Transcript 13 Lambert Physical Restraintsx

The use of Physical
Restraints in acute medical
care
Dr Lynn Alison Lambert
BSc., MB ChB, FRCP (UK) DTM&H
Consultant Physician (GIM)
Foothills Medical Centre and University of Calgary
Disclosures
 Trained in the UK
 Never used restraints in 26 years of UK practice in
GIM, elderly care and acute admission wards
 Am fundamentally opposed to the use of restraints
Not a new topic
 1980
 “Restrained in Canada- Free in Britain”
 Editorial in Health Care 1980, 22, 22
What are restraints?
 Any device attached or adjacent to the person
preventing free bodily movement
 Common devices
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Vests
Waist belts
Wrist and ankle ties
Tip back chairs
Fixed chair trays
Bedrails
Who gets them?
 Old people
 Confused people
 People who don’t speak English
 ICU patients
 children
 6-25% of patients depending on type of unit assessed
(12-47% in residential care)
 Your patients??
Why are patients restrained?
 Cultural reasons
 “everybody does it” “what else would you do?” “we always do it this way”
 Paternalism
 “this treatment is good for you and you will have it”
 “prevention of interference with therapeutic devices”
 Laziness
 easier than thinking of alternatives
 “ward is short staffed”
 Fear of legal action if not used
 “maintains patients safety”
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Belief that it is safe and provides benefits
Why are restraints harmful
 They are unethical and harm the user as well as the patient
 Physical harm to the patient
 Psychological harm to the patient
 Upsetting to relatives
 European Committee for the Prevention of Torture and
Inhumane and Degrading Treatment or Punishment states that
application of restraints amounts to ill treatment.
Principles of Biomedical
Ethics
 Autonomy
 Beneficence
 Non-maleficence
 Justice (equity)
 The use of restraints violates the first 3 of these
principles
Autonomy
 Based on the principle of respect for persons
 Patient or surrogate should give informed consent to
treatment
 Physician should take into account expressed wishes
of patient where consent cannot be given
 If no expressed wishes & no surrogate then determine
what a patient would prefer
 (Do your patients prefer to be tied down??)
Beneficence and Nonmaleficence
 Beneficence requires us to do good or to further the
patients interest
 Non-maleficence requires us to avoid doing harm to
the patient
 Where there is a conflict between the 2 principles the
principle of doing no harm takes priority
What are the harms from
restraints? Physical
 Direct impact:
 bruising, lacerations, nerve damage,
 ischaemic injury,
 asphyxiation, death by strangulation
 Indirect impact from forced immobilisation
 DVT,
 pressure ulcers, incontinence,
 loss of muscle tone, loss of independence
What are the harms from
restraints?
 Psychological
 Humiliation
 anger
 depression
 demoralisation
What are the benefits of
restraints?
Assumed benefits of
restraints
 “Falls prevention”
 Studies show no difference in falls rates
 Harm can be greater if patient climbs over cotsides (bed
rails) and falls from greater height
 Nurses have false sense of security that patient can’t move
and won’t fall so check less often
 Patient muscles weaker when restraints removed and
therefore more likely to fall afterwards
 “iv lines and NG tubes last longer”
What are the alternatives to
restraints?
Look for and treat the underlying cause
of the confusion or agitation:
 Hypoxia
 pain,
 infection
 constipation,
 opioid analgesics
 drug or alcohol withdrawal
Alternatives to restraints
 Modify the treatment
 Is the iv line, NG tube, iv drug, Foley catheter really
necessary?
 Sedate early and appropriately if required
 Treat alcoholics, drug users before symptoms are out of
control
 Put in the hearing aid, put on the glasses, introduce
yourself, find someone who speaks the language
Alternatives to restraints
Modify the environment
 Better lighting (reduces confusion and agitation)
 Nursing assistant /family member with patient
 Low level bed/mattress on the floor (less far to fall)
 Modified rooms - hazards removed
 Choose the correct room for patient
 Some better in a group setting, others need single room
 Discuss it with nursing staff
 Explain why restraints are not part of your treatment plan and
stop them
Conclusion
 Restraints have no place in
modern internal medicine
References
 Bak,J, Brandt-Christensen,Sestoft and Zoffman,. Mechanical restraint- A
systematic Review. Perspectives in Psychiatric care 2012 48 83-94
 Steen, O., Opjordsmoen, S. Thrombosis associated with physical restraint
Acta Psychiatrica Scand 2001 103 73-76
 Cheung,P., Yam, B., Patient Autonomy in Physical restraint, 2005, Journal of
Clinical Nursing, 14 3a34-40
 Lofgren et al, 1989 AJPH79,735-738
 Langley, G. Schmollgruber,S., Egan, A. Intensive and critical Care, 2010
Restraints in Intensive care units
 Beauchamp and Childress. Principles of Biomedical Ethics. Oxford Med Press
 Rutledge ,DN, Donaldson, NE, Pravikoff, DS Use of restraints The online
journal of clinical innovation 2003 6(2) 1-6