Introduction

For most people, the normal expectations are that they will live a full life, that parents will pre-decease their children and that the dying person will be able to deal with any unfinished business and die surrounded by loved ones, as portrayed in the media. There is an expectation that death will be natural, peaceful and, for the majority, pain free. In marked contrast to such expectations is the unexpected death of a loved one at an emergency department (ED) where sudden unexpected and violent death is not uncommon.

Death and dying patients are an inevitable part of emergency medicine practice. In 2011/12, 1956 people died in emergency departments in Australia and a further 5477 were pronounced dead on arrival [1]. These deaths can be either be sudden and unexpected or the natural evolution of a dying process. Sudden unexpected death from trauma or rapid overwhelming disease processes is somewhat unique to emergency medicine and management of patients and families in this situation is something with which all emergency physicians must be familiar. The management of the patient dying from a life-limiting illness in the emergency department needs a different skillset to unexpected death but is just as important. For some, facing a surviving family or counselling a dying patient may symbolize failure in the battle against disease; however, it is a privilege and, done correctly, can be an extremely fulfilling part of emergency medicine practice. In emergency medicine, one does not have the benefit of a long-standing doctor–patient relationship. The support and mutual understanding that are the cornerstones of family practice are missing and so rapport must be forged in the heat of the moment. Families need space and time to come to grips with death, but both are limited in the ED. Access block and overcrowding should not preclude sensitive, empathetic grief management.

To follow the strain and pace of a difficult resuscitation with the grace and emotional energy required to care for a family requires considerable effort. Emergency physicians also have a duty of care to the survivors who deserve compassion as much as the recently deceased.

Similarly, management of the patient dying from a life-limiting illness can be a complex and challenging task. Patients and their families in this setting attend emergency departments for many reasons including fear, unrelieved symptomatology and the inability to access appropriate services. This is not always a failure of the system; sometimes an emergency department is the only place that can deliver the care they require. ED clinicians should have sufficient knowledge of local processes to enable advocacy roles for these patients with special needs and foster partnerships with local care providers to facilitate transition into other services.

The 12 principles of a good death were outlined in an editorial in 2000 (Box 21.1.1) [2]. These apply equally to unexpected and expected deaths. Death in an emergency department of necessity violates some or all of these principles. Emergency physicians should apply these to practice as best they can within the constraints of a busy, crowded emergency department.

Quality management of grief states can prevent significant morbidity, as pathological or unresolved grief can lead to later problems with physical and mental health.

The death process

Diagnosing dying

Death does not occur at a finite moment. Cardiac death, cerebral death, brainstem death and cellular death form a continuum over minutes or hours. Considerable effort has gone into diagnosing death. Legal definitions for diagnosing brain death, cardiac death and the staff involved are outlined in the relevant transplantation and organ donation acts in various jurisdictions. This has been done largely to facilitate organ transplantation.

There is a paucity of research in the area of diagnosis of the dying process and the part emergency physicians can play in this. Diagnosing dying is a skill best exemplified by specialists in palliative care. It can be hard to estimate and comes with experience. Making this diagnosis can enable the emergency physician to engage patients on a dying trajectory and allow them to take control and plan for the time they have remaining (see Chapter 21.6).

Managing the dying process

When the point of dying is reached, the practitioner needs to be acutely aware of the needs of the dying person. While physical needs, such as analgesia, are relatively easily met, other domains can easily be ignored.

For patients whose death is inevitable or not unexpected, a protocol, such as the Liverpool care of the dying pathway, can be instituted in the emergency department [3]. This tool focuses team care on the needs of the dying patient and avoids unnecessary interventions. The intent is to provide hospice level care in other clinical settings. At this point, the principles of a good death can act as an aspirational target as clinicians attempt to rationalize the care provided to patients.

A large family may need significant space, which can interfere with the routine work of the ED so a private room should be available. Then all can pay special attention to physical comfort, symptom management, privacy and the confidentiality of the patient and family.

