Step 1: Ask
Identify at-risk patients, and ask about access to firearms
Identifying risk factors in patients is the first step to planning an informed conversation about risk for firearm injury and firearm safety. Risk-based screening is most feasible and relevant to patients’ health and safety.
There are three main categories of risk for firearm injury and death:
- Patients at acute risk displaying behaviors that signal acute risk for harm to themselves or others, such as suicidal or homicidal ideation
- Patients with individual risk factors suggesting increased risk for firearm violence:
»» Alcohol and other substance misuse
»» A history of violent behavior or victimization
»» Dementia or another form of impaired cognition
»» Serious and poorly controlled mental illness
- Patients belonging to a demographic group at risk:
»» Middle-aged and older men, for suicide
»» Adolescent and young men, for homicide
»» Children and adolescents
Step 2: Counsel
Advise at-risk patients on safe firearm practices
After identifying risk factors for firearm injury, the goal in counseling is to reduce that risk. The most appropriate strategies vary from patient to patient, and in different circumstances. If someone at risk has access to firearms, you'll want to know how the firearms are stored, and consider together with the patient if storage changes could reduce risk – and which are most feasible and acceptable to the patient.
Aim to inform of the importance of safe storage:
- Locked up, using a safe-storage device such as a cable lock, lock box, or safe
- Stored separately from ammunition, which is also locked up
Take a respectful approach:
- Tailor the approach to the individual patient’s risk factors, and relate it clearly to their health (or that of someone else in the home).
- Convey respect for the patient’s decision to own firearms. Acknowledge local customs and keep in mind ownership can be reflective of longstanding beliefs and values.
- One way to begin a conversation: “I want to ask you a couple of questions about firearms. Are there any firearms in or around your home?”
- Replace alienating language such as “restrict” or “surrender” with terms such as “keep safe.” Additional suggested phrasing is available on the WCYD website.
- Remember to follow up during the next visit.
Step 3: Intervene
Take action if it’s an emergency
It’s an emergency if a patient is at acute risk of violence to self or others, such as when a patient expresses suicidal (or homicidal) ideation or intent.
- In emergencies, when there is serious and imminent threat, clinicians may legally disclose what would otherwise be considered protected health information to law enforcement, family, or someone who can reasonably lessen that threat, authors explain in the Annals article.
- Referrals to social services or mental health services, substance-abuse referrals, or lethal-means counseling might be appropriate.
- Depending on the circumstances, you may need to contact local law enforcement or the patient’s family.
- If the patient or someone in the patient’s home is in a time of crisis, you can recommend firearms be temporarily stored outside the home. Though policies vary from state to state, some gun stores and law enforcement agencies may be able to store firearms temporarily. In some states, an ad hoc guardian may be an option.
- In some states legal interventions may be available, such as the gun violence restraining order (GVRO), also called an extreme risk protection order or ERPO. These court orders allow firearms to be temporarily removed from individuals in crisis, or can even be used to prevent firearm purchases. These are civil orders and in most states are available to immediate family members, household members, and members of law enforcement. California was one of the first states in the country to adopt this particular legislation, and 14 states have implemented this measure.
- Many states have also developed duty-to-warn laws that providers should be aware of.
The What You Can Do toolkit includes:
- Suggested phrasing and video role playing
- Handouts for providers and patients
- The Annals article
- FAQs and a resource glossary