Caring for the Dangerous Patient: Legaland Ethical ConsiderationsPatricia C. McMullen, JD, CRNP, Benjamin A. Howie, BA, MPH,William O. Howie, DNP, CRNA, and Nayna Philipsen, JD, RN

The Jo568

ABSTRACTWhen assessing and treating patients who report that they are thinking about hurtingthemselves or others, nurse practitioners (NPs) must consider not just their codes of ethicsbut federal laws, state laws, cases in the different courts, and the guidelines set forth bycredentialing boards and professional organizations, all of which impact the application of basicconfidentiality. The purpose of this article is to help NPs deal with unusual situations thatmight require a breach of patient confidentiality and to address legal concerns and possibleactions by state boards of nursing for breach of patient confidentiality. A list of 10considerations for NPs facing such a challenge is included.

Keywords: duty to protect, duty to warn, mental health, nurse practitioner, threat of harm toself or others� 2013 Elsevier, Inc. All rights reserved.

urse practitioners (NPs) and other healthcare providers learn that they owe a legal

Nand ethical duty of confidentiality to their

patients. It is part of their code of ethics and coreto their concept of professionalism. Sometimes theyencounter situations that make them feel uneasyabout this duty. One such conflict around this corevalue arises when they care for patients who arepotentially dangerous to others.

News of emotionally troubled individuals whoelected to hurt themselves or others has been in theheadlines throughout the country in recent years.Some of these individuals had been under the care of1 or more health care providers prior to such tragicevents.1-3 This is an age when “an army of 1” can bea reality in every home, raising the stakes if NPsmisjudge the mental stability of a patient. Practi-tioners and the public alike have become exasperatedand fearful. What went wrong with those in-dividuals? Was everything done that should havebeen to prevent tragedy? How could someone knowthat violence could happen and not tell? Practitionersask, “Are we doing all that we can to protect thehealth and safety of our communities from thedevastating effects of violence by even 1 person thatis made possible by today’s weapons?”

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When assessing and treating patients who reportthat they are thinking about hurting themselves orothers, NPs must consider not just their codes ofethics but the intent of and the exceptions to thesestandards. Federal laws, state laws, cases in thedifferent courts, and the guidelines set forth byrespective credentialing boards and professional or-ganizations all impact the application of the basic ruleof confidentiality. The purpose of this article is tohelp NPs deal with unusual situations that mightrequire unusual actions. Working together, frommaking policy to caring for patients, they candecrease the risk of future tragedies and their legalliability and concern about possible actions by stateboards of nursing for breach of patient confidentiality.

This article will provide an overview of the ori-gins of patient privacy, duty of confidentiality, andthe exceptions, including the so-called “duty towarn” and “duty to protect” in law. “Duty to warn”and “duty to protect” are particularly salient in therecent cases of gun violence where perpetrators hadvoiced to a health care provider their intent to harmthemselves or others.1-3 Several examples of the legalcases that have shaped the evolution and refinementof reporting requirements in the United States will bediscussed. After this review, the article offers some

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practical suggestions to assist the NP confronted witha patient who is potentially a danger to himself orto others.

PATIENT PRIVACY AND CONFIDENTIALITYNurses and other health care workers have long beenresponsible for safeguarding patients’ information.How are privacy and confidentiality different? Privacyis the right to be left alone. Privacy is something thatis personal and that can be controlled.4 Courts haveheld that the Constitution and its amendmentsguarantee the right to privacy. Confidentiality is theduty to respect someone else’s privacy, as in keepinga secret.4

When did nurses and other health care workersfirst have an identified duty to respect the privacy ofpatients? Was it with the Hippocratic Oath5 or theNightingale Pledge?6 Did it begin in 1996 with thepassage of the Health Insurance Portability andAccountability Act (HIPAA)7 or in 2010 with theHealth Information Technology for Economic andClinical Health Act?8

Health care providers have been bound by a legaland ethical duty to keep personal information dis-cussed during a patient and provider encounter ses-sion private as far back as is known.9,10 NPs’ duty tomaintain confidentiality is essential in clinical prac-tice. It communicates respect of patients and buildsthe trust that permits patients to reveal the vital andsometimes very personal information necessary toprovide optimal care.11 The ethical and legal re-quirements to maintain confidentiality among nursesis part of the American Nurses Association (ANA)Code of Ethics.10 So how could NPs ever “violate” it?Even the ANA recognizes that a nurse may faceexceptions to the duty to maintain confidentiality inorder to protect the patient’s and the public’s healthand safety. In some circumstances disclosure of pri-vate patient information may be mandatory forpublic health safety.10