Death

Families should be encouraged to be present during resuscitation efforts. A senior support person should be available for the family if at all possible during this time. If the outcome is hopeless, family members can be encouraged to be involved in decision making around abandoning resuscitation. After death, families should be encouraged to view, touch and talk to the deceased. It is well recognized that this improves the grieving process. They will remember these moments for the rest of their lives. Having participated in the resuscitation and in the decision to stop can be helpful

Introduction

Sexual assault is defined as an act of a sexual nature carried out against a person’s will. Following sexual assault, a patient presenting should first be evaluated for acute traumatic physical injuries and drug or alcohol intoxication. The victim should be offered prophylaxis for sexually transmitted infection (STI) and pregnancy as appropriate. If required to collect forensic evidence to assist in any police investigation, consent is obtained for recording the victim’s account of the assault, the findings on physical examination and for the collection of forensic material. Follow-up medical care and psychological support should be arranged prior to safe discharge.

Definitions

Every jurisdiction in Australia has its own legislation and definitions used to describe all types of sexual offences. Sexual assault has a number of elements. It is an act of a sexual nature that is carried out against the will of the victim. Consent is the crucial issue. The victim does not give consent, is intimidated to consent, or is legally incapable of giving consent because of youth or incapacity. It includes attempts to force the victim into sexual activity and includes rape (intentional penile penetration of the vagina, including the vulva), attempted rape, aggravated sexual assault (assault with a weapon or infliction of injury), indecent assault (oral or anal intercourse), penetration by objects and forced sexual activity that did not result in penetration. Penetration is not an essential element to sexual assault.

The absence of physical resistance by the victim is not regarded as consent. Consent by intimidation or coercive conduct without physical threat is also a criminal act. Consent requires free agreement and a person may be incapable of consenting because of the influence of drugs or alcohol.

Sexual assault by a carer upon a child is termed sexual abuse. This is sexual activity in which consent is not at issue and involves the child in sexual activity that is either beyond the child’s understanding or contrary to accepted community standards. There are legal definitions regarding age, generally in the order of 15–17 years depending on the jurisdiction. Sexual violence involving a disabled person may also be either abuse or assault depending on the nature of the act or the circumstances of the victim.

Epidemiology

Global statistics indicate at least one in five women experiences rape or attempted rape during her lifetime [1]. Crime statistics are limited; it is estimated, for example, in the Australian Bureau of Statistics Personal Safety Survey 2005 that only 19% women who were sexually assaulted reported the incident to police [2]. Victims hesitate to report because of humiliation, fear of retribution, fear they will not be believed, self-blame and lack of understanding of the criminal justice system.

In this survey, based on sampling the Australian population of women, 5.8% (443 800) experienced violence in the previous 12 months, including 1.3% experiencing sexual assault. Males experienced sexual assault less frequently at 0.6%. For females, only 22% were assaulted by a stranger, 21% by a previous partner, 39% by a family member or friend and 32% by another known person. Stranger assaults were more common in males (33%). An estimated 17% of women had experienced sexual assault since the age of 15 versus 4.8% of men.

Sexual assault is more common in vulnerable populations. Individuals in psychiatric facilities may be targeted and their report may not be believed as may occur with intellectually or physically disabled persons with diminished ability to detect or escape from such danger. Homeless women with serious mental illness have a very high lifetime risk for this violent victimization. Young adult male prisoners are also at risk [3].

Barriers to care

The ABS study [4] found that once an incident of sexual assault has been reported to the police, one in four cases result in the perpetrator being charged, but the conviction rate is low with less than 50% of defendants found guilty. The study showed 12.5% of women also did not report the assault to the police because of shame and embarrassment. Emergency physicians and nurses need to be aware of these attitudes that the victim and they themselves may have when approaching the sexual assault victim. A non-judgemental, accepting stance by care providers is essential. The victim has enough self-doubt without healthcare providers adding to that. It is not the health professional’s role to make a judgement as to whether the rape occurred; the courts will decide this. False allegations of rape are made, but given the perceived penalties associated with reporting a rape, such a person is likely to be disturbed and in need of help in any event.

