Patient RestraintsPatient Restraints

The View from the Ethical Window

Eike-Henner W. Kluge

University of Victoria

Sample CaseSample Case

R was in the middle stages of Alzheimer's Disease – Cognitive impairment

• Memory• Understanding• Reasoning• Emotions

Was a “wanderer” and “helper” Given to violent outbursts towards other

residents and staff• Rarely if ever physically aggressive

– No substantiated reports Severely impaired balance function

““restraint”: definition restraint”: definition

Device or protocol for restricting mobility of patient– slide rails that restrict patient’s movement and pt.

cannot remove rails– chairs– head / limb immobilization devices– seclusion where pt. cannot leave– etc.– [Medical / pharmacological restraints]

Two logically / ethically distinct Two logically / ethically distinct categoriescategories

Device or protocol necessary for treatment

Device or protocol not necessary for treatment– “protection”– convenience

Embedding of professional Embedding of professional actionsactionsProfessional actions occur in a social

contextThe social context is subject to legal

constraints.Therefore it may be appropriate to begin

with some legal considerations

Criminal Code of CanadaCriminal Code of Canada

s.265 (1) A person commits assault when

(a) without consent of another person, he applies force intentionally to that other person, directly or indirectly;

(b) he attempts or threatens, by an act or gesture, to apply force … if he has, or causes the other person to believe on reasonable grounds he has, present ability to effect his purpose…

Criminal Code of CanadaCriminal Code of Canada

s.265 (3) For the purposes of this section, no consent is obtained where the complainant submits or does not resist by reason of

(a) the application of force…

(b) threat or fear of application of force…

(c) fraud; or

(d) the exercise of authority

Criminal Code of CanadaCriminal Code of Canada

S. 27: legitimate use of force to prevent the commission of an offence– “to prevent anything being done that, on

reasonable grounds, he believes would, if it were done, be likely to cause immediate and serous injury to the person or property of anyone.”

Criminal Code of CanadaCriminal Code of Canada

S. 37: legitimate use of force to prevent assault– “.. Justified in using force to defend himself

or any one under his protection from assault, if he uses no more force than is necessary to prevent the assault..”

Some provincial statutory Some provincial statutory provisionsprovisions

ADULT GUARDIANSHIP ACT [RSBC 1996] CHAPTER 6 – 1. In this Act: "abuse" means the deliberate

mistreatment of an adult that causes the adult• (a) physical, mental or emotional harm, or• (b) damage to or loss of assets,• and includes intimidation, humiliation, physical

assault, sexual assault, overmedication, withholding needed medication, censoring mail, invasion or denial of privacy or denial of access to visitors;

ADULT GUARDIANSHIP ACTADULT GUARDIANSHIP ACT [RSBC 1996] [RSBC 1996]

CHAPTER 6CHAPTER 6 (cont.)(cont.) 44. The purpose of this Part is to provide for support

and assistance for adults who are abused or neglected and who are unable to seek support and assistance because of

(a) physical restraint, (b) a physical handicap that limits their ability to seek

help, or (c) an illness, disease, injury or other condition that

affects their ability to make decisions about the abuse or neglect

ADULT GUARDIANSHIP ACTADULT GUARDIANSHIP ACT [RSBC [RSBC

1996] CHAPTER 61996] CHAPTER 6 (cont.)(cont.)

45 (1) This Part applies whether an adult is abused or neglected in a public place, in the adult's home, a relative's home, a care facility or any other place except a correctional centre

Ss. 11-15 of the Health Care (Consent) and Care Facilities (Admissions) Act do not contain contrary indications.

Some (disquieting) facts:Some (disquieting) facts:

Inverse relationship between use in nursing homes and negative incidents (including deaths) – The relationship between physical restraint removal and falls and injuries

among nursing home residents. Capezuti E. et al. J Gerontol A Biol Sci Med Sci, 53(1):M47-52 1998 Jan

– Physical restraint use and falls in nursing home residents.Capezuti E. et al. J Am Geriatr Soc 1996 Jun;44(6):627-33.

– Restraint reduction reduces serious injuries among nursing home residents.Neufeld RR, Libow LS, Foley WJ, Dunbar JM, Cohen C, Breuer B. J Am Geriatr Soc 1999 Oct;47(10):1202-7.

