DOMESTIC ABUSE I

Majorie Atkins

57 years, Female

Role-play cases simulate real clinical practice to guide how candidates respond to clinical scenarios and real life practice.

Name: Marjorie Aktins
Gender: Female
Age: 57 years

Opening Line:
In a concerned tone, ‘I need to talk to you about my husband. He’s very stressed and angry, and things are getting worse.'

Background:
Marjorie is a 57-year-old woman who has presented to the GP with concerns about her 62-year-old husband, Dan. She has a history of multiple visits to the Emergency Department (ED) for falls and broken bones, including a sprained ankle, a head injury, and a broken wrist. She rpeatedly says she had a fall and no previous disclosure of abuse. Her falls risk assessment and mobility are always normal in the hospital discharge letters.

Today, she has come to discuss her husband’s behavior and request stress/anger counseling for him. Dan is stressed about work and financial issues, particularly since his business has been declining since the COVID-19 pandemic. He often slams doors and shouts at Marjorie when he is upset. Dan recently received a letter from HMRC stating the business owes a significant amount in taxes, which has added to the stress. Over the last few months, the situation has escalated, and he has hit her a few times.

Marjorie works part-time as a cook with a very low income and has been unable to increase her shifts. She feels guilty that she is unable to contribute more to the household income. She is unwilling to leave her marriage because she feels they are both getting older, and she worries about who would care for her in the future. Their adult children do not live nearby and are unaware of the domestic abuse and financial problems.

She wants the doctor to contact her husband under any pretense to discuss how he can manage his anger. She is open to disclosing information but will not agree to call the police. She will accept any other advice and help.

ONLY GIVE THE INFORMATION BELOW IF ASKED RELEVANT QUESTIONS
Symptoms:

Injuries: Multiple injuries from falls, including a sprained ankle, head injury, and broken wrist. The last was 2 months ago and you currently fine and have no current injury.
Behavior: Husband slams doors, shouts, and has hit her a few times in the last few months.
Financial Stress: Husband’s business is struggling, received a significant tax bill from HMRC.

Lifestyle:

Living Situation: Lives with her husband.
Occupation: Part-time cook with low income.
Family: Adult children who do not live close by and are unaware of the situation.

Ideas, Concerns, Expectations:

Ideas: Believes her husband’s stress and anger are due to work and financial problems.
Concerns: Worried about her safety and the worsening situation at home.
Expectations: Wants the doctor to contact her husband to discuss anger management. Does not want to call the police but is open to other forms of help and advice.

Behavior:

Open to Disclosure: Willing to share information about her situation.
Reluctant to Leave: Unwilling to leave her marriage due to age and concerns about future care.
Avoiding Police: Does not want to involve the police but will accept other advice and assistance.

You are a doctor in your routine clinic, ready to begin your day of consultations. A patient has been booked to see you,

Name: Majorie Atkins
Gender: Female
Age: 57 years

PMH:

No chronic illness.
Admin Entry last year: Multiple ED visits - 16 in last 12 months.Multiple injuries due to falls at home. Her falls risk assessment and mobility are always normal in the hospital discharge letters. Letter invite sent to discuss. No response.

Current Medical History: None. NKDA

Today
Routine apointment booked; says personal, would not disclose to reception.

Marking Scheme

Data Gathering and Diagnosis

Comprehensive Review of Presenting Complaints: Assess Marjorie's injuries from falls and recent incidents of physical abuse.
Document details of her husband's stress and anger issues.
Explore her reluctance to involve legal authorities and reasons for seeking stress counseling.

Assessment of Safety and Risk: Evaluate the severity and frequency of physical abuse.
Determine Marjorie's safety at home and risk factors.
Assess her support network and potential for escalation.

Understanding Social and Financial Context: Investigate Marjorie's financial dependence and constraints.
Understand her emotional ties and reasons for staying in the marriage.
Explore family dynamics and support system availability.

Interpersonal Skills / Relating to Others

Empathy and Support: Use empathetic language to acknowledge Marjorie's distress.
Validate her feelings and concerns about safety.
Provide reassurance and emotional support.

Communication Skills: Communicate clearly and sensitively, avoiding medical jargon.
Explain the importance of addressing domestic abuse calmly and directly.
Encourage open dialogue and ensure Marjorie feels heard.

Building Trust and Rapport: Build trust through active listening and maintaining eye contact.
Respect Marjorie's autonomy in decision-making.
Clarify the limits of confidentiality and ethical obligations.

Clinical Management and Ethical Considerations

Safety Planning: Collaborate with Marjorie to develop a safety plan.
Offer information on local support services and shelters.
Discuss legal protections and options without coercion.