The role of the doctor in attending to victims of sexual assault who have consented to forensic examination and evidence collection is not the usual model of a therapeutic relationship. There is a dual obligation, as it is recognized that they have both a therapeutic role and a duty to the court to provide completely objective expertise in collecting evidence and interpreting the findings on examination to a court of law, where the impartiality of experts is key to their duty.

Consent

Victims who experience sexual assault may have experienced a loss of control and feel in danger. For the person to regain control, every step of the process must be explained and consent gained. Consent must be obtained for the forensic examination and evidence collection and for the release of the information to the police. Consent must be informed, specific and freely given. The consent must be witnessed. The capacity of the victim to give consent has to be carefully assessed. The mental competence to understand the information can be impaired, for example, by drugs or alcohol and mental state should be first tested. Certain patients are bound by formal legal requirements, which vary in each jurisdiction, for consent or responsibility for medical treatment. These include intellectually disabled persons, psychiatric patients under involuntary admission and children under custody orders or under the care of the state.

The evidence collected under this consent must be accurately labelled and secured.

Chain of evidence

Once a forensic specimen has been collected from its origin, all aspects of its existence must be recorded. All persons coming into custody of the specimen must be identified and the details of all transfers of custody and maintained security of the material must be recorded. A forensic register must be maintained for all items in a dedicated and secure storage facility.

Medical evaluation of the victim

The medical, forensic and psychological needs of a complainant depend on the nature and timing of the assault. The immediate medical needs are paramount. Medical care for victims of sexual assault includes consideration of physical injury, toxicological issues and the risks of acquiring an infection or pregnancy.

Evaluation of acute traumatic injuries is the first priority. The literature typically describes about half the victims having some sort of physical injury [5], although less than 5% of victims require admission to hospital for treatment. An analysis of over 1000 cases in the USA [6] revealed that physical examination showed evidence of general body trauma in 64% of victims. Genital trauma was noted in 52%, while 20% had no injuries documented. An Australian study confirmed non-genital injuries in 46% of women and genital injury in only 22% [7]. These findings indicate that many sexual assault victims may not have either general or genital trauma on examination and this absence does not mean that an assault did not occur.

Potentially life-threatening injuries may include attempted strangulation, blunt traumatic injury to the head or face and torso and penetrating injuries, which may be occult. These should be fully evaluated prior to referring for forensic processes.

A study from Florida found that one in 1500 sexual assaults resulted in the death of the victim, with asphyxiation being the most common cause of death. While there has been no comparable Australian study, the Australian Institute of Criminology reports that there were 288 homicides committed in Australia in 2003 and a sexual assault was the precipitating factor in nine [8].

Non-fatal strangulation is an important risk factor for homicide of women [9]. Of 300 survivors of strangulation reported from the San Diego City attorney’s office [10], 150 had no visible markings. Examination findings, where present, can include ligature abrasions, finger tip bruising from the assailant’s grasp and curvilinear abrasions caused by finger nail markings, occurring singly or in sets, caused by the victim’s struggle to pry the grasp from her neck. Subconjunctival haemorrhage and petechial haemorrhages in the skin may be identified.

Strangulation is a form of asphyxia characterized by closure of the blood vessels or air passages of the neck as a result of external pressure usually by hands (throttling) or ligature strangulation (garrotting). External injury may appear trivial but is a marker of potentially significant sequelae that can develop in surviving victims, both acute and delayed.

Compression of the airway can lead to laryngeal injuries including fractures, soft-tissue swelling and mucosal oedema with potential development of airway compromise. Significant gulping of air together with vomiting and an episode of loss of consciousness may precipitate aspiration. Hypoxic cerebral damage depends on the duration of hypoxia and most victims either die or survive without obvious brain damage, but post-hypoxic encephalopathy has been reported. Carotid artery intimal dissection with subsequent thrombus formation has also been reported. This may present as a delayed focal deficit from subsequent stroke up to 2 weeks after the incident [11]. Attempted strangulation warrants a high index of suspicion to rule out injuries and a period of observation may be required.

