Transcript Chemical Restraint

Chemical Restraint
Neil Petrie
Consultant Pharmacist
September 2016
How do you define “Chemical Restraint”
• There is no legal definition of this term
– National Health Act or
– Aged Care Act 1997
– Accreditation standards for Residential Aged Care.
• It is mentioned in
– Mental Health Act 1986, the Disability Act 2006
How do you define “Chemical Restraint”
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Think of instances where “Chemical
Restraint” was used?
Medication
Situation
Chemical Restraint
• Chemical restraint is the control of a person’s behaviour
through the intentional use of any medicine
– Prescribed, Over the counter, Complementary or Alternative
medicines
• May be considered a chemical restraint
– when no medically identified condition is being treated
– where the treatment is not necessary for a condition
– to over-treat a condition.
Definition
• Key factor that differentiates restraint from other
forms of care or medical treatment is that it is always
applied intentially to restrict the movement or
behaviour of a person
• The appropriate use of drugs to reduce symptoms in
the treatment of medical conditions such as anxiety,
depression or psychosis DOES NOT constitute
restraint.
What leads to Restraint?
To control an episode of behaviour
To prevent falls
To protect from injury
To maintain treatment regimes
Meet request by families
May be considered a Restraint unless
Type of Medication
Antipsychotic
Anticonvulsants/
Mood stabilisers
Anxiolytics ie
benzodiazepines
Antidepressants
Accepted Medically Identified Conditions
Psychosis, delusions, hallucinations,
Schizophrenia, Bipolar disorder
Seizures, Neurological disorders, Bipolar
disorder
PRN short term for acute relief of anxiety in
diagnosed psychiatric illness
Depression, anxiety disorder
Sedatives/Hypnotics Where requested by resident to sleep
What do you think of this statement?
“This medicine is being used for Behaviour
Management and is NOT being used as a
restraint”.
One large organisation has asked staff to place this
sticker next to all antipsychotics!!!!!!!!!
Doctor records in notes after prescribing
risperidone
“This is not a chemical restraint”
Residential Aged Care Use
The use of Chemical Restraint in Aged Care may be
particularly insidious for two reasons
1. Actual use is relatively undetected and is not
specifically monitored.
2. Potential side-effects can be both substantial and
severely detrimental
Chemical Restraint
It is sometimes considered when care staff are concerned
about a residents behaviour.
We need to consider what is in the patient’s best interest.
Expected benefits need to be weighed up against risks
Considered high risk along with
Removing mobility aids and Bed rails
Decision to Use
Involves obtaining consent
Least restrictive form
Last resort
Should enable the resident to function better
Prevention is always the priority
Consent
Consent should be obtained
Resident
The person responsible for consent
It should be documented
It should be regularly reviewed.
Can be withdrawn at any time.
except in an emergency or where the law provides
otherwise.
Consent - Important Note
A family member or legal representative does not have the
legal power to require that a resident be restrained.
This is a clinical decision made by appropriately qualified
people.
Must document the reason for restraint use
Must document the process in making this decision
Those deciding are legally accountable for any consequences.
Accreditation
If chemical restraint is used there are processes
to ensure it is being used within guidelines and
that it is reviewed and monitored by
appropriately qualified health professionals
Assessment module compilation June 2014
Outcomes Standard Guidelines
Although are not strictly legally binding but are
also relevant
2.13 Behaviour Management
The needs of residents with challenging behaviours are
managed effectively.
The focus of this expected outcome is
‘results for residents’.
Expected outcome 2.7 Medication Management
When using pharmacological interventions, the aim is to
settle distress, without affecting clarity of consciousness
or compromising quality of life.
Chemical restraint should only be used when all other
options have been exhausted.
If chemical restraint is used
there are processes to ensure it is being used within
guidelines and that it is reviewed and monitored by
appropriately qualified health professionals
Assessment module compilation June 2014
Australian Government Australian Aged Care Quality Agency
Expected outcome 3.9
Choice and decision making
Before any medical treatment or procedure is
carried out, staff must obtain consent from the
resident/representative.
The consent must be informed, competent,
uncoerced and continuing.
The Agreement
The resident has the right to and shall be
provided with, adequate and appropriate care,
services and accommodation without
confinement or restriction unless permitted by
law.
Be free of unnecessary medication and
unnecessary restrictive treatments
Common Law Rights
Laws of assault and false imprisonment are also
relevant.
Locking a person in a room or using medication to
prevent a person’s movement is considered by the
law to be false imprisonment
Common Law Rights
If psychotropic medication is used on a resident
without her/his informed consent, unless its use
can be shown to be necessary, then the
chemical restraint may be illegal.
Medicolegal Pitfalls
Failure to recognize a medical cause for agitation or
assumed psychosis
Inadequate monitoring of vital signs after sedation
Failure to recognize potential lethal cardiac adverse
effects from medications given
Failure to comply with state laws regarding patient
competency and confinement
When should psychotropic
medications be used?
Treat a psychiatric condition or
When it is necessary to avoid self-injury or
Injury to others
Suitably Trained People
The use of chemical restraint should be
reviewed regularly by sufficiently trained person
Doctor
Nurse
Pharmacist
When is it not justified?
It should not be used to manage behaviour such as
Wandering
Pacing
Uncooperativeness
Sleeplessness
As a disciplinary measure
– For convenience of staff
Care Strategies
Develop a data base of care strategies
Remembering that care plans are individualised.
Regular care plan review
Consider a Behaviour Management Committee
To develop a team environment for best practice
To encourage “Proactive Care” as opposed to
“Reactive Care”.
To promote communication and consultation
Management Responsibilities
1. Develop policies and practices
2. Initiate prevention programs
3. Promote communication and consultation
4. Establish and maintain review processes
5. Ensure education and training support
6. Keep informed of best practice
The Health Service should
Have regular medication audits
To obtain a snapshot of the use of restraint
To provide information for further action
Be peer reviewed involving
General practitioners
Director of nursing
Pharmacist
See NPS Audit
Coroners Case
Case in South Australia
“harsh and unsympathetic staff were too quick to
seek pharmaceutical solutions to a dementia
patients behaviour problems”
Recorded reasons for use included
“John is a little restless”
“Given for settling tonight”
Usually no suggestion of threatening behaviour
Keep Informed about best practice
National Prescribing Service
Dementia Action Alliance
Dementia Behaviour Management Advisory
Service
1800 699 799
Myths about Restraint
Myth – “It doesn’t really bother old people to be
restrained.”
Reality – studies show that older people report
feeling fear, distress, humiliation, frustration and
agitation when restrained.
Belinda Evans – Elder Rights
Myths about Restraint (cont)
Myth – “The old should be restrained because they are
more likely to fall and seriously injure themselves.”
Reality – Residents under restraint, often:
suffer injuries such as falls or strangulation resulting from
struggling to be released;
experience confusion and cognitive decline;
suffer loss of functional capacity, for example, muscle tone
and balance.
Belinda Evans – Elder Rights
Myths about Restraint (cont)
Myth – “If we don’t restrain we could be sued.”
Reality –
Failure to restrain (after appropriate assessment) has
seldom resulted in a successful liability case.
However, liability has been found where restraint
has been applied inappropriately.
Belinda Evans – Elder Rights
Useful Information
Summary
Consider the reason for administering
Consent is important
Clearly document
Monitor the outcome.
If we spent as much time trying to understand
behaviour as we spent trying to manage or
control it, we might discover that what lies
behind it is a genuine attempt to communicate
Source: Goldsmith, M (1996) Slow Down and Listen to their
voices – Journal of Dementia Care 4(4)