U.S. Extreme Risk Protection Orders to Prevent Firearm Injury: The Clinician's Role
Authors: Kristy L. Blackwood, Paul P. Christopher
Journal: Annals of Internal Medicine (2021)

Ideas and OpinionsDecember 2021U.S. Extreme Risk Protection Orders to Prevent Firearm Injury: The Clinician's RoleFREEKristy L. Blackwood, BA and Paul P. Christopher, MDKristy L. Blackwood, BAAlpert Medical School at Brown University, Providence, Rhode Island (K.L.B., P.P.C.). and Paul P. Christopher, MDAlpert Medical School at Brown University, Providence, Rhode Island (K.L.B., P.P.C.).Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-2792 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In 2019, nearly 40 000 persons in the United States died from firearms, and many more experienced firearm-related injury (1). Firearms are a leading cause of suicide and potentiate danger from intimate partner violence (IPV). Among other efforts to address firearm-related violence, 19 states and the District of Columbia now allow courts to issue extreme risk protection orders (ERPOs)—a number increased from 5 states in 2018 (2). These laws permit family members, police, and—in some jurisdictions—physicians and other clinicians to petition courts to remove firearms from persons who pose an imminent danger to themselves or others. Extreme risk protection orders last up to 1 year, with opportunities for extension and appeal.Whether ERPOs can effectively mitigate firearm violence remains unknown. One study found that suicide rates decreased after 1 state authorized ERPOs (3). Notwithstanding the need for more research, President Biden directed the Justice Department to publish a model ERPO law in April 2021. He also called on Congress to incentivize states to adopt such laws and pass a federal ERPO statute. On 7 June 2021, the Justice Department published its model statute, outlining a role for physicians. Moreover, the American College of Physicians recently expressed support for ERPO legislation (2).With the release of the Justice Department's model ERPO statute, the potential for a federal ERPO law on the horizon, and increased state interest in adopting such laws, it is imperative that physicians know the status of ERPO legislation in their state and what roles they may be called on to play in ERPO implementation. Here, we offer practical guidance on the current scope of physician responsibilities within ERPO laws and discuss both procedural steps for executing these duties and ethical and liability concerns that may arise.Physician as PetitionerOf the 20 jurisdictions with ERPOs, only Maryland, Hawaii, and the District of Columbia authorize physicians to serve as petitioner. However, the Justice Department's model statute includes physicians and other clinicians as eligible petitioners, increasing the likelihood that future state laws will follow a similar path. As petitioner, a physician would notify courts of patients with high risk for gun-related violence. The procedure to file a petition varies by jurisdiction but generally involves submitting a standardized form to the court to identify the at-risk person and describing the concerns related to firearm possession. The Giffords Law Center to Prevent Gun Violence keeps an up-to-date list of ERPO procedures by state (https://giffords.org/wp-content/uploads/2020/02/ERPO_Table_2-26-20.pdf).Some physicians are well positioned to serve in this role, particularly those who treat persons at risk for suicide and IPV. Because contact with clinicians is common before suicide (4), ERPOs may provide a timely means to reduce suicides by firearm. For example, persons subject to an ERPO in Washington State had a relatively high rate (62%) of suicide ideation or attempt (5). Physicians also frequently encounter victims of IPV, and primary care screening for IPV should be routine (6). Moreover, perpetrators of IPV often show a willingness to discuss domestic conflicts (7). As part of a multitiered approach to IPV, allowing physicians to petition courts for ERPOs could prove helpful in selected high-risk circumstances.Still, the utility of allowing physicians to petition depends on their knowledge of ERPO legislation and willingness to incorporate this role into their practice. A recent study found that most physicians from 1 hospital were unaware of their state's ERPO law, although most were willing to petition patients at risk for suicide or violence if they received increased training (8). Respondents also expressed concern about the time needed to complete petitions and attending hearings (8). The study's small sample and relatively low response rate underscore the need for additional research on physician views about ERPOs.Physician as Evaluator or WitnessNearly all existing ERPO laws allow for physician input to aid the court's decision. This information often includes medical records, psychiatric hospitalization or civil commitment, and court-mandated substance use treatment. New Mexico and the District of Columbia explicitly require courts to weigh psychiatric records in their decision. Other states only advise courts to consider such history.Physicians may also serve as an evaluator or witness. Oregon authorizes persons subject to ERPO hearings to select a mental health clinician to serve as an expert witness. Maine requires all persons subject to ERPO petitions to have a clinical evaluation to assess the likelihood of mental health deterioration, the threat of serious harm in the foreseeable future, and whether access to a weapon exacerbates that threat (9). The Justice Department's model statute suggests but does not require that courts consider such evaluations.Liability and Ethical ConcernsSeveral