Adult Abuse: Ethics, Legal, and Organizational Aspects

Introduction

Adult abuse is a critical topic within the Population Health, Ethical, Legal, and Organizational Aspects of Medicine (PHELO) category for the MCCQE1. As a future Canadian physician, you must be proficient in identifying, assessing, and managing cases of abuse while navigating the complex ethical landscape of patient autonomy versus protection.

This guide aligns with the CanMEDS framework, specifically highlighting the roles of Communicator (sensitive interviewing), Health Advocate (protecting vulnerable populations), and Professional (adhering to mandatory reporting laws).

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Canadian Context: Unlike child abuse, where mandatory reporting is universal across Canada, the laws regarding adult abuse vary significantly by province and territory. The key determinant is often the patient’s capacity.

Classification of Abuse

Abuse can occur in various forms. It is essential to recognize the signs of each type during your MCCQE1 preparation.

Physical

Use of physical force that may result in bodily injury, physical pain, or impairment. Includes hitting, slapping, pushing, burning, or inappropriate use of restraints.

Epidemiology in Canada

Understanding the demographics is vital for the MCCQE1 to identify high-risk populations.

Elder Abuse: It is estimated that 4% to 10% of older adults in Canada experience some form of abuse.
Gender: Women are significantly more likely to be victims of elder abuse and intimate partner violence (IPV).
Indigenous Populations: Due to the legacy of colonization and systemic discrimination, Indigenous women and girls face disproportionately high rates of violence.
Perpetrators: In the majority of elder abuse cases, the perpetrator is a family member (spouse or adult child).

Risk Factors Checklist

Victim Factors

Social isolation
Cognitive impairment (Dementia)
Physical dependency
Shared living arrangements
History of domestic violence

Perpetrator Factors

Substance abuse (Alcohol/Drugs)
Financial dependence on the victim
Caregiver burnout/stress
History of mental illness

Clinical Assessment

The MCCQE1 assesses your ability to approach these sensitive situations methodically.

Step 1: Ensure Safety and Privacy

The interview must be conducted alone. If a caregiver or family member insists on staying, you must find a professional excuse to separate them (e.g., “I need to take the patient to radiology” or “It is hospital policy to examine the patient alone first”).

Step 2: Interviewing Techniques

Use a non-judgmental, supportive approach.

Direct Questioning: “Do you feel safe at home?” “Has anyone hurt you?”
Indirect Questioning: “How are things going at home?” “Are you having trouble paying for medication?”

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Critical MCCQE1 Rule: Never use a family member as an interpreter in cases of suspected abuse. Always use a professional interpreter or a verified neutral party.

Step 3: Physical Examination

Look for pathognomonic signs of abuse:

Bruises in various stages of healing.
Injuries on the “bathing suit” area.
Defensive injuries (forearms).
Bilateral bruising on upper arms (shaking/grabbing).
Signs of neglect: Decubitus ulcers, malnutrition, poor hygiene, overgrown nails.

Step 4: Assessment of Capacity

This is the pivot point for management in Canada.

Competent Adult: Has the right to live at risk. If they refuse help, you cannot force them (unless a specific law mandates reporting, such as gunshot wounds, or if a child is also at risk).
Incompetent Adult: You have a duty to protect. This usually involves contacting the Public Guardian and Trustee or Adult Protective Services depending on the province.

Management and Legal Framework

Documentation

Documentation must be meticulous as it may be used in legal proceedings.

Use the patient’s own words (quotes).
Draw body maps of injuries.
Take photographs (requires specific consent).
Document the explanation of injuries given by both the patient and the caregiver (look for discrepancies).

Mandatory Reporting in Canada

This is a high-yield topic for MCCQE1.

