
Mistreatment of a child may include visible physical injury or nonvisible injury, including neglect, emotional abuse, or sexual abuse.
If the patient discloses abuse, question the patient carefully, without leading. If the patient does not disclose abuse, arrange any interviewing to be at a child advocacy center or another setting with a qualified team of interviewers that allows the patient to be interviewed only once.
Refer to individual state laws and licensing boards for training and reporting requirements for mandated reporters.
All members of the hospice care team are designated as mandatory reporters of child maltreatment in accordance with local, state, and federal laws.undefined#ref2">2 Certain members of the hospice team (e.g., hospice aides, volunteers, medical equipment delivery people) may not report directly to child protective services if they find suspicion of abuse or neglect, but should confer with the hospice care team to ensure that it is reported to child protective services. Pediatric patients in hospice care may be subjected to abuse. Although there are several definitions of abuse, in general, it is any knowing, intentional, or negligent act by an adult charged with the care of a child or any other person who causes harm or serious risk of harm to a child, whether that person is chronologically an adult or physically an adult.1
Forms of mistreatment include:1
There are several factors that place children at higher risk for being abused. Although child abuse crosses all socioeconomic classes, poverty, financial stress, and crowded living conditions increase the child’s risk for abuse. Other factors for the child in hospice care include a patient with developmental delay, chronic illness, and complex health care needs. Factors that may be relevant include families that are isolated or lack support, single-parent families, young parents, parents with multiple stressors, parents with lack of knowledge regarding the patient’s care, and parents with depression.1,3
Cultural practices may appear to be a form of abuse. Cultural beliefs and practices must be included in the assessment to determine if abuse is present. Bruising may be due to cupping (the practice of placing heated cups on the back that produces suction as they cool, leaving circular bruises) or coining (the practice of rubbing the skin with a coin up and down the back, leaving vertical, linear abrasions or bruising). These procedures, used in some Asian cultures, may appear as abuse, although no abuse is present. Additionally, bruising and bone and muscle loss associated with terminal illness can sometimes appear as abuse.
When screening for signs of abuse, the reported history of how an injury occurred that is inconsistent with the patient’s physical or developmental abilities or the patient’s injuries should be considered suspicious. Patterned bruises or burns may be from belts, looped electrical cords, cigarettes, or irons.4 Abusive burns on the hands, feet, or buttocks have sharp lines of demarcation, lack splash burns, are symmetric, and appear as glove-like or sock-like injuries.4 Pediatric patients with abusive head trauma (formerly known as shaken baby syndrome) may have no external signs and subtle clinical manifestations, including an unexplained change in mental status. There may be bruising on the arms or chest from being held while being shaken. As the brain injury gets worse, the patient may experience seizures.1
Barriers to hospice care team members reporting suspected abuse are common. There are significant gaps in funding, policy, research, education, and training to address abuse and neglect. Team members may be uncertain that abuse has occurred and may fear making false reports. The law does not require incontrovertible proof, only a suspicion.2 Team members may fear legal retaliation by the family member or caregiver. In reality, many states have laws that can charge a mandated reporter with failure to report.2 Reporting involves extra time and energy, and some hospice care team members believe that it may jeopardize their relationship with the family. Some do not want to become involved in family matters, whereas others may fear what will happen to the victim if the abuse is reported. Ongoing staff education and administrative support can decrease these concerns and increase reporting. Mandated reporters are not required to identify the abuser; that is the responsibility of the police and legal system. Even if the mandated reporter suspects the identity of the abuser, the mandated reporter must treat the suspected abuser as any other family member or caregiver because it may be impossible to know for sure until the investigation is performed.
Rationale: As the patient’s condition deteriorates, this creates greater demands on the family’s time and resources, and the risk for caregiver strain and stress increases. Signs of caregiver role strain may be arguing during conversation, refusing to leave the patient alone with hospice care team members, being evasive, or evading specific questions related to care.
Rationale: A threatening or accusing tone of voice or attitude from the hospice care team member may cause the patient, family, and caregivers to be defensive and not share information. The family and caregivers may then resist any education efforts the team member attempts to provide.
Rationale: The patient may be fearful of the caregiver and is more likely to share information if the caregiver is absent from the interview.
Use caution not to lead the patient. Pediatric patients may give answers they think the interviewer wants to hear. If possible, to defer an interview so it can be done once, keep questions to a minimum.
Rationale: Abusive family members or caregivers may deny that they mistreat the patient. They may react with anger and may attempt to intimidate, threaten, or yell at the team member and resort to physical violence.
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