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Explore This IssueApril 2019
A 60-year-old woman with a six-month history of retroperitoneal fibrosis transfers her care to you. She initially presented with severe bilateral flank pain radiating to the abdomen and chest. A computerized tomography (CT) angiogram of the abdomen demonstrated an infrarenal abdominal aortic aneurysm surrounded by a thick inflammatory rind entangling the left renal vein and ureter, resulting in left hydronephrosis and 70% stenosis of the proximal left renal artery.
She underwent percutaneous endovascular repair of the aortic aneurysm and was started on prednisone and mycophenolate mofetil. She subsequently required bilateral ureteral stents and left nephrostomy tube placement. Her course of treatment has been complicated by numerous nephrostomy tube malfunctions requiring repositioning in addition to the anticipated periodic ureteral stent exchanges.
As you review her chart, you note that she has had six inpatient admissions, approximately one per month, since the onset of her symptoms. At this initial visit she is, objectively, doing well. You note that her inflammatory markers—once markedly elevated—have normalized. Additionally, serial abdominal CT scans show significant improvement in periaortic inflammation. She is tolerating her medications and reports that her pain has improved. However, the objective improvement in laboratory data and imaging does not reflect the tearful woman sitting in front of you.
As you look to her to speak, she bursts into sobs. Her narrative is not one of steady improvement in the face of life-threatening illness, but one of the emotional, psychological and physical toll this disease has exacted. Upon further questioning, you are surprised to learn that she is not concerned for her own health. Rather, she is anxious about her husband.
You learn that her husband has been angry with her and that he blames your patient for her medical problems. At best, he fails to engage with her and withdraws when she tries to initiate conversation. At worst, he is preoccupied with medical bills, prolonged hospitalizations and the constant threat of emergency department visits. She denies that he has been physically abusive or threatening. She confesses that she is devastated and is uncertain their marriage will survive. You confirm that she feels safe at home and that she is neither concerned for her own safety nor for that of her husband.
In a state in which no statutes govern mandatory reporting of domestic violence, sufficient suspicion of partner violence may invoke a physician’s ethical obligation—albeit not a legal one—to report their suspicion to the governing body.
She next reveals that her husband will soon be seeing you as a new patient.
Is there enough evidence in this case to raise suspicion of physical abuse? What is legally required of a physician regarding the reporting of suspected domestic abuse? Does the fact that her husband will also be your patient have any bearing on the situation? What are your ethical obligations to your patient?