The duty of health care professionals to maintainpatient confidentiality has come under scrutinyrecently because of well-publicized acts of massviolence. News headlines have confronted Amer-icans too often with reports of the suffering anddeath of innocent people going to school, going to amovie, participating in a marathon. In 2012 alone

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there were at least 5 widely reported mass-shootingevents: Chardon High School in Ohio, 6 shot with3 dead; Oikos University in Oakland, California,10 shot and 7 dead; Aurora, Colorado, 70 shot,12 killed; College Station Texas, 6 injured, 3 killed;Newtown, Connecticut, 27 dead, including theshooter. In each of these tragedies, the perpetratorhad a history of mental instability, was a knownrisk for violent behavior, and was thought ofas being potentially capable of committing aviolent act.3

As a result of continuing mass acts of violencein the US, a major attempt is underway to reformexisting gun control laws to limit access to guns and“weapons of war” among civilians.3 Obviously, thepresence of such a weapon greatly multiplies the riskof 1 angry and uncontrolled individual. The fact isthat the danger of powerful weapons is ever-present.The result is that the damages from the misdiagnosisof a patient’s risk of violent behavior are far out ofproportion to the damages that can result from similarerrors in other areas of practice.

Another response, 1 that directly impacts NPpractice and that NPs can control to a much greaterdegree than access to modern weapons, is the ques-tioning of conflicting duties to promote health.When should a duty of confidentiality and the valueof patient autonomy yield to the value of beneficenceand the greater good, if ever? What is the ethicalduty of NPs to decrease the risk of harm to othersfrom a patient by reporting information obtained asa result of the NP-patient relationship to thoseoutside of it? Would this duty also hamper an NP’sability to even get that information, for individualtreatment or for public protection? The followingsection will explore some recent key events thatillustrate the importance of community awarenessand intervention by NPs and others in order toavert mental health associated violence, with orwithout guns.

RISK OF HARM AND THE DUTY TO REPORTIn November 2012 police arrested a Bolivar, Mis-souri, man who was planning mass shootings at the“Breaking Dawn” movie screening and at a localWalmart store. Prior to his arrest this individual hadthreatened to stab and kill a Walmart employee. He

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had stalked the employee around the store before hewas stopped by authorities, but subsequently he wasreleased. After this incident, his mother suspected thathe still posed a danger. She notified authorities thatshe had reasons to fear that her son would committhe threatened killings.

When authorities searched his home, theydiscovered more than 400 rounds of ammunition andseveral assault rifles. During police questioning, headmitted that “he had a lot in common with thepeople involved in (recent mass shootings), that hewas quiet, kind of a loner, had recently purchasedfirearms and didn’t tell anybody about it, and hadhomicidal thoughts.He admitted to police thathe had bought a rifle on Monday and another onTuesday with the intention of shooting audiencemembers who attended [the movie screening] .andhe also planned to continue shooting at a localWalmart because he thought he could have accessto additional ammunition. He had been practicingwith the weapons at a shooting range.”12

In the above case an alert and aware mothernotified authorities to protect her son and herneighbors from harm. Unfortunately, incidents atVirginia Tech University (2007), Aurora, Colorado(2012), and Sandy Hook Elementary School inConnecticut (2012) had much different outcomes. Inthese tragic cases, either no one alerted authoritiesof the danger until after the shootings had begun,or they failed to order an emergency psychiatricadmission for the perpetrator.3 In the Connecticutmassacre, the shooter’s mother was aware of her son’sunusual behavior but elected to avoid an emergencypsychiatric admission. She was in the process ofpetitioning the court for a conservatorship so that shecould institute involuntary psychiatric treatment.13

The Aurora shooter was under the care of apsychiatrist, but his psychiatrist did not believe thathis behavior rose to the level where non-psychiatricinterventions were warranted.14 A court had orderedpsychological evaluation of the Virginia Tech shooterprior to his rampage, noting that he “presents animminent danger to himself as a result of mentalillness” and “presents an imminent danger to othersas a result of mental illness,” but he was released tooutpatient psychiatric treatment. He went on tocommit the deadliest school shooting in US history.15

