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Danisha Jenkins, MSN, RN, CCRN; Judy E. Davidson, DNP, RN, FCCM, FAAN; Lynette Cederquist, MD
A middle-aged man presented to the emergency department with a gunshot wound to the face. He underwent open reduction and internal fixation of the mandible with maxillomandibular fixation. During his recovery, a police officer came to the unit and notified nursing staff that the patient was a felon. The officer stated that the police department did not have the funds to keep the patient in custody while the patient was hospitalized, but that nursing staff were obligated to notify the police department when the patient was discharged, to facilitate his arrest. The nurse directed the officer to the hospital’s security department, but the officer continued to come to the unit and call the unit repeatedly. According to hospital policy, no patient information was released to the officer.
During numerous encounters, the police officer informed nursing staff that the patient was “very dangerous” and that not providing updates on the patient’s condition was “interfering with law enforcement.” Given the extent of his wounds and medical needs, safe discharge directly to an incarcerated status could not be coordinated. Medical staff attempted to coordinate discharge to home with family for extended antibiotic therapy, care of the oral mucosal wall graft, and continued adjustment of the jaw wires. As the patient neared discharge, police officers arrived on the unit and proceeded to arrest the patient. Medical staff reiterated that the patient was not cleared to discharge to a custody setting. The officer removed the patient from the ward and took him to the emergency department, presumably for medical clearance. The patient was not seen again.
On reviewing the case with the privacy office, it was ascertained that the hospital did not have a clear process to address this situation. It was suggested by the privacy office that, because reported lack of funding prohibits law enforcement from placing inpatients in custody, it should be the nurses’ responsibility to notify law enforcement of impending discharges to facilitate arrests. Those involved felt that to expect nurses to participate in the guarding and reporting of alleged criminals for the purpose of arrest upon discharge constituted an ethical dilemma. The lack of structured guidance and expectations of nurses’ interactions and collaboration with law enforcement complicated the issue. Because the patient had continued healthcare needs and the team did not have the opportunity to ensure that the receiving providers were prepared for his needs, there was a potential patient safety issue. Clinician safety and the safety of the other patients on the ward were also concerns. Those involved felt that the tension between obligations to care nonjudgmentally versus acting as agents of the law conflicted with the established nursing code of ethics.1
Caring for accused and convicted criminals is an inherent duty in trauma care. While law enforcement and custodial institutions operate with rigid and clear guidelines, their normal operations become convoluted in the inpatient healthcare setting. Because of law enforcement budget cuts, patients who previously had an officer posted at the bedside are now arrested upon discharge. The goals of law enforcement and those of nurses in this situation are at odds. There is an inherent dissonance between the culture of custody in prison versus the culture of caring in healthcare. Moral and ethical dilemmas can be expected when seemingly incompatible cultures such as these coexist.2 Further, it may be construed that, because imprisonment is an act of punishment, there is an intention of deliberate harm in being imprisoned, whereas the intention of healthcare is to optimize wellbeing and prevent harm. In the worldview of healthcare clinicians, liberty is a positive construct and optimal health includes freedom from physical and existential pain. These juxtaposed intentions function in ethical opposition to each other and are likely to produce dilemmas where the intentions collide.3
Where law enforcement officers see a criminal, nurses see a patient, and the nurse’s duty remains unchanged. When asking a nurse to mentally and emotionally act on a patient’s alleged crimes, care can be affected. Disclosing details of the potential prisoner-patient’s alleged crimes presents an opportunity for clinicians to make judgments regarding the case, thereby transforming these clinicians into an arm of the law. In turn, caregivers can become directly involved in the process of punishment.3 On the contrary, nurses are educated and expected by their own code of ethics to eliminate biases to optimize development of a respectful, caring, nurse-patient relationship, which in itself is part of the healing process.1,4
A community assessment was conducted, which found that other local hospitals experienced similar situations and had the same difficulties in devising an effective, safe, and ethical means to handle the requirements of law enforcement. Attempting to solve the problem through the security department and privacy office alone were ineffective. It was not until the ethics team was consulted and all parties subsequently met together that a solution was reached.
The ethics team was consulted to assess the organizational ethics of this one case, under the assumption that the situation would occur again in the future. While the process of a formalized policy was underway, it was determined that the ethics committee, nursing division, privacy office, and security department would come together to create a process that would remove the primary nurse from responsibility for calling for the arrest of patients. In this unique situation, both the law and ethics needed to be considered equally.
It was ultimately determined that all law enforcement inquiries would be directed to the security department, and strict adherence to HIPAA and state and federal information release guidelines would be followed. In situations in which it was confirmed that an in-hospital arrest would be likely, it was determined through the creation of an algorithm that an emergency huddle with unit leadership, the security department, and the clinician would take place to determine the interventions necessary to maintain the safety of all involved. It was agreed that the security department, privacy office, and ethics team would be available and would participate as appropriate. Patients would not be arrested in a multi-bed ward. The arrest would need to be timed so that the discharge plan could include communication with the receiving healthcare team before transfer, to ensure patient safety.
Establishing therapeutic and trusting relationships is at the core of ethical practice. Health centers are safe havens in which all patients have the right to receive unbiased care. Clinicians must continue to assess for and advocate against impeding societal and structural forces that could negatively impact their ability to provide holistic care.