Ethical Considerations :Explain ethical duties to ensure Marjorie's safety while respecting autonomy.
Maintain confidentiality while balancing reporting obligations.
Avoid colluding to bring Marjorie's husband into the clinic under false pretenses.

Referral and Support Services: Provide referrals to counseling services for Marjorie and her husband.
Offer resources for financial advice and community support.
Coordinate with social services or domestic violence organizations for ongoing assistance.

These are the key issues in this clinical scenario.

Key Issues in Managing Marjorie's Case

Domestic Abuse: Marjorie is experiencing physical abuse from her husband, Dan, including incidents of being pushed and hit. This poses immediate risks to her safety and well-being.
Safety Concerns: Marjorie's safety at home is compromised due to ongoing domestic violence. She has injuries from falls and incidents of physical harm, indicating a pattern of abuse that requires urgent intervention.
Financial Dependence: Marjorie's low income and financial dependence on her husband limit her options for leaving the abusive relationship. She fears being unable to support herself independently.
Reluctance to Seek Legal Help: Marjorie is unwilling to involve the police, which may be due to fear of retaliation or further escalation of violence. This reluctance complicates efforts to ensure her safety and hold her husband accountable.
Ethical Concerns: It would be unethical for the doctor to collude with Marjorie to bring Dan into the clinic under false pretenses. Such actions could breach trust with both patients and compromise professional integrity.
Confidentiality: Maintaining confidentiality while addressing domestic abuse is crucial. Any breach of confidentiality could further endanger Marjorie and undermine her willingness to seek help.
Legal Obligations: The doctor has a legal obligation to ensure the safety of Marjorie and report instances of domestic abuse where there is a risk of harm. However, this must be handled sensitively to respect Marjorie's wishes and maintain her autonomy.
Support and Resources: Marjorie requires access to support services tailored to domestic abuse survivors, including counseling, legal advice, and safe accommodation options.
Long-term Planning: A comprehensive plan should be developed to support Marjorie in securing her safety, financial independence, and emotional well-being, considering her reluctance to leave the marriage.

Addressing these key issues requires a careful balance of empathy, ethical considerations, and practical interventions to ensure Marjorie's safety and empower her to make informed decisions about her future.

1.NICE/CKS: https://cks.nice.org.uk/topics/domestic-abuse/management/managing-domestic-abuse/

2.Lecture: PLAB Guide Academy: https://youtu.be/uWX71AFBvM0?si=AD92Qk9jaF6JSkOv

3.Lecture: Domestic violence https://www.youtube.com/watch?v=qlVwbylrPUw

4. Watch These Video (Not RCGP format/perfect, but great learning points!)

Think: What was done well?
What could be better?
Identify the cues given.
Listen to the tactics and phrases used in starting the conversation

• Domestic Violence Screening for Healthcare Professionals: Reluctant Disclosure https://youtu.be/qdJFDUj0ErE?si=Raz39gdHo5_IOzDq

• DV Screening for Healthcare Professionals: Upfront Disclosure
https://www.youtube.com/watch?v=E6y3qCx4-V4

• Teen Domestic Violence https://youtu.be/0bFB0ms5gbI?si=0c5Ojwl-eaWGGCcz

Domestic violence in a pregnant lady: https://youtu.be/vW-kizSigzI?si=DdAFoSWPg6bzHmc

Here are some phrases that can be used to improve Interpersonal Skills (IPS) when communicating with Marjorie:

Empathy and Support:"Marjorie, I understand this must be a very difficult time for you."
"I'm here to listen to you and support you in any way I can."
"It's understandable to feel scared and overwhelmed in this situation."

Communication Skills:"Let's talk through what's been happening, using simple language to make sure we're on the same page."
"I want to ensure everything we discuss is clear and understandable."
"I'm here to provide information and answer any questions you may have."

Building Trust and Rapport: "Your safety and well-being are my priority, and I want you to feel safe discussing these concerns with me."
"I want you to know that everything you share with me will be kept confidential."
"I appreciate you trusting me with this information. It's important that we work together to ensure your safety."

Encouraging Open Dialogue: "Please feel free to share anything that's on your mind. Your perspective is important."
"It's okay to take your time and share as much or as little as you're comfortable with."
"I'm here to listen without judgment and support you through this process."

Offering Reassurance: "I want to reassure you that there are resources and options available to help you."
"You're not alone in this. We can explore different avenues to support you."
"Together, we can work on a plan that prioritizes your safety and well-being."

Respecting Autonomy: "I understand that decisions about your next steps are yours to make, and I'm here to provide information to support you."
"Your choices are important, and I'll respect whatever decision you make."
"You have the right to decide what feels safest and most comfortable for you."

These phrases aim to foster a supportive and trusting environment for Marjorie, emphasizing empathy, clear communication, and respect for her autonomy in navigating her situation of domestic abuse.

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