The use of restraint, whether physical or chemical, has always been a normal practice in the medical field when dealing with critical-ill patients and the elderly. Many would justify this act as a form of protection, in order to decrease the number and chances of self-inflicted harm. However, sometimes, it strips the patient’s autonomy in decision-making, resulting in a discussion on how exactly should restraint be approached.
The number of elderly people in developed countries has gradually increased over the years. In Australia in the year 1991, 11% of the total population comprised of the elderly (65 years old and above). It has been projected that the 11% will increase to 18% in the next ten years. For people who are 85 years old and above, they comprised about 8% of the total population in 1991. It increased in 2001 to 11% (Australian Institute of Health and Welfare 2002). With this fact, nursing homes are needed to cater to older people.
There are many reasons why the elderly would enter into a nursing home. It is unlikely that they are entering it because they like it (Harker 1997). Entering a nursing home would mean that the person has to give up his possessions and some of his freedom would be stripped away from him, like being able to go anywhere he wants. He would not be able to eat wherever he wants or walk in the park whenever he wants. A nursing home, for some, is like a waiting area for death. It is very rare for those who are admitted to the nursing home to go back to their homes after entering a nursing home.
A person’s poor health is one of the major reasons for entering a nursing home. They would need access to nursing care that is not available in their own homes. There are home-based nursing cares available but these are very expensive and they cost a lot to maintain. Long ago, when the elderly would need care or assistance, family members are usually available to assist with their needs. Their children would take care of them in their own homes, or some of them would move into their parents’ homes to take care of them. In present times, this situation is close to impossible because both husband and wife have to work, or a single child has to work in order to support himself. Because the immediate family could not offer any help to them, they have no choice but to go into a nursing home (Harker 1997).
For some people, the decision to go into a nursing home lies in the hand of their children or other immediate family members because he or she might not be able to make a sound decision for himself or herself because of her sickness or disease (i.e. Alzheimer’s disease) or various handicaps.
I chose this topic because I know that one day I will have to consider staying in a nursing home because I could not live on my own when I am old. There will be a possibility that my children could not take care of me because they will have their own families to support. This would help me prepare to be competent enough to decide for myself despite of old age or any unforeseeable sickness.
Another reason why I chose this topic is because of my father. My father is currently in the hospital because he has cancer, in its last stage already. I could not be beside my father all the time to take care of him because I still have to work and go to school at the same time. Although I know that my father is in good hands with the hospital staff, I could not help but worry about him. With this paper, I hope to gain better understanding on restraint on the elderly.
Restraint in Nursing Homes: Barriers in the Health Care System
The elderly has mixed feelings regarding their experience with restraint (Gallinagh et al. 2001). For some patients, the practice of using restraints, like bedside rails or wheelchair bars, are sometimes positive. They tend to give them a feeling of safety and stability. Others do not always think of dependence as something negative. In fact, most elderly patients greatly appreciate the assistance that nursing home staff would offer. Unfortunately, a lot more elderly has negative feelings when it comes to restraint. The use of the methods for restraints has traumatic than therapeutic effects for many older people. Most of them lose their dignity, self-respect, and identity. They become embarrassed, anxious, and disillusioned (Gastmans & Milisen 2005).
Physical restraint is defined as the use of any object or piece of equipment that is attached to or near the body of a person and which that could not be controlled or simply removed by the person. It stops or intentionally prevents a person from moving on his own will. (Gastmans & Milisen 2005) Examples of physical restraints are the following: vests, straps/belts, bedside rails, wheelchair bars, bed sheets that are tucked too tightly, etc.
Another type of restraint is the chemical (or pharmacological) restraint. This involves the use of drugs to hold back a certain behavior or movement. Other than hypnotic or antidepressant drugs, institutions also use psychotropic drugs like chlorpromazine, diazepam, haloperidol and thioridazine. (Powell et al. 1989) Other methods like being locked in a room, electronic surveillance, and being forced or pressured to do medical examinations and treatments (Gastmans & Milisen 2005).
In taking care of older people in nursing homes, it is sometimes unavoidable to use restraint. This is usually done to keep them away from any accidents or harm they would inflict on themselves. But lately, because of the growing concern among relatives of elderly patients, long-term care services providers for old people are now required by licensure and accreditation agencies to have a restraint-free culture as a standard practice. However, many fail to achieve the intended result because of so many barriers. These different unavoidable barriers, which are also reasons for restraint on the elderly, are to be discussed in the following paragraphs.