jurisdictions shield eligible petitioners from liability for filing a petition or failing to do so. Unfortunately, neither the Justice Department's model statute nor the jurisdictions that allow physician petitioners include such liability protection. No ERPO statute mandates that physicians file petitions for at-risk patients; however, legislators should include provisions that explicitly shield physicians from liability, especially given physicians' poor awareness of ERPO laws and ability to address risks through other means.Physician involvement in ERPOs raises additional questions about balancing commitments to confidentiality and public safety, as well as difficulty in predicting future risk for violence. Moreover, whether physicians should notify patients or potential victims when filing ERPOs is unclear. Widespread physician engagement with ERPOs seems unlikely without additional guidance from either in-depth ethical discussion of these questions or policy positions from professional bodies.ConclusionAs ERPO laws and their use continue to expand, physicians should be aware of the existence and nature of such laws in the jurisdiction in which they practice and their potential to serve as petitioner, evaluator, or witness. States that seek to include physicians as petitioners should attempt to minimize administrative burdens of filing ERPO petitions and include provisions that safeguard physicians from liability from filing or failing to file. Finally, professional societies should provide guidance to physicians about how to ethically incorporate ERPOs into practice. These efforts would help promote the use of ERPOs among physicians seeking to reduce firearm-related death and injury.References1. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying cause of death, 1999-2019. CDC WONDER. 2020. Accessed at http://wonder.cdc.gov/ucd-icd10.html on 24 September 2021. Google Scholar2. Butkus R, Doherty R, Bornstein SS, et al; Health and Public Policy Committee of the American College of Physicians. Reducing firearm injuries and deaths in the United States. A position paper from the American College of Physicians. Ann Intern Med. 2018;169:704-7. [PMID: 30383132] doi:10.7326/M18-1530 LinkGoogle Scholar3. Swanson JW, Norko MA, Lin HJ, et al. Implementation and effectiveness of Connecticut's risk-based gun removal law: does it prevent suicides. Law Contemp Probl. 2017;80:179. Google Scholar4. Ahmedani BK, Westphal J, Autio K, et al. Variation in patterns of health care before suicide: a population case-control study. Prev Med. 2019;127:105796. [PMID: 31400374] doi:10.1016/j.ypmed.2019.105796 CrossrefMedlineGoogle Scholar5. Rowhani-Rahbar A, Bellenger MA, Gibb L, et al. Extreme risk protection orders in Washington. A statewide descriptive study. Ann Intern Med. 2020;173:342-9. [PMID: 32598226] doi:10.7326/M20-0594 LinkGoogle Scholar6. Miller E, McCaw B. Intimate partner violence. N Engl J Med. 2019;380:850-7. [PMID: 30811911] doi:10.1056/NEJMra1807166 CrossrefMedlineGoogle Scholar7. Penti B, Tran H, Timmons J, et al. Physicians' experiences with male patients who perpetrate intimate partner violence. J Am Board Fam Med. 2017 Mar-Apr;30:239-47. [PMID: 28379831] doi:10.3122/jabfm.2017.02.160258 CrossrefMedlineGoogle Scholar8. Frattaroli S, Hoops K, Irvin NA, et al. Assessment of physician self-reported knowledge and use of Maryland's extreme risk protection order law. JAMA Netw Open. 2019;2:e1918037. [PMID: 31860108] doi:10.1001/jamanetworkopen.2019.18037 CrossrefMedlineGoogle Scholar9. An Act To Enhance Personal and Public Safety by Requiring Evaluations of and Judicial Hearings for Persons in Protective Custody Regarding Risk of Harm and Restricting Access to Dangerous Weapons, Sec. A-1, 34-B, Me. Rev. Stat. Ann. §3862-A (2019). Google Scholar Comments0 CommentsSign In to Submit A Comment Traci Kurtzer MDNorthwestern18 July 2022 ERPO training for MDs Doctors for America has a training on ERPO and Safe Storage counseling for health care professionals with various scenarios provided and tips for a patient centered, culturally competent, non-biased discussion with a patient at risk for self harm or at risk of harming or being harmed from firearms in the home (DV, dementia, children in home.) Disclosures: On DFA Community Health and Prevention committee. Author, Article, and Disclosure InformationAffiliations: Alpert Medical School at Brown University, Providence, Rhode Island (K.L.B., P.P.C.).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-2792.Corresponding Author: Kristy L. Blackwood, BA, 222 Richmond Street, Providence, RI 02903; e-mail, [email protected]edu.Current Author Addresses: Ms. Blackwood: 222 Richmond Street, Providence, RI 02903.Dr. Christopher: Box G-BH, Brown University, Providence, RI 02912.Author Contributions: Conception and design: K.L. Blackwood, P.P. Christopher.Analysis and interpretation of the data: K.L. Blackwood, P.P. Christopher.Drafting of the article: K.L. Blackwood, P.P. Christopher.Critical revision of the article for important intellectual content: K.L. Blackwood, P.P. Christopher.Final approval of the article: K.L. Blackwood, P.P. Christopher.Collection and assembly of data: K.L. Blackwood, P.P. Christopher.This article was published at Annals.org on 19 October 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited bySurvey of Washington clinicians' willingness to use and preferences related to extreme risk protection orders December 2021Volume 174, Issue 12Page: 1738-1739KeywordsFirearm injuriesHearingIntimate partner violenceLegislationPsychiatry and mental healthSuicide ePublished: 19 October 2021 Issue Published: December 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...