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Patients are sometimes explicit about the harmthat they plan to do to themselves and others, even totheir NP. The case of Victoria Sparrow serves as anexample. Sparrow was a 43-year-old county courtclerk. On November 5, 2009, she saw her familyNP. During the visit she told the NP that she wasdepressed over her marriage and had thoughts ofpoisoning herself, her 3-year-old daughter, and thefamily dog. The NP let her leave with advice to seekcounseling and antidepressant medications. Threedays later, her son came home and found Sparrow,her daughter, and the dog unresponsive. Sparrowsurvived, but her daughter and the pet died from themany prescription drugs Sparrow had receivedthrough her family practice and had administered tothem. Sparrow claimed she was legally insane at thetime she poisoned her child and dog. However, thecourt found she was legally sane and sentenced her tolife in prison, with all but 50 years suspended.16,17

What guidance do US courts provide that couldhelp NPs develop standards for situations like the 1that the NP caring for Sparrow faced? Looking atcourt rulings that may provide guidance for practi-tioners is the next step.

PROFESSIONAL DUTY AND TARASOFF, AWATERSHED CASECourt cases may not directly determine ethicalstandards, but they do contribute to legal standardsarising from public policy. A seminal case concerninga provider’s duty to report a patient who may presenta risk of harm to himself or others is Tarasoff.1 Briefly,Prosenjit Poddar was a student studying naval archi-tecture at the University of California-Berkley. Ayear after commencing his studies, he met TatianaTarasoff. Poddar made several attempts to start arelationship with her, all of which were unsuccessful.He began to show signs of clinical depression and lostinterest in his studies. A friend urged him to seekmental health counseling.

In August 1969, Poddar sought counseling fromDr. Moore, a clinical psychologist at the University ofCalifornia. He confided to the psychologist that hewanted to kill Tarasoff. Moore warned campus policeof the threats, and the police briefly detained Poddarand searched his apartment. They then released himbecause he appeared rational and promised to stay

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away from Tarasoff. However, neither Moore northe campus police warned Tarasoff about Poddar’sthreat to kill her, and on October 27, 1969, hedid.1,18

After Tarasoff’s death, her parents filed suit againstMoore’s employer (the university) and the campuspolice on 2 grounds: the failure to confine Poddar,even though he told them of his intentions to killTarasoff, and their failure to warn Tarasoff or herparents. The lower court, the Superior Court ofAlameda County, dismissed the lawsuit, finding thatthere was not a valid cause of action against the de-fendants (that is, that the Tarasoff family had no rightto sue) because the university owed no duty of careto Tarasoff.1

The Supreme Court of California reversed thedecision of the lower court, finding that defendantsdid have a legal responsibility (a duty) to warn allindividuals who could foreseeably be endangered.The court further noted, “When the avoidance offoreseeable harm requires a defendant to controlthe conduct of another person, or to warn of suchconduct, liability is imposed only if the defendantbears some special relationship to the dangerousperson or the potential victim.”18 Special relation-ships may include those between a provider and apatient. The court weighed the impact of the con-fidential nature of the communication between apatient and therapist but found that the public policyinterest in protecting the public from a known threatrequired disclosure of the confidential informationto avert a preventable injury or death.19-21

After the widely published issuance of the Tarasoffruling, an increasing number of states mandated thatpersonnel involved in the mental health treatment ofa patient had the right and the duty to warn poten-tially affected people of a patient’s dangerousness.20 Aperiod of considerable confusion ensued, includingthe fact that some states wrote laws about a provider’s“duty to warn” and some specified a provider’s “dutyto protect.” What is the difference? The duty to warnarises when a patient makes a threat to harm others.A clinician can discharge a “duty to warn” in suchcircumstances by warning the persons who the pa-tient has identified as possible victims. The duty toprotect goes a step farther, obligating the provider tonotify authorities or initiate a civil commitment order

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to protect the health, safety, and well-being of boththe patient and possible victims.21

Federal laws can certainly simplify compliance andenforcement. For example, at present there is nonational consensus on whether a provider has a dutyto warn others who are not his or her patients, a dutyto protect them, or both. In some states providershave a duty to warn potential victims; other statesgrant a permissive duty to warn, with the decision ofwhether to warn left to the provider; and in a thirdgroup of states providers have no legal duty to warnpotential victims. This means that NPs need to knowtheir own state law in this regard.22 Fortunately, theNational Conference of State Legislatures providesregular updates on state laws and cases that addressNPs and other providers’ responsibilities in thisarea.23 Table 1 summarizes current state statutesconcerning a provider’s duty to warn potential vic-tims or to protect the patient and possible victims.

