The Perpetrator: A Victim and a Patient

The Perpetrator: A Victim and a Patient
I. Care for the Suspected and Convicted Offender
A. The perpetrator of a crime is also likely to become a victim.
B. Injury or death may occur
During or after commission of the crime
?? When victims attempt to defend themselves
?? When suicide is attempted after commission of the crime
?? During the arrest process
?? During incarceration
?? In an altercation with a crime partner
C. Providing health care to the perpetrator who has committed a violent act may cause some health care professionals to question their individual ethical and moral values.
D. It is necessary to remember the basic premise of the nursing profession, that of providing care that promotes a state of physical and mental wellness to those suffering from illness or injury and to help them return to a functional state of being.
E. The injured and deceased victims (or perpetrator) of violent trauma or crime are varied in background and ideology, which should have no bearing on degree of health care and treatment available and received. Refer to the following:
1. Fourth Amendment to the Constitution: Right to privacy
2. American Hospital Association (1973): Statement on a
Patient’s Bill of Rights
3. Hospice Association of America: Rights for Hospice Patients
4. Joint Commission on the Accreditation of Healthcare
Organizations
5. American Civil Liberties Union
F. When a suspected criminal presents to the health care facility for treatment, the forensic nurse must understand that the basic premise regarding the Fourth Amendment to the U.S.
Constitution protects against unlawful search and seizure.
1. The Fourth Amendment does not definitely prohibit all search and seizures; it only identifies unreasonable search and seizure.
2. This exclusion is the most common rule that may affect the forensic nurse or nurse in relation to the suspected offender and the victim.
3. In the case of Mapp v. Ohio (1961), the U.S. Supreme Court stated that evidence obtained through an unreasonable or unlawful search cannot be used against the person whose rights have been violated.

II. Direct Evidence Collection
A. Blood test evidence
1. The blood sample must be drawn in a medically reasonable manner; see People v. Kraft (1970).
2. According to Commonwealth v. Gordon (1968), blood tests are admitted as evidence when the tests are medically necessary and not requested by police.
B. Note: A forensic nurse or nurse or a physician who draws blood without the patient’s consent may be liable for committing battery even if the patient is a suspected offender and the blood is necessary for medical purposes.
C. Implied consent laws have been enacted in many states as part of the motor vehicle laws.
1. These laws state that when an individual applies for a driver’s license, the person implies consent to submit to a blood alcohol test if arrested for driving drunk.
2. The forensic nurse must be aware of the state law arrests for drunk driving and if the implied consent law applies.
D. When evidence is obtained during a surgical procedure or nonsurgical invasive procedure, immediately handing over the evidence to law enforcement may result in the evidence being inadmissible in a court of law.
1. In 1985, the U.S. Supreme Court ruled that the constitutionality of court-ordered surgery to acquire evidence must be decided on a case-by-case basis
2. Individual privacy and security interests must be weighed against the interest of society in the collection of evidence.
3. Contraband may be swallowed by drug couriers to prevent detection or arrest and may be recovered after elimination.
4. The U.S. Supreme Court in United States v. Montoya de Hernandez ruled that police may lawfully detain drug couriers until the swallowed item is recovered and seized.
5. The forensic nurse must be cautious when assisting law enforcement in obtaining evidence from the offender, especially if the offender does not give consent. Law enforcement must be able to prove that there is reasonable suspicion that the individual is a drug courier and that there is reasonable cause to suspect that contraband has been ingested.
E. When a forensic nurse/nurse removes evidence and later hands it over to law enforcement without a request, it is admissible as evidence (State v. Perea, 1981) since no government intrusion was involved, and there was no violation of the offender’s Fourth Amendment rights.
F. When the forensic nurse or nurse examines an unconscious patient and discovers evidence, this evidence is admissible in court (United States v. Winbush, 1970) because the search was conducted to obtain identification of the patient and any available medical history.