Penetration with foreign bodies can cause overt or occult pelvic injury. Further investigation or operative intervention may be necessary.

Forensic history, examination and evidence collection

The forensic examination is carried out for the purpose of obtaining evidence of the rape or assault that could be used in a prosecution. The aim is to record the victim’s report of the assault and collect and record evidence related to this report and collect DNA. Specific consent should be sought before this examination is undertaken, as therapeutic benefit is not intended. Specific consent must be additionally obtained to turn over the specimens to the police. Police services produce kits that give a comprehensive guide to the history and examination including body charts required for various aspects of the prosecution. Emergency departments should have access to a multidisciplinary team with a clinician trained in such collection.

Physical examination recorded for the forensic record must include every wound detected on meticulous forensic examination. Injury could have been inflicted by the assailant or in the victim’s attempted defence or escape; in the interpretation of the injury, even minor wounds that may not require treatment take on key forensic significance. Physical examination requires a sympathetic but professional and methodical approach of every body surface as with the collection of relevant forensic samples. Every injury must be carefully recorded on a body chart. Height and weight is required for interpretation of toxicological results.

Standard nomenclature including lacerations, abrasions and bruises should be used in wound description. Correct anatomical sites must be recorded and labelled in genital examination. Evidence collection kits provided in each jurisdiction contain anatomical body charts for recording all body areas, which must be assessed for evidence of injury including the ears, mouth and throat.

A wound is a disruption in the continuity of tissues produced by physical injury. Description of the physical characteristics of a wound includes the site, size, shape and depth of the wound as well as the appearance of the wound edges and adjacent tissue, the contents of the wound and whether there is evidence of healing.

An abrasion is a superficial injury of the skin caused by pressure and movement applied simultaneously. Abrasions can be of importance in the forensic context, as they may identify direction, as with friction abrasions, or patterns of the causative object as with imprint abrasions or they may contain embedded trace materials.

A bruise is an area of haemorrhage within or beneath the skin due to blunt trauma. This is also known as a haematoma, contusion or haemorrhage. The discoloration is caused by blood leaking from damaged blood vessels. The age of a bruise cannot be determined by its colour as this can undergo considerable variation. It takes more than 18 hours to develop any yellow discoloration [12]. Bruises may not occur at the site of the trauma and their size does not always correlate with the applied force; they may be altered by coincident conditions, such as anticoagulant therapy.

A laceration is a ragged or irregular tear in the skin, subcutaneous tissue or organs resulting from blunt force. Lacerations can be distinguished by irregular or crushed margins, bands of intact tissue forming bridges across the wound and intact structures, such as tendons, within the wound. The term laceration is often misused to describe an incised wound. An incised wound is an injury produced by sharp-edged objects. The edges of incised wounds are sharply defined and blood loss may be extensive as the vessels are divided rather than crushed. The correct classification of injuries can assist in determining the mechanism of injury or the object or weapon that caused the injury.

Patterns of injury may be observed. Blows to the head, face and neck may cause bruising, lacerations and fractures and include hyphaemas, dental trauma and tympanic membrane perforation. Fingertip bruising and imprint bruising may be evident. Defensive responses may show warding off injuries to the hands, for example, incised wounds to the palm or bruising on extensor surfaces of the arms. Fingertip bruising can be present on the medial thighs. Bite marks may be seen on breast or buttocks. Abrasions from contact with unshaven skin may be detected. Postmenopausal women are significantly more likely to need surgical management and repair of genital injuries than are younger women [13].