What about the fact that complying with a duty towarn may require a breach of duty to maintain pa-tient confidentiality? Of some reassurance to NPs isthat, as of January 2013, all but 5 states provide someprotection to mental health professionals (and likelyto others caring for patients) against both civil andcriminal liability, if they “in good faith” discloseotherwise confidential information to protect thepatient from self-injury or to prevent the patient frominjuring others.23 In such cases, the courts usuallylook at whether the defendant’s (NP’s) actions wereconsistent with what a reasonably prudent providerwould have done under the same circumstances,whether the NP’s actions were motivated by goodintentions and not by ill will, and whether there wasa reasonable basis for the NP to act the way he orshe did.24

Additionally, many state confidentiality laws arebeing modified to include guidelines that requiremandatory reporting when a provider assesses a pa-tient as being a risk to himself or others. These lawsare receiving increased scrutiny and evaluation, inpart to shifting public policy priorities as a responseto the increase in US mass shootings.25

NPs must not only be aware of their state lawsgoverning their duty to warn, their duty to protect,and their duty to keep patient information confi-dential; they also must watch for changes in these

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Table 1. Duty to Warn Statutes/Case Law, By State23

Mandatory Duty to Warn Permissive “May Warn”

No Duty to Warn,

May Have a Duty

to Protect

Expressly Limited

Duty of a Provider

to Warn

Alabama, Arizona, California, Colorado,

Delaware, Idaho, Illinois, Indiana, Iowa,

Kentucky, Louisiana, Maryland,

Massachusetts, Michigan, Minnesota,

Missouri, Montana, Nebraska, New

Hampshire, New Jersey, New York, Ohio,

Pennsylvania, Puerto Rico, Tennessee,

Utah, Vermont, Virginia, Washington,

Wisconsin, Wyoming

Alaska, Arkansas, Connecticut,

District of Columbia, Florida,

Hawaii, Kansas, Mississippi,

New Mexico, Oklahoma, Oregon,

Rhode Island, South Carolina,

South Dakota, Texas, US Virgin

Islands, West Virginia

Georgia, Maine,

Nevada,

North Carolina,

North Dakota

Guam

North Carolina

laws. An example of a recent change in confidenti-ality statutes occurred in New York on January 15,2013. In that state it is now mandatory for mentalhealth professionals to report to authorities whenthey have reason to believe a patient may pose adanger to himself or to others. The new statue allowslaw enforcement members to remove firearmsowned by patients reported to be a personal or publichealth threat. This law further provides protection forthe reporting provider against civil or criminal lia-bility, if the report was made with no malice and theprovider acted in good faith to avert a potentiallypreventable violent act.23

NPs need to be aware that most laws governingpublic health and safety, including Nurse PracticeActs, are state laws. Federal laws and health regula-tions are often enforced through the allocation orwithdrawal of federal funds, such as Medicare andMedicaid. Most NPs are familiar with the codifica-tion of rules protecting patient privacy in federal law.The Title II HIPAA Privacy Rule in particular hasraised the awareness of NPs about their need to verifywho can have access to patient information beforesharing it.26 This requirement is in addition to longprofessional valuing of patient privacy. Unfortu-nately, some health care workers do not understandthe limitations or exceptions to general rules inHIPAA. Among these is public health and safety.HIPAA was never an impermeable wall betweenpatient privacy and competing needs, but a set ofrules to help practitioners navigate what is sometimesa real quagmire.

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In response to the recent mass shootings in theNewtown and Aurora, the Department of Healthand Human Services (DHHS) recently emphasizedthat the HIPAA privacy rules are not intended tohamper a provider’s ability to disclose necessary in-formation about a patient to law enforcement, familymembers, or other potentially at risk persons, if theprovider considers the patient a serious danger tohimself or others.27 Under a new position statementissued by DHHS, a health care provider may disclosepatient information, including information frommental health records, if he or she deems it wouldbe helpful to law enforcement, family members, orrelatives of the patient or other people who may beable to prevent or lessen the risk of potential harm.Under this position statement, HIPAA permits themental health provider to notify police, a parent orappropriate family member, school administrator orcampus police, and potential other people who maybe able to intervene to avert potential harm based ona credible threat.27 This position by DHHS is goodnews for NPs and others who render care to patients.

