Transcript Restraints - Web.UVic.ca

Patient Restraints
The View from the Ethical
Window
Eike-Henner W. Kluge
University of Victoria
Sample 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

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
categories

Device or protocol necessary for
treatment

Device or protocol not necessary for
treatment
– “protection”
– convenience
Embedding of professional
actions
Professional actions occur in a social
context
 The social context is subject to legal
constraints.
 Therefore it may be appropriate to begin
with some legal considerations

Criminal 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 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 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 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
provisions

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 ACT [RSBC 1996]
CHAPTER 6

(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 ACT [RSBC
1996] CHAPTER 6

(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:

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:



1Janet
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
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
Relevant Ethical Principles
Beneficence
Non-Malfeasance
Impossibility
Autonomy and Respect
Fidelity
Equality and Justice
Derivative Ethical Principles

Legitimate Infringement

Least Intrusive Alternative
Ethically, restraints can be ordered /
agreed to by
Physician or hcp in charge
 Duly empowered proxy
 [Role of relevant Legislation]

Standard ethical indications:
Principled practice

Danger to self
– Beneficence, non-Malfeasance, Fidelity

Danger to others
– non-Malfeasance, Fidelity

Necessary to achieve legitimate
therapeutic aim
– Fidelity
Convenience 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 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 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 and
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 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 Restraints
Chemical restraints are subject to the same
considerations as physical restraints – with the added
caution of pharmacological interaction.
The End
Informed consent

Parties
– Patient
– Proxy decision-makers

Standards
– Reibl v. Hughes
– Fleming v. Reid
– Ciarlariello v. Schacter
.
Autonomy and respect for
persons

[
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 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.
Beneficence

Everyone has a duty to try and
maximize the good.
Non-Malfeasance

Everyone has a duty to try and
minimize harm.
Fidelity

The existence of a duty entails a
corresponding obligation to fulfil the
duty to the best of one’s ability.
Impossibility
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
Infringement: basic version
 The
fundamental rights of the
individual person are
conditioned by the equal and
competing rights of other
persons.
Principle of the Least
Intrusive 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.