– Deaths caused by physical restraints Miles SH , Irvine P.. Gerontologist 1992;32(6):762-6

Some (disquieting) facts: Some (disquieting) facts:

Medical order– Documentation spotty1

– Blanket orders? PRN ?– Time limit?– Reason? “to help settle“

Frequently nursing decision when applied Frequency range 7.4% to 17% in acute care setting2

1Janet V. Kow, David B. Hogan. Use of physical and chemical restraints in medical teaching units CMAJ 2000;162:339-340 2 Robbins LJ, Boyko E, Lane J, Cooper D, Jahnigen DW. Binding the elderly: a prospective study of the use of mechanical restraints in an acute care hospital. J Am Geriatr Soc 1987;35:290-6.; Frengley JD, Mion

LC. Incidence of physical restraints on acute general medical wards. J Am Geriatr Soc 1986;34:565-8.

The View from the Ethical Window

Beneficence

Non-Malfeasance

Impossibility Equality and Justice

Autonomy and Respect

Fidelity

Relevant Ethical Principles

Derivative Ethical PrinciplesDerivative Ethical Principles

Legitimate Infringement

Least Intrusive Alternative

Ethically, restraints can be Ethically, restraints can be ordered / agreed to byordered / agreed to by

Physician or hcp in chargeDuly empowered proxy[Role of relevant Legislation]

Standard ethical indicationsStandard ethical indications: : Principled practicePrincipled practice

Danger to self – Beneficence, non-Malfeasance, Fidelity

Danger to others – non-Malfeasance, Fidelity

Necessary to achieve legitimate therapeutic aim– Fidelity

Convenience vs. practical necessityConvenience vs. practical necessity

Convenience Practical necessity

– Danger • to self• third party

– Hcp as agent of institution– Duty to warn / alert

• administration• patients / substitutes• authorities• public

Fidelity

General proceduresGeneral procedures

Ethically based requirements– Necessity

• Impossibility• Beneficence• non-Malfeasance

– Least intrusive alternative • Autonomy• Fidelity

– Informed consent if possible (pt. or substitute)• Autonomy• Equality• Fidelity

Standard ethical protocolsStandard ethical protocols By authorised professional Not for convenience or punitive

– Legitimate infringement, Equality, Fidelity, Beneficence Continuously assessed, monitored and re-evaluated

– Fidelity, non-Malfeasance Evaluated within one hour by physician or

independent qualified hcp– Fidelity, non-Malfeasance– One-hour rule standard in most jurisdictions

• Autonomy, Fidelity, non-Malfeasance

Training of staff – Fidelity, non-Malfeasance

Simultaneous use of restraint Simultaneous use of restraint and seclusionand seclusion Higher level of necessity

• Impossibility, Fidelity, Legitimate infringement, Least intrusive alternative

Greater level of care • Fidelity, non-Malfeasance

– Continuous monitoring face-to- face with hcp or– Continuous monitoring through video and audio

with pickups in close proximity to patient

Sample website: www.hcfa.gov/quality/4b2.htm

Some basic considerationsSome basic considerations

Is restraint a matter of convenience? Is restraint a matter of necessity? Who identified the necessity? What is the place of the restraint in

– the specific treatment plan– the overall protocol– in the professional / institutional culture

Has there been– review– consultation

Other RestraintsOther Restraints

Chemical restraints are subject to the same considerations as physical restraints – with the added

caution of pharmacological interaction.

The EndThe End

Informed consentInformed consent

Parties– Patient – Proxy decision-makers

Standards– Reibl v. Hughes– Fleming v. Reid– Ciarlariello v. Schacter

.

Autonomy and respect for Autonomy and respect for personspersons

Everyone has the right to be treated not as an object but as an autonomous decision-maker who is

entitled to respect as an individual.[

Equality and justiceEquality and justice

All persons are the same insofar as they are persons, and should be treated equally. Differential treatment should be based solely on ethically

relevant differences.

BeneficenceBeneficence

Everyone has a duty to try and

maximize the good.

Non-MalfeasanceNon-Malfeasance

Everyone has a duty to try and

minimize harm.

FidelityFidelity

The existence of a duty entails a corresponding obligation to fulfil the

duty to the best of one’s ability.

ImpossibilityImpossibility

No-one can have a duty to do what is impossible under the circumstances that obtain.

Limiting condition– The impossibility is not due to an

inappropriate action on part of the

individual her/himself.

Principle of Legitimate Principle of Legitimate Infringement: basic versionInfringement: basic versionThe fundamental rights of the

individual person are conditioned by the equal and competing rights of other persons.

Principle of the Least Principle of the Least Intrusive AlternativeIntrusive Alternative

A right may be infringed only for ethically proportionate reasons.

The infringement must be demonstrably necessary to achieve the otherwise legitimate aim.

The infringement must infringe the relevant right only to the degree necessary to achieve the otherwise legitimate aim.