ADVICE TO NURSE PRACTITIONERSDespite the longstanding expectation that the confi-dentiality of private patient information should beguarded at all costs, there has been a steady move-ment toward defining situations when the provider isrequired by law to report to appropriate authoritiesall suspected physical or mental danger to the patientor to others. In addition, virtually all states require ahealth care provider to report specific injuries and

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013

wounds (gunshots, animal bites, stab wounds), sus-pected child abuse, elder abuse, and/or vulnerableadult abuse to appropriate law enforcementagencies.25

NPs may find the following points helpful toconsider when caring for patients who threaten toharm themselves or others.

1. Most states mandate that providers reportsome types of threats or potential harm. Somehave limited reporting requirements to spe-cific professionals, such as psychiatrists, psy-chologists, and mental health professionals.Others are more general and use the termhealth care provider, which in a growing num-ber of states may include NPs. Consequently,NPs must be fully aware of the provisionsof their current state laws in this regard todetermine what actions are required regardinga duty to warn or a duty to protect.28

2. New laws are emerging in response to currentsocietal needs. New legislation and new courtdecisions may change the duty to warn or dutyto protect requirements imposed on the NP.29

3. Careful assessment of whether a patient pre-sents an imminent threat of danger to himselfor others includes any or all of these criteria1:

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a. Has the patient made any specific threats tocause self-harm or communicated a po-tential intent to harm others?

b. Has the patient identified a specific indi-vidual or target?

c. Has the individual identified a plan toimplement the threat?

d. Has the patient identified a means (such aspossession of a firearm or learning abouthow to construct a bomb) that could makethe plan a reality?

4. If the patient speaks about self-harm orharming others, NPs should initiate the pro-cess to have him or her voluntarily or invol-untarily admitted as an inpatient for furtherpsychiatric workup.29

5. If the patient does not fully meet the criteriafor involuntary commitment, but the NP isstill concerned, he or she should urge thepatient to voluntarily commit himself toinpatient treatment.29

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6. If an NP is concerned that the patient pre-sents an immediate and realistic threat tohimself, others, or a provider, he or sheshould plan and prepare for his or her safetyfirst. In this situation, the legal standard for“duty to warn” does not take priority overclinicians protecting themselves. They shouldkeep in mind that providers are the closet firstvictim. Therefore, they need to have a policyand plan of action in their facility that includessignaling an emergency and protectingthemselves and their staff or coworkers.30

7. NPs should carefully document the advicethey give the patient. If the patient refuses tofollow advice, document the patient’s refusalalong with any reasons the person gives fornot following that advice.28

8. If an NP feels the patient is unfit to drive a caror ride on public transportation because ofobvious balance issues or slurred speech (ap-pears impaired), he or she should try to getconsent for a toxicology screen for drugs oralcohol.28

9. If an NP is unsure about what course of actionto take with a difficult situation or patientpresentation, he or she should seek a consul-tation with another provider who specializesin this type of condition. Sometimes theconsultation should be with a mental healthpractitioner and sometimes with an attorneywho specializes in the activities of concern.31

10. NPs should carefully consider the ethicalobligation to prevent harm (non-malfeasance)whenever possible. The prevention of injurynot only protects the intended victim but alsomay help protect the patient from significantlegal responsibilities if he or she carries out theviolent act. This fact remains true regardless ofwhere an NP practices in the US.31

11. NPs should consider obtaining advice fromthe state board of nursing, legal counsel at theworkplace, and the Occupational Health andSafety Administration (OSHA) in drafting apolicy and procedure manual that addressestheir rights and responsibilities when consid-ering a potentially violent patient and theirduty to protect or warn others.

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CONCLUSIONClearly, the US lacks a unified federal statute tominimize variations in state expectations of providerswho identify potentially dangerous patients. This gapis attributable to constitutional provisions that chargeindividual states with protecting the health, safety,and well-being of their citizens. Nurses should con-sider active advocacy efforts to help enact a change inthe current ambiguous “duty to protect” and “dutyto warn” laws. A better delineation and a morethorough understanding of basic expectations andprotections will lead to less hesitation among NPs andother health care providers regarding a best responsewhen they are confronted with an apparentlydangerous patient.

