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Ethical Issues in Patient Restraint

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Ethical Issues in Patient Restraint Keywords: Restraint/Ethics/Mental Nursing Practice health/Dementia/Stroke care Discussion ●This article has been double-blind Restraint peer reviewed How to use the “four-quadrant” approach to analyse different restraint situations Ethical issues in patient restraint These comments suggest how chal- In this article... lenging the issues are; the head of patient The use of restraint in nursing practice safety at the National Patient Safety The four-quadrant approach to analysing ethical dilemmas Agency acknowledges that there are situa- tions when nurses have to intervene to Using this model to analyse different restraint situations prevent harm to a patient (Healey, 2010). However, according to Healey, vests, as well as belt and cuff devices are unaccept- Author Ann Gallagher is a reader in nursing by restraint by describing a “posey vest”. able and have resulted in deaths and ethics, director of the International Centre This fits over a patient’s clothing and has a serious harm. for Nursing Ethics, University of Surrey, and zip at the back and cloth ties at either side. As well as an ethical imperative to pre- editor of Nursing Ethics. Arms and legs can move freely, and the vent unjustifiable restraint, there is also a Abstract Gallagher A (2011) Ethical issues waist ties are attached to a bed or chair to legal framework that includes: Offences in patient restraint. Nursing Times; 107: prevent the patient from getting up. Against the Person Act 1961; the Mental 9, 18-20. Ms Morgan concluded: “I would rather Capacity Act 2005; Adults with Incapacity This article examines the ethical issues that have a conversation with a patient or their (Scotland) Act 2000; Human Rights Act arise in relation to restraint in mental health, family about why a posey vest is a good 1998; and the Mental Health Act 1983 (see dementia care and stroke care. The themes idea, than have to explain afterwards why a Royal College of Nursing, 2008). can, however, be applied to all areas of hip fracture occurred in the middle of the healthcare. The article also discusses how night.” She expressed surprise at UK Types of restraint “four quadrants” of practice situations – nurses’ reticence to use restraint when Let’s Talk about Restraint: Rights, Risks and medical indications, patient preferences, they are so concerned about patient safety. Responsibility (RCN, 2008) identified five quality of life and contextual features – can Responses from UK nurses revealed types of restraint: physical, chemical, be used to analyse three different restraint diverse views about the role and ethics of mechanical, technological and psycholog- situations. restraint: ical. Physical restraint involves holding patients down or physically intervening to recent opinion piece about the “A blanket system (either yes or no to stop them from leaving an area. Chemical role of restraint in UK nursing restraint) is not the best way.” restraint is when a restless patient is practice (Morgan, 2010), pub- sedated as a form of restraint. Alished on the Nursing Times “Dignity has to be our guiding principle. The posey vest described earlier is a website, generated a great deal of discus- Please explain to me what is dignified form of mechanical restraint. Other exam- sion and dissent among readers, particu- about confused or aggressive patients ples include bedrails and baffle locks, but larly in relation to patient safety. These creating mayhem on a ward or in a furniture, such as tables and chairs, posi- comments prompted the question: “In nursing home, upsetting all the other tioned in such a way as to restrict freedom what circumstances, if any, might restraint confused patients and putting staff on edge of movement are also forms of mechanical in care be justified?” as they try to ‘think around the problem’.” restraint. The author, American nurse Sara Technological developments have Morgan, expressed surprise that UK nurses “To see your mother bruised and bloodied resulted in more sophisticated forms of concerned with patient safety should be because she has lost her faculties and restraint such as tagging, door alarms and against restraint. She stated: “In the US, become a danger to herself is awful. I’ll be closed-circuit television. What is called nurses and doctors were pragmatic about honest, if someone had talked to me about technological surveillance amounts to this and we happily used whatever tools we restraint I would have agreed.” restraint when the technology results in could get our hands on to stop confused people being prevented from leaving an patients from getting out of bed without “I work with [older people] and area or having their movement controlled. help. Yes, this included restraints.” dementia patients. The idea of physical or Psychological restraint deprives She went on to qualify what she meant chemical restraint