1. 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

2. 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

3. Not a new topic 1980 “Restrained in Canada- Free in Britain” Editorial in Health Care 1980, 22, 22

4. What are restraints? Any device attached or adjacent to the person preventing free bodily movement Common devices Vests Waist belts Wrist and ankle ties Tip back chairs Fixed chair trays Bedrails

5. 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??

6. 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” Belief that it is safe and provides benefits

7. 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.

8. Principles of Biomedical Ethics Autonomy Beneficence Non-maleficence Justice (equity) The use of restraints violates the first 3 of these principles

9. 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??)

10. Beneficence and Non- maleficence 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

11. 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

12. What are the harms from restraints? Psychological Humiliation anger depression demoralisation

13. What are the benefits of restraints?

14. 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”

15. 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

16. 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

17. 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

18. Conclusion Restraints have no place in modern internal medicine

19. 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