The DHHS’ “Message to Our Nation’s HealthCare Providers” provides some degree of security toNPs and other providers who fear litigation or boardof nursing penalties in circumstances where theysacrifice patient privacy to report a patient’s threats toharm themselves or others to the authorities.21 Insuch instances, the NP should consider the 10 itemsthat we list above in making what may be a difficultdecision. The NP will want to document the specificpatient statements or behaviors that led to the con-cern, whether or not he or she obtained a consulta-tion from a colleague, and any actions that weretaken to protect the patient’s health and well-beingand those who were threatened. While there is noguarantee that these activities will always protect theNP from liability or board of nursing action, they arecertainly an indication that the NP was acting ingood faith.

References

1. Tarasoff et al v. The Regents of the University of California et al. 17 Cal.3d 425;

551 P.2d 334; 131 Cal.Rptr 14 (1976).

2. Inquisitor. A history of violence: top 10 most violent acts of 2012. www.

inquisitr.com/351330/a-history-of-violence-top-10-most-violent-acts-of-2012/.

Accessed March 31, 2013.

3. Hoyer M, Heath B. Mass killings occur in USA once every two weeks. USA

Today. http://www.usatoday.com/story/news/nation/2012/12/18/mass-killings-

comman/1778303/. Accessed March 30, 2013.

4. University of California at Irvine. Privacy and confidentiality. http://www.

research.uci.edu/ora/hrpp/privacyAndConfidentiality.htm. Accessed April 28,

2013.

5. Hippocratic Oath. http://dal.ca.libguides.com/content.php?pid¼313&sid¼25677. Accessed April 28, 2013.

6. American Nurses Association. Florence Nightingale Pledge, 2012. http://www.

nursingworld.org/FunctionalMenuCategories/AboutANA/WhereWeCome

From/FlorenceNightingalePledge.aspx. Accessed April 28, 2013.

7. US Department of Health and Human Services. The Health Insurance

Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules.

http://www.hhs.gov/ocr/privacy/. Accessed April 28, 2103.

The Journal for Nurse Practitioners - JNP574

8. US Department of Health and Human Services. The Health Information

Technology for Economic and Clinical Health (HITECH) Act. http://www.hhs.

gov/ocr/privacy/hipaa/administrative/enforcementrule/hitechenforcementifr.

html. Accessed April 28, 2103.

9. Olson J, Cutcliffe B, O’Brien B. Emergency department design and patient

perceptions of privacy and confidentiality. J Emerg Med. 2008;35(3):317-320.

10. American Nurses Association. Code of ethics for nurses with interpretive

statements. Washington, DC: American Nurses Publishing; 2001.

11. Webster D, Vernick J, Vittes K, McGinty E, Teret S, Frattaroli S. The Case for

Gun Policy Reforms in America. Baltimore: Bloomberg School of Public

Health, 2012. http://www.jhsph.edu/research/centers-and-institutes/johns-

hopkins-center-for-gun-policy-and-research/publications/WhitePaper102512_

CGPR.pdf. Accessed March 31, 2012.

12. Castillo M. Police arrest Mo. man planning mass shooting at “Breaking

Dawn” screening, Walmart. CBS News. November 16, 2012. http://cbsnews.

com/8301-201_162-57551315/police-ooting-at-breaking-dawn-screening-

walmart/. Accessed April 6, 2013.

13. Winter J. Fear of being committed may have caused Connecticut gunman to

snap. Fox News. http://www.foxnews.com/us/2012/12/18/fear-being-committed-

may-have-caused-connecticut-madman-to-snap/. Accessed April 10, 2013.

14. Nelson S. James Holmes shared ‘homicidal thoughts’with psychiatrist before

Aurora shooting. US News &World Report. April 5, 2013. http://www.usnews.

com/news/newsgram/articles/2013/04/05/james-holmes-shared-homicidal-

thoughts-with-psychiatrist-before-aurora-shooting. Accessed April 6, 2013.

15. Potter N. Va. Tech killer ruled mentally ill by court; let go after hospital visit.

ABC News. April 18, 2007. http://abcnews.go.com/US/story?

id¼3052278&page¼1. Accessed April 10, 2013.

16. The Capital Newspapers. Judge: Mom legally sane when she killed her

daughter: faces life in prison for poisoning her 3-year-old. The Capital

Newspapers. August 7, 2009. http://www.tmcnet.com/usubmit/2009/08/07/

4314112.htm. Accessed March 10, 2013.

17. Sparrow v. State. Circuit Court for Queen Anne’s County. Sept 28, 2009.

http://casesearch.courts.state.md.us/inquiry/inquirySearch.jis. Accessed

March 1, 2013.