The main concern in using restraint on elderly patients is to make sure that they would be safe from any accident that would result to injury. Nurses, caregivers, and other institutional staff fear that the elderly patients might fall anytime. However, there had been a study that 67% of the patient falls from the bed were from those who are physically restraint. (Lee et al. 1999) In the same study, it was also mentioned that inadequate staffing was also another reason for physical restraint since the staff could not keep an eye on all the patients all the time. It was revealed that 36% of nurses confirmed that physical restraint was used when they could not closely monitor the patients. Ironically, when the elderly patients tried to resist the physical restraint imposed on them, it results to undesirable consequences, therefore, they will be needing more nursing care-the opposite result of what the nurses, who preferred physical restraints when understaffed, were hoping to achieve (Varone et al. 1992).
There is no clear confirmation that restraints prevent injury in clinical settings. To continue such ways without thorough assessment of the situation is an outcome of not sticking to evidence-based practice. Staff could be charged with allegations of professional misconduct and legal actions from patients and their families (Cheung & Yam 2005).
Physical injury comes in two categories. First, it is related with the direct impact of the device used for restraint on the patient. Examples of these injuries are bruises, nerve damage, asphyxiation, and even sudden death. Second, it is associated to the injuries attained because of enforced immobilization. This includes loss of muscle tone, contracture, or reduced functional ability. The injuries in the second category are more intense for the elderly patients because this might extend their stay in the hospital, cause them to fall, and triggers pressure ulcers (Cheung & Yam 2005). Robbins et al. (1987) reported that morbidity and mortality rates are eight times higher among restrained patients compared to those who are unrestrained.
Restrained patients could also suffer from psychological harms aside from physical injuries. They often have negative responses like “anger, fear, denial, demoralization, humiliation, depression, agitation and regressive behaviors (Gorski 1995). Other patients have complained about the loss of dignity. They have considered those kinds of experiences to be humiliatingly against their human rights. Apathy and depression become worse for many older, restrained people that they feel a sense of abandonment. Studies on social behaviors in different nursing homes showed that there is a big difference with restrained and unrestrained elderly patients. The former usually stops any form of social interaction (Folmar & Wilson 1989).
Other studies showed that nurses sometimes have a difficult time in facilitating treatment regimens that they resort to physical restraint. For example, a patient is confused and is having an intravenous infusion drip. He tries to pull out the drip, which may cause him to bleed. A nurse will have to strap his hands so that he would not be able to pull the drip out, and injuring themselves. (Lee et al. 1999) However, according to studies, the use of restraint in these kinds of situation increases the agitation of patients, which ironically again, makes them more susceptible to injury (Thomas et al., 1995).
Incompetence, due to psychiatric diagnosis or cognitive impairment, is usually another reason for restraint among elderly patients. Staff could easily argue that the patient is too confused or demented to make a reasonable decision for his own welfare. They believe that competence is a medical issue and could be resolved only through scientific evidence. However, Leifer (1963) cited facts that showed inconsistencies between pathological and clinical findings for mental incapacity. In short, he tried to explain that there is no reliable connection between “the state of the brain and the legal criterion for competency” (Schafer 1985).
A certain judge in the United States District Court of New Jersey emphasized that one must not automatically assume that insane patients are not competent to give or hold back consent for treatment or medication (Schafer 1985). A patient has every right to refuse any treatment and the people around him should always respect that. There are three ways in determining the validity of a patient’s consent. First, the patient must have the capacity or competence to make a decision. Second, the patient must be thoroughly explained of all the pros and cons and other information that would help him reach a decision. Lastly, the patient must never be forced to make a decision. (Gert et. al. 1997)
Until a court finds the patient incompetent, the patient must always be assumed to be competent. In some cases, psychiatrists often define this as a medical emergency, which would require compulsory treatment and intervention on the patient’s autonomy. There are times when the staff is really qualified to provide effective care but the patient is just too difficult to handle. (Schafer 1985)
Issues with Restraints
There was a study that pointed out that with physical and chemical restraint, nurses feel safer and they are more psychologically comfortable. It showed that the nurses were more concern of their own comfort than the welfare of the elderly. They were thinking that when they fail to restrain patients, they would become legally liable for any accident that might happen. This places the elderly patients at a higher risk of injury because of confusion, agitation, and pressures. It only gave the nurses a false sense of safety (Thomas et al., 1995).
The attitude of the staff has a great effect on both the quality of treatment of older people and the consideration given to preserving their dignity and autonomy. By maintaining their dignity and autonomy, it minimizes the distress felt by the patients. Dignity refers to the self-respect maintained by an individual and valued by others. Autonomy refers to the control of making decisions, in any aspect of life, for oneself (Lothian 2001).
