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Book Review

On The Edge – 2011

Quick Reference to Adult and Older Adult Forensics; A Guide forNurses and Other Health Care Professionals by Mary E. Muscari and Kathleen M. Brown

Reviewed and Submitted by Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CPEN, SANE-A, EMT-P

Springer Publishing Company has once again proven its place in the forensic book niche and the authors have consistently met a need for an excellent resource that is easy to navigate.   After having reviewed  last year Quick Reference to Child and Adolescent Forensics: A Guide for Nurses and Other Health Care Professionals by Mary E. Muscari  and Kathleen M. Brown, I received another book by the same authors entitled Quick Reference to Adult and Older Adult Forensics: A Guide for Nurses and Other Health Care Professionals.  I was just as eager to begin reading this book, in the hopes it was just as practical, well written and user-friendly as the first.  This did not disappoint and like the other; I anticipated the next chapter even more than the last as I made my way through the book and even read the book in one sitting.  

One of the strengths both of these books, I quickly found, is that it is not just a book geared to the SANE nurse, but to anyone caring for patients in which they have to view their care through a forensic lens.  In fact, the narrative on the back of the book states, “this book is designed to serve as a quick resource for practicing health care providers treating adults and older adults, as well as for students or practitioners new to the field.”  This certainly summarizes the intent of this book and also the reality of this book. 

The book is divided into four distinct sections, which make navigating it particularly easy.  In fact, Section 1 is a solid foundation of the book and like any good resource; this has just the right amount of statistics and facts about violence against adults.    Section 1 is a great primer for the novice forensic practitioner as well as an important review of basic principles for the seasoned one with many excellent principles of general forensics.  In this section, there are chapters on assessment and documentation, principles of evidence, and expert witness testimony. 

Additionally, there is an excellent and critically important chapter on professional stress and burnout that shows the reader practical ways to both identify and prevent this from happening as well as reassuring the reader that they are not alone in experiencing compassion fatigue in caring for this particular population.  I was hoping to find somewhere in the book a chapter on violence in the health care setting, since this is a particularly critical contemporary issue.  Indeed, there is a chapter and I find it to be relevant and appropriate, as well as helpful.

Section two contains chapters on situations where the adult and older adult are the victims.  Some of the chapters are what you would expect to find in a section such as this, such intimate partner violence and elder abuse.  However, the authors leave no stone unturned when they include chapters on elders abused by health care workers, victims of human trafficking , stalking and lesbian, gay, bisexual and transgender IPV.  I found the chapter on Victim of Adults and Older Adults with disabilities very helpful as there were specific practical and caring interventions and tips for working with patients with a variety of disabilities within the population, such as mental illness, hearing impaired, developmental disabilities and those with Alzheimer’s disease. 

The third section illustrates situations in caring for the offenders.  Each chapter is liberally concluded with a patient teaching section and includes suggestions for primary, secondary and tertiary interventions. Some of the chapters include offenders in correctional facilities, abusive parents, parenting while incarcerated, animal cruelty and offenders with mental illness and cognitive impairment.  While caring for perpetrators may prove difficult for the caregiver, this section provides helpful insight into the challenges, complications and outcomes related to individuals in this population and the care that we provide.   

The last section on unnatural deaths is also a superb resource on medico-legal death investigation, suicide, autoerotic asphyxia, suicide, deaths of elders in long term care facilities and homicide survivors. Each chapter is formatted with the etiology and principles of assessment, testing, intervention and the same patient teaching and primary, secondary and tertiary intervention section that the reader will find helpful.

A suggestion to the authors for any subsequent editions would be to have a chapter specifically devoted to legal considerations.  While there is some helpful legal points scattered throughout the chapters, such as consent for photography, it would be helpful to have a chapter devoted to this topic.  While it is understood that often this varies from state to state, having a source of truth for various issues such as the unconscious patient or the patient under the influence of a substance would be helpful, especially in the format of being a quick reference. It also might be helpful to have some colored tabs to clearly identify the sections of the book, indeed improving the reader’s ability to find facts quickly and perhaps go even further with colored type delineating the subheadings within the chapters.

Eight pages of color photographs help to illustrate some important findings for the reader.  All chapters are well organized and consistent throughout the book, with short sections, descriptive subheadings and important bullet points interspersed among the narrative, making it easy to use this book as the quick reference it was designed to be. The reader will find that because the authors have worked to achieve that dependability, the chapters are consistently organized throughout the book with definitions, prevalence, etiology, general principles, history and physical assessment, diagnostic testing and screening, interventions, prevention and patient teaching.  Additionally, because this book’s title is Quick Reference, it does not disappoint. At the end of each chapter is the expected reference section which is thorough and complete, but also an exceptionally helpful resource section with phone numbers and web addresses for the reader to access for further information.  Quick Reference to Adult and Older Adult Forensics most assuredly needs to have a prominent place in the library of any forensic nurse or health professional and have very worn pages from its frequent use.

Joyce Foresman- Capuzzi is a Clinical Nurse Educator in Emergency Department at Lankenou Medical Center, Main Line Health System, Wynnewood,  Pennsylvania.

