Marianne, 82, has dementia. She doesn't understand why two young men in hospital uniforms are trying to lay hands on her. She is frightened and tries to get away. Although she can no longer put such things into words, she feels terribly vulnerable in her nightgown. In addition, her coffee was cold when the breakfast tray arrived, but she drank it and now needs to urinate. The two young men seem to want to take her somewhere she doesn't want to go. At last, they make her lie down on a gurney and, to her horror, strap down her hands and feet. She fears they are taking her to unwanted surgery. She pulls against her restraints, screaming at the glaring overhead fluorescent lights, feeling she is in a waking nightmare. She wets her nightgown. People in the corridor are staring. Her mortification and terror are complete.
Is the use of physical restraints on persons like Marianne justified?
Medicare has strict regulations on the use of physical or chemical restraints, as does the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). States also have additional laws and regulations. Findlaw summarizes state and federal statutes applying to the use of restraint as almost always: 1.) including the necessity to have written authorization from a physician, 2.) a limited time of use, and 3.) application by a qualified person. Beyond that, it is usually required that less restrictive methods of keeping the patient safe or medically treated must first be exhausted and the use of the restraints reviewed by a physician at least every 24 hours.
The Food and Drug Administration (FDA) and the Health Care Financing Administration (HCFA) say the use of restraint must be limited and used only "to the extent necessary for treatment, examination, or protection of the patient or others." The FDA defines a restraint as a device used on the person. The HCFA's definition includes devices used adjacent to the person, which would include chairs that restrict movement ("geri-chairs"), trays designed to keep a patient in place, and bedside rails. Both organizations note that restraints should never be used for staff convenience or as punishment.
An Act with Inherent Ethical Implications
Applying restraints to a person is an act that carries inherent moral and ethical implications. Nurses interviewed by Claudia KY Lai for a BMC study said they never apply restraints without some rumblings of conscience, yet they say they must use restraints to keep patients safe.
Except that restraints don't keep patients safe. A 2009 study published in the International Journal of Geriatric Psychiatry showed that, across nations, the use of restraints and antipsychotics (which are known as "medical restraints") are associated with adverse outcomes for patients. The study found that the potential negative outcomes of the use of restraints include more falls, physical degeneration, infections, pressure ulcers, mental health problems, increased aggressive behavior and even death. Researchers Nicolas Castle and John Engberg found that restrained residents of nursing home had poorer health outcomes when it came to behavior, cognitive performance, falls, independence in walking, activities of daily living, and other health factors. Therefore, it seems that arguments that restraints keep patients safe are inaccurate.
"There is substantial evidence that the use of physical restraints on older hospitalized patients exposes the patients to significant risks of physical injury."
Marshall B. Kapp
University of Dayton School of Law
Marquette's Elder Advisor
An Act with Inherent Dangers
In actuality, a strong preponderance of scientific literature shows that restraints often result in increased patient injuries. Law professor Marshall B. Kapp says in an article for Marquette's Elder Advisor, "Evidence that restraints effectively accomplish the objective of preventing serious fall injuries . . . lies somewhere between scant and nonexistent." He adds, "There is substantial evidence that the use of physical restraints on older hospitalized patients exposes patients to significant risks of physical injury."
These injuries occur when patients fight against the restraints, try to overcome them (such as by climbing out of a bed with side rails) or when they contract infections from being immobilized for long periods, or, tragically, suffocate or strangle when restraints are improperly applied or neglected. Kapp says being over 65 is a risk factor in most hospital settings for having physical restraints used. Kapp notes that there are also deleterious mental and emotional effects to being restrained.
Castle and Engberg, who are doctors, wrote in the publication Medical Care that reducing the use of physical restraints in nursing homes would result in substantial benefits. They said the use of physical restraints is a poor clinical practice.
"Physical restraint use represents poor clinical practice, and the benefits to residents of further reducing physical restraint use in nursing homes are substantial."
Drs. Nicholas Castle and John Engberg
Prior to the 1980s, the United States and other countries routinely used physical restraints on the elderly. As noted, merely being over the age of 65 was a risk factor for being put in restraints in a health care setting. Interest in the moral and ethical issues arising from restraints burgeoned in the 1980s after studies showed widespread abuses. The Nursing Home Reform Act of 1987 (NHRA) was part of the Omnibus Budget Reconciliation Act of 1987 (OBRA-87) and strongly recommended reduction in the use of restraints. The law, which was implemented by 1991, also mandated that physical restraints could only be used when required to treat medical symptoms.
Castle's research showed that use of restraints decreased from being applied to 44% percent of nursing home residents in 1989 to 16% by 1997. Castle credited the law for this decrease. Yet individual nursing homes, he asserted, might pose a different story. His research showed that an important factor causing nursing home and hospital personnel to avoid the requirements of the law is under-staffing. A high staff-to-patient ratio was associated with reductions in physical restraint use. Nurses also noted in Lai's interviews that staff shortages led them to increased restraint use.
As shortages of doctors, nurses and other medical personnel grows with an expanding aged population, the use of restraints is an ethical issue that should be revisited often to protect the vulnerable elderly from violations of their civil and human rights - and dignity.
Castle, N. G. & Engberg, J. (2009). The Health Consequences of Using Physical Restraints in Nursing. Abstract. Medical Care 47(11): 1111-1187. Available at http://journals.lww.com/lww-medicalcare/Abstract/2009/11000/The_Health_Consequences_of_Using_Physical.8.aspx. Retrieved 1/8/2016.
Castle, N.G., Fogel, B., & Mor, V. (1997). Risk Factors for Physical Restraint Use in Nursing Homes: Pre- and Post-Implementation of the Nursing Home Reform Act. The Gerontologist, 37(6): 737-747. Available at http://gerontologist.oxfordjournals.org/content/37/6/737.full.pdf.
Feng, Z., Hirdes, J. P. Smith, T. F., Finner-Soveri, H., Chi, I. et al. (2009). Use of physical restraints and antipsychotic medicines in nursing homes: a cross-national study. International Journal of Geriatric Psychiatry, 24(10):1110-1118. Doi: 10.1002/gps.2232.
Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3764453/. Retrieved 1/8/2016.
Findlaw. (n.d.) Understanding patient restraints: A hospital's decision to use restraints.
Food and Drug Administration (FDA). Available at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/HospitalBeds/ucm123678.htm. Retrieved 1/8/2016.
Kapp, M. B. Physical Restraint Use in Acute Care Hospitals: Legal Liability Issues. Marquette's Elder Advisor, 1(1) Summer. Available at http://scholarship.law.marquette.edu/cgi/viewcontent.cgi?article=1276&context=elders&sei-redir=1&referer=http%3A%2F%2Fwww.bing.com%2Fsearch%3Fq%3Dscholarship%252C%2Blaw%252C%2Bmarquette%252C%2Brestraints%252C%2Belderly%26qs%3Dn%26form%3DQBLH%26pq%3Dscholarship%252C%2Blaw%252C%2Bmarquette%252C%2Brestraints%252C%2Belderly%26sc%3D0-22%26sp%3D-1%26sk%3D%26ghc%3D1%26cvid%3D1603FCE4DA174EE1989368D4D6FCB095#search=%22scholarship%2C%20law%2C%20marquette%2C%20restraints%2C%20elderly%22. Retrieved 1/08/2016.
Lai, C. KY. (2007). Nurses using physical restraints: Are the accused also the victims? A study using focus group interviews. BioMed Central. BMC Nursing, (6)5. Doi: 10.1186/1472-6955-6-5. Available at http://bmcnurs.biomedcentral.com/articles/10.1186/1472-6955-6-5.