Scenario	Reporting Requirement
Child Abuse (<18 or <16 depending on province)	MANDATORY in all provinces/territories. Suspicion alone is sufficient.
Competent Adult (IPV/Elder Abuse)	Generally NOT MANDATORY to report to police without consent. Respect autonomy. Offer resources/safety plan.
Vulnerable/Incompetent Adult	VARIES. Many provinces (e.g., NS, NL, BC) have mandatory reporting to Adult Protection Services. In Ontario, reporting is mandatory for residents in Long-Term Care (LTC) homes but not necessarily community-dwelling adults.
Gunshot/Stab Wounds	MANDATORY in most provinces (e.g., ON, BC, AB, SK, MB, QC, NS) to report to police.
Colleague Misconduct	MANDATORY to report to the regulatory body (College of Physicians) if sexual abuse or incompetence is suspected.

Safety Planning

If a competent patient declines intervention:

Acknowledge their decision (validate).
Express concern for their safety.
Provide emergency numbers and resources (e.g., shelters, Seniors Safety Line).
Arrange close follow-up.
Develop an “escape plan” (e.g., keeping a bag packed with ID and medications).

Key Points to Remember for MCCQE1

Autonomy vs. Beneficence: For competent adults, autonomy supersedes beneficence. They can choose to stay in an abusive relationship.
The “Sandwich” Generation: Caregivers caring for their own children and aging parents are at high risk for burnout and subsequent abusive behaviors.
Institutional Abuse: Be aware of abuse in Long-Term Care (LTC) facilities. In Ontario, the Long-Term Care Homes Act mandates reporting suspicion of abuse to the Ministry.
Abandonment: Leaving a dependent elder at an emergency department is a form of abuse/neglect.

Canadian Guidelines

Public Health Agency of Canada (PHAC): Provides guidelines on family violence prevention.
Canadian Medical Association (CMA): Code of Ethics emphasizes the duty to report where required by law and the duty to protect vulnerable persons.
Provincial Laws: Be aware that laws like the Adult Protection Act differ by province. For the MCCQE1, knowing the general principle (protect vulnerable, respect competent) is usually sufficient, but be aware of the “Gunshot/Stab wound” mandatory reporting.

Sample Question

Case Presentation

A 78-year-old female presents to the Emergency Department with a fracture of the distal radius. She is accompanied by her middle-aged son, with whom she lives. The son appears agitated and answers all questions for her. He states she “tripped over the rug.” On examination, she appears withdrawn, has poor eye contact, and you notice several bruises on her upper arms in different stages of healing. She appears alert and oriented.

Question

Which of the following is the most appropriate initial step in the management of this patient?

A. Report the case immediately to the local police.
B. Confront the son about the inconsistent history and bruises.
C. Ask the son to leave the room to facilitate a private interview and examination.
D. Order a skeletal survey to look for old fractures.
E. Admit the patient to the hospital for “social reasons.”

Explanation

The correct answer is:

C. Ask the son to leave the room to facilitate a private interview and examination.

Detailed Explanation:

C is correct: The immediate priority is to establish a safe environment to assess the patient. You cannot screen for abuse or assess capacity while the potential perpetrator is present. A private interview is the standard of care.
A is incorrect: Reporting to police is not the initial step. First, you must confirm suspicion and, crucially, assess the patient’s capacity. If she is competent, she may choose not to involve the police (unless specific provincial laws regarding vulnerable adults apply, but assessment comes first).
B is incorrect: Confronting the son may escalate the situation and endanger the patient further. It may also cause the son to remove the patient from care immediately.
D is incorrect: While a skeletal survey might be part of the workup later, it is not the initial step. History taking in a safe environment takes precedence.
E is incorrect: You cannot admit a patient without their consent (unless they lack capacity) or a medical indication. Assessment of safety and capacity must happen first.

References

Medical Council of Canada. (n.d.). MCCQE Part I Clinical Decision-Making and Multiple-Choice Question Objectives.
Public Health Agency of Canada. (2020). Stop Family Violence. Retrieved from Canada.ca
Canadian Medical Association. (2018). CMA Code of Ethics and Professionalism.
Statistics Canada. (2022). Family violence in Canada: A statistical profile.
Royal College of Physicians and Surgeons of Canada. CanMEDS 2015 Physician Competency Framework.