Health Care Crime: Investigating Abuse, Fraud and Homicide by Caregivers by Kelly M. Pyrek

Reviewed and Edited By Roger A. Canaff, JD – Column Editor

Healthcare Crime is an eye-opener, both to the unfortunate prevalence of wrongdoing in the healthcare professions as well as to the vast opportunities that present themselves when a small but dangerous percentage of criminals infiltrate them.  The author, an accomplished journalist with close ties to the healthcare industry, breaks her examination into four major areas: Exploitation, Fraud, Abuse, and Murder.  She appropriately notes that most healthcare practitioners are decent and competent providers. But, she stresses that healthcare, like all professions, attracts its share of miscreants, and that the harm done- to often the most vulnerable people imaginable- is particularly disturbing and deeply personal. She also believes that much healthcare crime is preventable, and in the last chapter suggests strategies for the industry looking forward.

The book begins with a discussion of the critical role trust plays in the caregiver-patient relationship and underscores how most people trust and admire providers, a circumstance that can allow for even more abuse toward a generally uncritical public.  In terms of explaining why some providers cross the line to criminality, the author points to several possible reasons.  Among them, and especially within the context of the enormous complexity of the US healthcare system, are the increasing stressors associated with the profession.  While the utilization of health care services continues to rise, shortages of providers (nurses, doctors and others), rises as well.  Additionally, healthcare is becoming a more dangerous profession as assaults on healthcare workers increases along with other risks.  The author is also unafraid to examine more nefarious reasons for criminality, such as hard core criminal traits and even psychopathy when discussing assault and homicide.  She also explores the sometimes more subtle psychological process that takes place when professional boundaries are ignored or broken between providers and patients.

The chapters that follow are insightful and at times frightening in terms of the scope of potential harm- including homicide- that the author examines.  In the chapter about patient abuse she examines the issue from the perspective of different types of providers, including dentists, psychiatrists, pediatricians and nursing assistants and aides.  Particularly disturbing are the accounts of pediatricians and other hands-on providers who sexually abuse patients, sometimes in large numbers and over years.  In the chapter on exploitation she points out how unauthorized photography of patients has increased dramatically because of advances in technology and personal communication devices armed with cameras. In addition, misuse of social networking websites to post violative or inappropriate content regarding patients is an expanding problem covering all aspects of the system.  A related and larger question she raises is whether patient privacy is in itself a fallacy, even with federal law like the Health Insurance Privacy and Portability Act (HIPAA) in place.  Given both the means to violate privacy that exist and the occasional motives to do so (exposing medical information of celebrities, for instance), it seems almost impossible to stem the tide of exploitation that continues. 

Healthcare fraud is also an area the author explores in detail, and her examination of the issue and is a concise and comprehensive examination of a gargantuan problem.  The complexity of the healthcare system, as the author discusses, gives rise to fraud in every conceivable area, including insurance, billing of patients, prescriptions and drugs, and identity theft.  She discusses how both individuals and organized crime groups infiltrate systems, and examines how fraud committed within healthcare presents considerable challenges to investigators and prosecutors.  As in the chapter on abuse of patients, she examines different types of providers and also the means to commit fraud, such as forgery and improper billing.

By far, though, the scariest topic is covered in Chapter 5 on suspicious death and homicide.  Readers with any connection at all to the healthcare system (just about everyone) will find this chilling reading.  The author describes health care serial killers in detail, complete with individual stories of some of the most notorious perpetrators and their potential motives.  She does a good job exploring what motivates healthcare killers, from the cold-blooded thrill seeker to the misguided “mercy killer.”  Especially compelling is her exploration of the incredibly fine lines that often exist between treatment- particularly in palliative care- and murder.  She describes circumstances where professional boundaries, if not meticulously maintained, can melt easily into homicidal acts despite initial, arguably decent intentions.  And of course, for the truly deranged or evil who also enter the field in order to kill, the opportunities are abundant given the life and death circumstances that are ubiquitous, and the tools at immediate disposal. 

The book ends with two chapters, one covering investigations, sanctions and discipline, and one with specific strategies for the industry going forward.  The prescriptions for improvement are daunting, and involve first and foremost the industry coming to terms with the seriousness and pervasiveness of the problem.  She recommends among other things an ambitious combination of better screening, quality improvement systems and supportive legislation.  Healthcare Crime is an interesting and important book about a shameful but remarkably important problem; one that is desperately in need of addressing as an aging population faces more and more interaction with the healthcare system.

Roger Canaff is a widely known child protection and anti-violence against women advocate, legal expert, author and public speaker.  A career Special Victims prosecutor, he has devoted his legal career to the eradication of violence against women and children.  He has worked as a prosecutor in Alexandria, Virginia, the Bronx, New York, and as an Assistant Attorney General with the state of New York as well as a Senior Attorney with the National District Attorneys Association.  In June 2009, he became a Highly Qualified Expert with the US Army, training and advising military prosecutors on Special Victims cases.

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