is abhorrent to me.” patients of choices and involves them 18 Nursing Times 08.03.11 / Vol 107 No 9 / www.nursingtimes.net For more articles on the Nursing ethics of restraint go to Times.net nursingtimes.net/restraint diagnosis of dementia and is becoming 5 key fig 1. analysiNg ms morgan’s increasingly frail. She wanders continu- points situatioN ously around the home and repeatedly goes There are five to the front door and says she wants to go 1types of Medical indications Patient preferences home. One of the staff tells her: “You cannot restraint: physical, What are the goals of Does Ms Morgan have go home today. It’s Sunday and there is no chemical, care and treatment for Ms capacity? If so, what does she transport.” Mrs Jamison accepts this and mechanical, Morgan? Is her diagnosis of want? If not, has she continues to wander from room to room. technological and bipolar disorder correct? expressed preferences in an Staff discuss how to manage Mrs Jam- psychological What are the probabilities of advance directive (Atkinson, ison. Her husband is particularly anxious restraint is different interventions (least 2011). Is she willing or that she remains safe; he tells staff when 2not a panacea coercive first) achieving the unwilling to cooperate with she was at home he had to ensure doors and can present goals of treatment and care? care and treatment? Why? Is were locked and she had a table fixed on significant risks her autonomy respected? her chair to prevent her from getting up so to patients she could rest. He suggests staff might use The four- Quality of life Contextual features a tracking device that will sound an alarm 3quadrant What distress is Ms Morgan What family issues might if she attempts to leave the home. approach is a experiencing? Will her quality influence decision-making? Is helpful framework of life after intervention be there a staff member, family scenario analysis for ethical analysis acceptable to her? Or might member or friend Ms Morgan Each of the scenarios is analysed using the of situations intervention compromise the trusts who could help to gain four-quadrant approach in Figs 1-3 (Jonsen involving restraint success of future care? What her cooperation? What et al, 1992). This is used in clinical ethics Understanding interventions will enhance her religious, cultural or legal and is outlined by the UK Clinical Ethics 4the legal quality of life? How can issues need to be taken into Network (2011) as a “series of questions requirements of intervention benefits be account? Are there conflicts that should be worked through in order”: healthcare practice maximised and harms of interest? What 1. Indications for medical intervention is necessary to minimised? After the acute interventions, for example, are – what is the diagnosis? What are the protect patients episode, how can nurses in her best interests if she treatment or intervention options? What from unjustifiable collaborate with her to lacks capacity? Are staff is the prognosis for each of the options? restraint minimise the chances of such working within the law? 2. Preferences of the patient – is the patient restraint situations happening again? competent? Does he/she have capacity 5should be to make a decision about treatment and considered as a care? If so, what does he/she want? If last resort and scenario 1 not, what is in his/her best interests? practitioners Charlotte Morgan is an inpatient on an 3. Quality of life – will the proposed should consider acute mental health unit and has a diag- treatment or intervention improve the alternative nosis of bipolar disorder. She is experi- patient’s quality of life? Or will the interventions to encing psychotic symptoms and is burdens or risks of the intervention promote safety refusing oral medication, fluids and nutri- outweigh the benefits? and respect the tion. Ms Morgan is overactive, appears 4. Contextual features – what cultural, dignity of the dehydrated and has not slept for at least religious, contextual or legal factors person three days. Nurses are concerned her affect decision-making? physical health will deteriorate further being told they are not permitted to do and are considering whether they should Chemical and physical restraint in something; setting limits on what they can restrain her and give her medication mental health do, such as times to go to bed; and without her consent. The four-quadrant approach can help with depriving them of the means to be inde- analysing the ethical issues and decision- pendent. This can include keeping them in scenario 2 making processes involved in Ms Morgan’s nightwear and not letting them have out- Ronald Freeman has been admitted to hos- case. Patterson (2011) describes such a case door clothing, walking or visual aids. pital after a stroke. He has been assessed as one where “restraint, seclusion or rapid and it is agreed that his swallowing is tranquilisation may be warranted in restraint in nursing practice impaired.
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