1.Consent and refusal
10. Ethical use of restraints
Joan G. Quaine and David B. Waisel
The Cases
Case 1
A muscular 25-year-old requires post-operative mechanical ventilation following laryngospasm-induced negative pressure pulmonary edema. The nurse applies restraints prior to lightening his sedation and calls the intensivist for an order, explaining that he is concerned that the patient will extubate himself as he wakes up.
Case 2
After a stroke, a 76-year-old man is intermittently communicative, occasionally aware of self and place. He is being physically restrained with wrist restraints to minimize the likelihood of dislodging his intravenous and arterial catheters. The wrist restraints occasionally agitate him for short periods. His non-medical daughter is extremely disturbed by the use of restraints and repeatedly requests their removal. His son, a physician, does not object.
Restraint therapy is instituted to prevent injuries to patients or others by restricting a patient’s movement. If used improperly, restraint can cause accidental injury or even death. In order to reduce associated risks and protect a patient’s health, safety and well-being, while concomitantly preserving a patient’s dignity and rights, physicians are ethically obliged to limit the use of restraints to clinically and adequately justified situations.
What is medical restraint?
Intent, not mechanism, determines whether movement restriction is considered restraint. Medically necessary restraints are designed to avoid harms from unplanned interruption of therapy, such as self-extubation, removal of catheters, or interruptions to operative sites. Behavioral restraints are used to maintain safety for the patient and others. Forensic restraints are those used by law enforcement to constrain individuals. Medical care should not be hindered by forensic restraints. Medical immobilization to accomplish a procedure is not considered restraint therapy. Examples of medical immobilization including placing a baby in a papoose to perform a frenulectomy and holding down a toddler to perform a mask induction of anesthesia.
Restraint therapy should be used thoughtfully. Comprehensive, individualized assessments should be performed before and throughout restraint therapy. Clinicians should obtain informed consent from available decision-makers before instituting restraint therapy. If there are no available decision-makers, the decision to use restraints should be based solely on beneficence, the obligation to do good, or nonmaleficence, the obligation not to harm. It is assumed that appropriate use of restraint therapy is consistent with the desires of patients to receive safe and quality medical care. Restraints should not be used for clinician convenience, as a solution for insufficient staffing, or as a substitute for adequate medical care.
Common physical restraints include wrist, chest and waist restraints. Wrapping the hands in bandages is used to prevent patients from using fingers. Chemical restraint is the use of drugs to control behavior and limit movement. Medication is not considered a restraint when used to treat a clinical condition such as pain.
Principles
Restraint therapy should maintain the patient’s dignity and comfort by using the least restrictive restraint possible (Table 10.1). Determining the least restrictive restraint involves determining both the extent of restraint needed to accomplish the goals and the specific benefits ostensibly obtained by restraint therapy.
To decrease the need for restraint therapy to treat agitation, clinicians should sooth patients through
Table 10.1. Principles of restraint use
diversion, music, reorientation, enhanced comfort, and reduction of light and noise stimulation. At the same time, clinicians should treat potential medical sources of agitation such as hypoxemia, hypercarbia, electrolyte disorders, drug withdrawal and pain. Ventilation settings, endotracheal tube position and the fit of masks used for noninvasive ventilation should be optimized. Better methods of securing the endotracheal tube may also reduce the need to use restraint therapy.
Physicians should consider whether the benefits of restraint therapy are worth the harms. In certain situations, clinicians may consider removal of certain therapies, such as endotracheal tubes and extracorporeal membrane oxygenation lines in the very ill, to have potentially devastating consequences. Other times, however, maintenance of the therapy may be easily reinstituted, or the loss of the therapy may not be considered harmful. Between 63% and 89% of self-extubated patients do not require reintubation, suggesting that, for these patients, unplanned extubation was not harmful.1
Potential risks of restraint therapy include regurgitation and aspiration in the supine patient, skin breakdown, dehydration and accidental death. Straining against restraints may cause muscle injury and may increase agitation. It is unclear if restraints affect the extent of posttraumatic stress disorder that occurs in ICU patients.