18. Case Briefs. Tarasoff v. Regents of University of California. http://www.

casebriefs.com/blog/law/torts/torts-keyed-to-dobbs/the-duty-to-protect-from-

third-persons/tarasoff-v-regents-of-university-of-california/. Accessed April 1,

2013.

19. Gosling D. Confidentiality, privilege and the public interest. In: Jenkins P, ed.

Counseling, Psychotherapy and the Law. 2nd ed. Thousand Oaks, CA: Sage;

2002:101-128.

20. Ewing C, McCann T.Minds on Trial: Great Cases in Law and Psychology. New

York: Oxford University Press; 2006.

21. Herbert P, Young K. Tarasoff at twenty-five. J Am Acad Psychiatry Law.

2002;30:275-281.

22. Soto F Jr. Public health law. Optometric Care within the Public Health

Community. Cadyville, NY: Old Post Publishing; 2009. http://webpages.

charter.net/oldpostpublishing/oldpostpublishing/Section%202,%20Principles

%20of%20Public%20Health/Sect%202,%20Public%20Health%20Law%20by%

20Soto.pdf. Accessed April 1, 2013.

23. National Conference of State Legislatures. Mental Health Professionals Duty

to Warn/Protect. 2013. http://www.ncsl.org/issues-research/health/mental-

health-professionals-duty-to-warn.aspx. Accessed April 10, 2013.

24. Rottenstein Law Group. What is “good faith”? http://www.rotlaw.com/legal-

library/what-is-good-faith/. Accessed April 10, 2013.

25. Durborow N, Lizdas K, O’Flaherty A, Marjavi A. Compendium of State

Statutes and Policies on Domestic Violence and Health Care. Washington, DC:

The Family Violence Prevention Fund; 2010. http://www.acf.hhs.gov/sites/

default/files/fysb/state_compendium.pdf. Accessed April 7, 2013.

26. US Department of Health & Human Services. Health information privacy.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html.

Accessed April 28, 2013.

27. US Department of Health & Human Services. Message to Our Nation’s Health

Care Providers. January 15, 2013. http://www.hhs.gov/ocr/office/

lettertonationhcp.pdf. Accessed April 10, 2013.

28. Buppert C. Legal obligations to the dangerous patient. http://www.medscape.

com/viewarticle/707580. Accessed April 1, 2013.

29. Watson C. The duty to warn/protect doctrine and its application in

Pennsylvania. Jefferson J Psychiatry. 2005;19(1):13e18. http://jdc.jefferson.

edu/cgi/viewcontent.cgi?article¼1447&context¼jeffjpsychiatry&sei-

redir¼1&referer¼http%3A%2F%2Fwww.bing.com%2Fsearch%3Fq%3D

The%2Bduty%2Bto%2Bwarn%252Fprotect%2Bdoctrine%2Band%2Bits%

2Bapplication%2Bin%2BPennsylvania%26src%3DIE-SearchBox#search¼%

22duty%20warn%2Fprotect%20doctrine%20its%20application%

20Pennsylvania%22. Accessed August 7, 2013.

30. Schoener G. Dangerous clients and the threat of violence. http://www.walkin.

org/sites/default/files/DutyToWarn_0.pdf. Accessed March 14, 2013.

31. Striefel S. Duty to protect or warn. Biofeedback. 2008;36(3):86-89.

Volume 9, Issue 9, October 2013

Patricia C. McMullen, PhD, JD, CRNP, FAANP, is anordinary professor and dean of the School of Nursing at TheCatholic University of America in Washington, DC. She can bereached at mcmullep@cua.edu. Benjamin A. Howie, BA,MPH, is a research assistant at the Siemer Biomolecular ResearchLaboratory and an intern at Front Porch, a nonprofit center inCalifornia. William O. Howie, DNP, CRNA, is a staffanesthetist at R. Adams Cowley Shock Trauma Center and LTCUS Army Reserves in Baltimore, MD. Nayna Philipsen, JD,

www.npjournal.org

PhD, RN, FACCE, CFE, is an associate professor and directorof program development in the Helene Fuld School of Nursingat Coppin State University in Baltimore, MD. In compliancewith national ethical guidelines, the authors report no relationshipswith business or industry that would pose a conflict of interest.

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The Journal for Nurse Practitioners - JNP 575