III. Forensic Nursing in a Health Care Facility
A. The patient has a right to confidentiality and privacy regarding his or her medical information as well as any privileged information the patient chooses to discuss.
B. The Federal Privacy Act of 1974 states that any unauthorized or improper disclosure of medical information can be a legal misdemeanor or felony with punishment consisting of a fine or imprisonment.
C. The forensic nurse may place his or her professional license in jeopardy if confidentiality is breached.
D. It is necessary to differentiate if an incriminating statement is a “dying confession” or a violation of Fifth Amendment rights against self-incrimination.
E. In addition to constitutional rights, the American Nurses
Association Code for Nurses states that the nurse will safeguard the patient’s right to privacy by protecting confidential information.
Only pertinent information related to the patient’s treatment and welfare may be disclosed and disclosed only to those directly involved in the patient’s care.
F. According to the Scope and Standards of Forensic Nursing Practice, Standards of Professional Practice: Standard V (American Nurses Association and International Association of Forensic Nurses, 1997), ethics defines the forensic nurse’s decisions, actions are determined in an ethical manner, and each forensic nurse is aware of and adheres to local, state, and federal laws governing practice.
G. Each health care facility has established safety policies and procedures for the forensic nurse and other health care providers to follow when providing care and treatment to the patient who is detained for legal purposes.
H. Safety measures are a part of health care facility policies to maintain a safe environment for those providing care.
I. All competent patients have the right to refuse any care, treatment, and medication regardless of their legal status.
J. It is also very important to understand that there may be exceptions to some policy or procedure based on individual circumstances.
These exceptions may revolve around legal, social, safety, and health issues, to mention only a few.

IV. Forensic Health in the Correctional Environment
A. After conviction, an offender does not forfeit all constitutional rights.
B. The Eighth Amendment protects the incarcerated offender against cruel and unusual punishment.
1. Prison officials and health care workers cannot knowingly or intentionally ignore a prisoner’s medical needs.
2. The state has an obligation to provide medical care for those imprisoned.
C. The correctional environments are some of the most controversial and stress producing in society.
D. The forensic correctional population is varied, ranges from the young to the old, and includes both males and females, victims and perpetrators.
E. Basic types of correctional facilities include
1. Federal prison
2. State prison
3. Jail (local)
F. The most common barrier to the patient seeking medical or mental health care is the culture, especially within the prison system:
1. The correctional environment does not allow, accept, or tolerate any signs of weakness, either physical or psychological.
2. Prison society values order, compliance, and submission.
3. Normal behavior includes use of drugs and physical and mental abuse among the prison population.
V. Nursing Care
A. Nurses represent the largest group of health care professionals practicing in forensic mental health and correctional settings.
B. Working daily with offenders can be physically and psychologically demanding.
C. Offenders may be abusive, manipulative, and hostile toward the nurse and other health care providers.
D. A competent offender may refuse medical treatment; however, the offender does not have the right to refuse lifesaving measures, such as oxygen, hemodialysis, and insulin (Commissioner of
Correction v. Myers, 1979). If an offender refuses lifesaving measures, the forensic nurse must immediately inform the administration of the facility.
E. For the forensic nurse to provide appropriate nursing care, the nurse must follow the guidelines of the profession relating to providing care in a manner of respect, ethical practice, legal considerations, and positive outcomes.
1. Understand and adapt to the culture of the specific facility
2. Be highly focused and objective
3. Be confident of personal assessment skills
4. Be familiar with the facility policies and procedures regarding organizational structure and those regulating the provision of health care
5. Be familiar with own duties and responsibilities when providing physical or psychological care
6. Understand and respect the various cultures and beliefs
7. Provide treatment based on individual assessment and evidence
8. Provide objective and complete documentation

VI. Mental Health and Risk for Violence
A. Confidentiality and privacy issues in the patient suffering from a diagnosed mental disability are varied based on the individual level of competence.
B. Offenders suffering with mental illness represent a majority of those in correctional facilities.
C. Being incarcerated is a significantly stressful event for those who do not suffer from mental illness and produces an exacerbation of symptoms in those suffering from mental illness.
D. The issue of placing offenders with a known mental illness within the criminal justice system has been the subject of current and future planning to improve the jail and prison system.
E. Society as a whole continues to view prisons and jails as the most appropriate venue to place offenders with mental illness and demands that federal and state governments develop and provide a system of care and treatment for these offenders separate from the general population.
F. A thorough forensic mental health examination is essential to rule out or confirm the presence of any other mental health symptoms and identify a diagnosis based on the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000).