Chemical restraints may be seen as kinder and less invasive than physical restraints and frequently are used without the requisite oversight and continual reassessment of physical restraints. However, use of chemical restraints in lieu of using other measures has individual and societal costs. Deep sedation used for restraint may increase intensive care unit stay, perhaps decreasing access to the limited resource of intensive care unit beds. Longer intensive care unit stays expose patients to more bacterial infection, muscle wasting, and critical illness polyneuropathy, among other problems.2
Lengthy withdrawal of sedation can be minimized by either conversion to physical restraints or use of multimodal therapy at the appropriate time. A 2004 editorial stated that in the UK, while “physical restraint of patients is considered unacceptable in the [UK] … the importance of the timely withdrawal of sedation cannot be overemphasized, and the judicious use of physical restraints may legitimately be built into an overall treatment plan …”2
Case discussion
We can apply these principles to both of the example cases. In the muscular 25-year-old man with negative pressure pulmonary edema, the desire for the restraints may be misguided. The nurse may worry that he will miss the onset of agitation because other nursing responsibilities keep him from the bedside, or that inadequate in-house coverage may mean that an unplanned extubation would have a devastating effect (note that unplanned extubation might well not be harmful). Unquestioned acceptance of the nurse’s request for restraint therapy may lead to inappropriate therapy as well as a missed opportunity to highlight an institutional system-level problem. On the other hand, avoidance of restraint therapy may lead to the use of chemical restraints, which may increase the duration of mechanical ventilation and intensive care unit time. This complexity is best addressed by adopting well-considered protocols to help ensure appropriate use of restraint therapy in order to best achieve the desired goals.
The second case exhibits the effects of restraint therapy on the family. While restraints minimize the likelihood of catheter dislodgement (possibly necessitating replacement), they occasionally appear to agitate the patient. Wrapping the arterial line such that it could not be removed may be inconvenient for the nurses, who have to document the appearance of the arterial line site at specific intervals. The family’s reaction to the restraints was perhaps indicative of the public’s perception. The nonmedical adult daughter was horrified and campaigned daily for removal of the restraints. The physician-son recognized the benefits of the restraints, and was capable of assessing the appropriateness and possible consequences of restraint therapy. He may also have been inured to the use of restraints after years of working in intensive care units. Despite the son’s explanation to his sister that there was no treatable cause of their father’s agitation, that he appears to tolerate the restraints well, and that the loss of the arterial line would require painful reinsertion, the daughter continued to focus on the restrains. Following additional strokes, the patient had fluid and nutrition therapy withdrawn. Yet, several years after her father’s death, the daughter’s narrative of her father’s death focused on the restraint therapy.
Key points
• Used appropriately, restraint therapy reduces patient risk and improves outcome.
• The general impression by oversight bodies is that physical restraint therapy is overused in the US, but may be underused in the UK and elsewhere.
• By considering the use of restraints as a therapy, clinicians will go through the natural process of seeking a thorough understanding of indications, risks, and benefits, and will likely use restraint therapy appropriately.
• The ethical principles of respect for patient self-determination (including informed consent obtained from surrogate decision-makers), beneficence and nonmaleficence should weigh heavily in the decision to employ restraint as a mode of treatment.
References
1* Maccioli, G.A., Dorman, T., Brown, B.R., et al. (2003). Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies – American College of Critical Care Medicine Task Force 2001–2002. Crit Care Med, 31, 2665–76.
2* Nirmalan, M., Dark, P.M., Nightingale, P., and Harris, J. (2004). Editorial IV: physical and pharmacological restraint of critically ill patients: clinical facts and ethical considerations. Br J Anaesth, 9,789–92.
Further reading
Council on Ethical and Judicial Affairs, American Medical Association. Opinion 8.17 Use of Restraints. Code of Medical Ethics.
http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion817.shtml.
Hine K. (2007). The use of physical restraint in critical care. Nurs Crit Care, 12, 6–11.
The Joint Commission. (2010). Hospital Standards Manual: PC.03.02, 03.02,03.05. 3.
http://www.jointcommission.org/.
Kunken, F.R., McGee, E.M., and Stell, L.K. (2001). Strap him down. Hastings Cent Rep, 31, 24; discussion -6.
Ofoegbu, B.N. and Playfor, S.D. (2005). The use of physical restraints on paediatric intensive care units. Paediatr Anaesth, 15, 407–11.
Van Norman, G. and Palmer, S. (2001). The ethical boundaries of coercion and restraint of patients in clinical anesthesia practice. Int Anesth Clin, 39(3), 131–43.
Zun, L.S. (2003). A prospective study of the complication rate of use of patient restraint in the emergency department. J Emerg Med, 24, 119–24.