In a research by Bernard in 1998, he found evidences that implied that a significant number of people working in the medical field hold pessimistic views on older people. An important way of tackling poor attitudes by staff towards the elderly patients is though extensive and continued training. Evidence showed that exposure to a more specialized training in geriatric care is beneficial. People, who still have grandparents as role models, have also been found to treat older people with better attitudes. (Haight et al. 1994) Staff, who are trained, becomes sensitive to the different issues around an older person’s dignity and autonomy, are better equipped to treat older patients (Lothian 2001).
In the UK, there are two major legal issues regarding both physical and chemical restraint. The first issue concerns about the “law of assault, the threat of violence, and the actual and direct use of unlawful physical force on another person (also known as battery) even though they are not really harmed. The second one involves the risk of negligence (Trivedi et al. 2009).
An example could better describe this. A court in Germany held a nursing home responsible for violations of obligations when an elderly female resident had a fracture. The patient fell off he toilet inside her room while the nurse went to the bathroom sink to wash the patient’s dentures. The nurse was not able to prevent or stop the fall because she could not see the patient from where she was. The patient was still mobile and could still walk with help days before the accident. In spite of this, she was already in her last stages of Alzheimer’s disease so her actions were more of a series of events rather than premeditated actions. The nurse should have anticipated any abrupt changes since she knew about the disease already. The court placed this error on the nursing home as negligence (Sammet 2006).
Some other judgments have been made that are similar to the situation above. According to Sammet (2006), possible movements should have been anticipated and predicted. The nurse’s control should substitute the patients incapacitated will as a way of protection. In cases of serious dementia, the patient’s personal wish should not be taken into account. Since he or she could not make a reasonable wish at all. Sammet (2006) described this kind of care and protection as disease-centered. In this case, the medical data matters and not what the confused patient’s wants. Therefore, there should be a balancing of values. The nursing home staff should be in a position to restrain patients to safeguard them from harm and injury. Intervention is necessary and the elderly are often not given the privilege to refuse because they are usually not capable anymore of doing so (Sammet 2006).
Strategies in Overcoming Restraint
More focus should be placed on educating nurses to reduce the unfitting use of restraints on elderly patients. Thorough nursing assessment is especially needed before using any restraints (Lee et al. 1999). The use of restraints should always be the last resort, not the first option. When healthcare providers do not have any other choice but to restrain the elderly patients, utmost care and attention should be provided.
Nurses and caregivers should also acknowledge that they have an ethical duty to clarify and give details to elderly patients and their families the purpose for making use of restraints and should always get an informed consent as much as possible. Coordinating with other healthcare professionals should be promoted since combined efforts will allow them to identify other means or approaches to care apart from using restraints (Lee et al. 1999).
Ethicists have created a list of principles for the right way of using restraints on demented patients. This list is usually used by government agencies. Moss and La Puma (1991) suggested the following guidelines: (1) mechanical restraints should never be ordered in a regular manner and should not be used as a replacement for careful patient surveillance; (2) arrangements for restraints should start a medical investigation for the purpose of pointing out and correcting the medical or psychological complication that triggered the order of the restraint; (3) the patient’s representative who is involve in decision-making should agree to the restraints and be fully informed of the different risks and benefits; (4) mechanical restraints should be used carefully (and only for a temporary time), making use of the least-restrictive device as much as possible; and lastly, (5) chemical or pharmacological restraints should only be prescribed by the proper professional, should be in the lowest effective dose, and the patient’s status must be frequently reassessed.
Clinical ethics is about considering the ethical values and standards that acts as guidelines for clinical actions. Every elderly should be treated as a person (Janssens 1980-1981). This serves as the first value. Human dignity could not be given up, not even through disease, disability or approaching death. Caregivers and nurses should always respect the dignity of patients (Gastmans & Milisen 2005). As a second value, one should always take into consideration that each human being is a responsible individual. Humans act base on their conscience, in a free but responsible means (Janssens 1980-1981). The elderly, as human beings, should be allowed to make choices and should be respected.
A high regard for the overall welfare is the third value that should be secured. When it comes to a time when decisions for physical restraint have to be made, social, psychological, and moral aspects of a person’s wellbeing are all considered. (Gastmans & Milisen 2005). The fourth ethical value is about promoting self-reliance among the elderly. This could, in many cases, postpone or prevent the use of any restraint on the elderly. Nursing homes could help by specific measures (lowering the bed to avoid or prevent painful falls, using shock-absorbing and non-slip floor covering, walking aids, hip protectors), by measures to optimize the environment (using ample lighting without glare, familiar surroundings orientation, prevent or minimize sensory overload), by individualized care (by encouraging social interactions by talking and listening to them and motivate them to participate in activities), and by preventing or decreasing factors for fall like nutrition management, routine toileting, stimulating mental processes, balance training and exercises (Gastmans & Milisen 2005).
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