The Perpetrator
1. There is no single factor that can identify an individual as a potential offender; rather, there are a multitude of factors that contribute to development of offenders.
2. The U.S. Department of Justice, Federal Bureau of Investigation, found that the perpetrators of violent crime have the right biological predisposition, framed by their psychological makeup, that exists at a critical time in that person’s social development.
3. Not all offenders of frequent violent crime (serial murders) are psychopaths; however, psychopathy alone does not explain the motivation for the violent criminal offenses.

I. Post-traumatic stress disorder (PTSD)
1. The most common mental health disorder used in a criminal defense is PTSD.
2. It is essential that the forensic examiner be familiar with the
DSM-IV-TR definition of PTSD and the various traumatic stressors that may precipitate symptoms.
3. For a PTSD defense to be valid, the defense must prove adherence to the DMS criteria.
4. In many cases, the primary goal of the defendant is to try to convince the forensic examiner that the act committed is due to the PTSD condition, thus prompting a more lenient sentence.
5. Traumatic memories must be correlated with objective evidence.
J. Dual diagnoses: Offenders are often diagnosed after incarceration with dual diagnoses.
1. Substance abuse is most often a major factor in dual diagnosis and is usually associated with:
a. Antisocial personality disorder
b. Bipolar disorder
c. Schizophrenia
d. Mood disorders
2. Substance abuse can and does lead to increased aggression and violence.
3. Developmental disabilities and mental illness.


K. Criminal profiling: A tool for criminal investigation
1. The basic premise of criminal profiling is that behavior reflects personality.
2. Criminal profiling is used most extensively by behavioral scientists and law enforcement in an investigation to narrow the field of suspects who possess certain behavioral and personality features that are discovered in the way a crime is committed.
3. In interpreting the offender’s behavior at the crime scene, certain traits and characteristics can be attributed to the unknown offender.
4. The most valuable data consist of a combination of crime scene examination, investigative experience, an understanding of offender and victim behavior, knowledge of wound patterns, and forensic evidence.
5. An additional use of a profile is to request assistance from the public by providing specific information displayed by the unknown offender that may have been observed by another person.
6. As a result of psychological criminal profiling, a significant aspect of the developmental process of violent offenders has emerged and is now accepted as evident to some degree in all offenders who commit multiple violent criminal acts (serial murder); it is called the homicidal triad.





L. Legal aspects of mental health
1. Understanding an offender’s state of mind has incredible bearing on the legal proceeding that plays an important part in determining the offender’s guilt or innocence.
2. The goal of a thorough psychiatric assessment is to uncover any psychiatric disorder and to establish the offender’s thought processes and cognitive abilities.
3. In addition to the psychiatric assessment, the forensic nurse must perform a thorough physical assessment.
4. Medical disorders and their treatment may alter cognition and behavior, just as psychiatric disorders and their treatments may alter an active medical disorder.
5. Physical and psychiatric assessments should also include the individual’s past history (both medical and social). Observe nonverbal communications, vocal tone, overall appearance, and behavior. Does the behavior match the story? Does the story match the behavior?
6. Competency to stand trial relates to the current mental state of the defendant and the defendant’s current ability to make a defense in court.
7. An insanity defense relates to the state of mind of the defendant at the time of the offense.
8. A finding of guilty but mentally ill means that the offender is found guilty but as a result of the plea that the mental illness caused the individual to commit the crime, the offender is sent to prison and treated for that mental illness.

VII. Nursing Diagnosis and Forensic Nursing Care
A. Simply by being in the wrong place at the wrong time, the suspected or convicted offender or perpetrator is just as susceptible to becoming a victim of crime as the victim who survived a drive-by shooting.
B. The professional forensic nurse sees no difference in the two victims; both receive the best possible nursing care and treatment, the most competent medical care and treatment with the same respect and dignity deserving of any person suffering either mentally or physically.
C. The nursing process identifies a specific nursing diagnosis, and provides the forensic nurse with an organized and appropriate guideline for the provision of care and evaluation of outcomes and both long- and short-term goals.