After the assessment, an intervention strategy can be developed (see FlG. 111-2). These cases are complicated, and they require a muLtidis-ciplinary approach (eg, physicians, nurses, social workers, lawyers, police, and psychiatrists).
First, the health professional must consider whether interventions have been implemented in the past. Information about previous interventions (eg, court orders of protection) and the reasons they failed should be obtained to avoid the same approach.
The health professional must decide whether emergency intervention, which usually involves emergency medical attention and law enforcement, is required. Circumstances that dictate such intervention include the urgent need for medical or psychiatric attention and life-threatening mistreatment.
In all cases, interventions may include medical assistance; education (eg, teaching victims about abuse and available options and helping them devise safety plans); psychologic support (eg, individual psychotherapy and support groups); law enforcement and legal intervention (eg, arrest of the abuser and orders of protection and advocacy on behalf of the victim in the criminal justice system); and alternative housing (ranging from sheltered senior housing to nursing home placement). Because counseling the victim usually requires many sessions, the health professional should anticipate incremental progress, not a short-term resolution.
With a competent victim, the health care provider presents options, and the victim decides how to proceed. With a judgmentally impaired victim, the multidisciplinary team should make most decisions. Decisions need to be based on the severity of the violence, the lifestyle choice history of the person, and the legal ramifications. The aim should be to implement the least restrictive plan. Often, there is no single correct decision, and each case must be carefully followed up.
In most states, reporting is mandatory when abuse occurs in the home. In all states, it is mandatory when abuse occurs in an institution. State laws vary as to which agency receives these reports. Thus, health care workers should become familiar with the mandatory reporting laws in their state and the available protective service resources.

If a competent patient rejects treatment that the physician believes is in the patient’s interest, especially if the treatment would prolong life, the physician should explore the patient’s reasons and correct any misunderstandings. However, a physician should not impose treatment if the patient refuses it—even if the treatment could prolong life. Instead, the physician should explore alternatives that might be acceptable to the patient; as discussed earlier, sometimes this involves transferring the patient to the care of a physician or institution that will respect the patient’s wishes. In all cases, including those in which a patient refuses a specific treatment, the physician and the institution have an obligation to continue offering supportive care and treatment for pain and suffering.
Physicians and other health care providers should also respect advance directives to refuse treatment given by patients who have become incompetent as well as decisions to refuse treatment made by the patient’s appointed representatives (see ADVANCE DIRECTIVES in Ch. 108). If a patient becomes incompetent and no advance directive exists, there is a strong tradition that the next of kin (often an adult child or spouse who is likely to know and share the patient’s values) makes decisions for the patient. However, sometimes the next of kin is emotionally distant or hostile, and another person, such as a friend, may be a better surrogate. When someone other than the next of kin is the designated surrogate, the reasons for the choice should be documented.
Often, the surrogate for an elderly person is a group of family members who may disagree with one another. If the controversy threatens to obstruct what seems to be the best course of action, the physician may call upon clergy, nurses, social workers, or the hospital ethics committee to help resolve the conflict. If this approach is unsuccessful, an outside review and court-appointed guardianship may be necessary.