Examination of the genitalia includes inner thighs, buttocks and anus. Common locations for genital injuries include tears or abrasions of the posterior fourchette (where the two labia meet posteriorly), abrasion or bruising of the labia minora and fossa navicularis (directly anterior to the fourchette) and bruising or tears of the hymen. After relevant forensic specimens have been collected, it may be necessary to use a Foley catheter to tease out any folds in hymenal tissue to facilitate the inspection of hymenal injury. An examination of the vagina and cervix can then be completed using a speculum, any evidence of injury recorded and any bleeding or discharge recorded with the source identified. Perianal injury may need a moistened swab to tease out folds for inspection and proctoscopy may be required for inspection as appropriate.

Despite the relatively low frequency of obvious injury, the documentation of such injuries increases the chance of successful prosecution [14]. Photography must have the specific consent of the victim and is best performed by an experienced practitioner and the secure storage of images must be ensured.

Collection of forensic specimens

The perpetrator may have left evidence on the victim. Sampling from sites of contact between the victim and assailant is the basis of evidence collection. Specimens collected are guided by the circumstances. Standardized evidence collection kits used in each jurisdiction contain both forms of swabs and slides appropriate to obtain trace evidence of saliva, semen, blood and skin-to-skin contact. Samples should be sampled, allowed to dry, sealed and packaged with all contents carefully labelled and the chain of evidence maintained. Slides should be made where the presence of semen is suspected.

Any sample collected from the victim that contains cellular material from the victim’s assailant can be used for DNA testing. This includes spermatozoa, semen if it contains cells or blood or tissue from under fingernails, which should be clipped. DNA evidence left on or in the body of a victim, particularly in moist areas, degrades quickly over 2–10 days. The forensic assessment should thus be made as soon as possible. Underpants and panty liners worn during or after the assault may be contaminated with forensic material and should be retained. As DNA degrades quickly if moist, with the overgrowth of organisms, underclothes should be stored in paper not plastic bags.

Proof of sexual contact is established by the detection of spermatozoa or semen either on or within the victim or on the victim’s clothes. The likelihood of detecting spermatozoa or semen from the vagina is generally very low by 72 hours. However, under some circumstances, spermatozoa may persist for days longer and can be obtained from the endocervical os or cervix. The detection of sperm or semen from the rectum or mouth is possible but very dependent on the actions of the victim after the assault, which should be recorded. The presence of DNA in deposited saliva may give a positive result for up to 2 days. Skin swabs for epithelial cells are generally unhelpful after 12 hours.

Care must be taken when the victim undresses for the examination. Hair or clothes fibres from the offender or other traces from the crime scene may have adhered to the body or clothes of the victim. The victim should undress standing over a drop sheet, which should then be included in a bag into which clothes are placed. This becomes part of the physical evidence.

The most accurate laboratory method currently available to identify the assailant is DNA testing. The chance of incorrectly identifying an alleged assailant as the source of DNA material is very small. However, the risk of contamination of the evidence samples with that of DNA belonging to other individuals is significant and has resulted in wrongful incarceration [15]. Accordingly, forensic collection and analysis techniques are under increasing scrutiny by the legal system and sources of contamination must be excluded. All measures to minimize DNA cross-contamination in the clinical setting, including the consistent use of gloves, gowns, mask and drapes and in the techniques of collection must be taken and recorded.

Toxicological issues

Drugs may be administered to the victim in order to facilitate sexual assault. The commonest drug is alcohol, but large numbers of drugs, including flunitrazepam and gamma hydroxybutyrate (GHB), have been implicated and the victim may be unaware or have no memory of events surrounding the assault. Self-reported alcohol consumption immediately prior to assaults is very common, including up to 77% of those reporting drug-facilitated sexual assault [16] and this study revealed levels in 37% of those reporting with an average blood alcohol concentration of 0.11% at the time of examination. This is likely to have had a significant impact on conscious state and the ability to consent at the time of assault and may impair the victim’s subsequent recall of events. The victim is at additional risk, particularly where there is a combination with prescription or recreational drugs. Covert administration of drugs in the setting of sexual assault appears uncommon in this Australian study. The interpretation of drug levels and their possible effects is difficult. In general, urine is the preferred specimen, although blood samples should be collected within 24 hours of the assault and these must be refrigerated prior to laboratory analysis.