Restraints: a current perspective.

If there continues to be doubt about their removal, perhaps these guidelines will help

The use of physical restraints for elderly patients exemplifies a major ethical dilemma. That is, how do we balance the patient's right of autonomy or self-determination with our concern for the patient's safety? Unfortunately, no simple solution exists. Often, one is forced to choose between equally undesirable alternatives.

Autonomy vs. Beneficence. Our society places high value on personal autonomy, which is considered the dominant ethical principle in Western cultures.(1) In fact, the ability to live life as we choose according to our belief systems is regarded as a right in our society?(2) The recent passage of the federal Patient Self-Determination Act signifies the government's recognition of the individual's right to accept or refuse medical treatment.

Restriction of autonomy can have adverse consequences for individuals of any age, but the elderly are especially sensitive to limits on personal freedom. Lack of personal autonomy has been demonstrated to be detrimental to the elderly person's psychologic, physiologic, and physical health?(3)

Beneficence, on the other hand, is a value that is greatly regarded by nurses. One of the main aims of nursing, since the time of Nightingale, is to do good for the patient, or to look after the patient's best interest. Beneficence is also the basic ethical principle within the American Nurses Association's Code of Ethics.(1)

Actions done in the patient's own best interest but that override the patient's autonomous choice can be defined as paternalism. Neither beneficence nor paternalism is all good or all bad. What the health care provider needs to realize is that, even with the best of intentions, they may find no satisfactory solution to a problem they face. Moreover, risks are inherent in any choice or approach taken. No matter how beneficent are one's motives, the outcomes may still be poor.

Beneficence is certainly not limited to the nursing profession. Concern for the patient's best interest motivates all of medical care. In the medical model, action is usually taken quickly to minimize the possibility of any further harm. We, as health professionals, chafe at any long delays in action.

Civil Liberty

The civil liberty model is another model that is used to weigh the rights of the individual against the need to provide protective services when the individual is unable to care for himself or herself. Unlike the medical model, however, there are a variety of procedural safeguards built into the civil liberty model to protect the person's freedom. The proof rests upon those who would restrict that freedom.(4)

Let's go back to the major dilemma. How do we balance our value system of beneficence with the patient's value system of independence and his or her right to choose a course of action?

Six Guidelines

There are no easy answers. There are guidelines, however, from the civil liberty model to evaluate the patient's right for autonomy in the light of our concerns for patient safety. Schafer(4) proposed six questions to answer whenever one is faced with this difficulty:

1) How likely is it that the patient will come to harm? Is this a person at high risk of coming to harm if not restrained -- say, an 80% chance? Or, is there a low possibility of this? The lower the likelihood of harm, the less reason to apply restraint.

2) What probability of harm would justify one's decision to restrict a person's freedom? This really varies among individual nurses, i.e., some nurses are willing to take more risks than others. The main point is that, to justify choosing beneficence over personal autonomy, that decision must be viewed as a universal one -- i.e., one that the decision maker would have arrived at any time under similar circumstances.

3) Just how must harm will the patient incur? Is the potential harm life-threatening to the patient, such as displacement of a ventilator's endotracheal tube? Or is the harm minor to the patient but inconvenient for the staff, such as disruption of a "keep-open" intravenous line?

4) How dose the individual react to the restriction? Some patients may not object to the presence of a physical restraint. Other patients become extremely agitated or demoralized when in physical restraint.(5,6)

5) How long will the restraint or the deprivation of freedom continue? Will this be a short-term or long-term restriction?

6) Is there any alternative by which the therapeutic goal can be achieved without depriving the patient of his or her liberty? Evans and Strumpf(7) found that American nurses typically know fewer alternative strategies to deal with problematic patient behavior than do English and Scottish nurses. As more nursing homes address the practice of physical restraint under the OBRA guidelines, the repertoire of various nursing approaches for the management of patient care problems is likely to grow.

Determining Competency

One of the difficulties in weighing beneficence vs. autonomy is determining the patient's competency to make medical decisions. To be autonomous, one must be capable of rational thought or self-governance. If such is not the case, then someone else must take over the decision-making. Unfortunately, the point at which decision-making should be assumed by another is not clearly defined, either ethically or legally. It's possible for patients to be capable of autonomy or self-governance in some areas of their life or care, but not in others.(1)

When evaluating competency in medical care decisions, several factors should be considered. Is the patient able to make and to express his or her choices? The comatose patient and the severely demented patient are easy examples of patients who are clearly unable to make or to express their choices. Not so easy to judge are the mild to moderate dementia patients' or depressed patients' choices. Are the outcomes of the patient's choice reasonable and are the choices based on rational reasons?

To help focus on this issue, document if the patient is aware of the problem and understands the risks it may have to his or her health. Next, document if the patient is aware of the risks and benefits of the alternative choice(s) of action. Make sure the patient truly understands the implications and consequences of the alternative choices. If the patient demonstrates an understanding or insight into the problem and accepts the risks of his or her preferred choice, then the patient's autonomy outweighs the professional's concern for safety.

If the patient is paranoid or confabulatory, then question the rationality of his or her reasons. Do the patient's choices affect others negatively? Autonomy is only the higher principle as long as one's choices don't infringe on others.

Lastly, information must be complete and provided without the interference of the nurses' values. One cannot and should not base judgment of competency on whether or not the patient happens to agree with the health professional's preferred choice.

The Spectre of Malpractice

The use of physical restraint in the care of elderly patients is a practice primarily limited to the United States. The fear of litigation has been cited as a major influence in the American medical professional's concern for patient safety and, hence, the greater prevalence of physical restraint use.(8-10)

The fear of malpractice or litigation can have very real detrimental effects on the quality of care provided to patients.(11,12) For example, a health professional who restrains an elderly patient at risk of failing, primarily because of fear of litigation due to the chance event of a harmful fall, practices in a way counter to the basic tenets of geriatric standards of care.(2,12) Kapp(12) stated succinctly that not only does practice based on fear of malpractice suffer in quality, but such practice wastes valuable resources.

Ironically, while fear of malpractice may strongly influence individual clinicians, the elderly for their part don't often use the legal system. Moreover, there have been no successful claims due to the absence of physical restraint in the long term care setting. Where a claim has been successful, it has been for overall negligence of care. On the other hand, there have increasingly been successful claims due to the misuse or inappropriate use of physical restraints.(13-15)

Health care professionals who base their care on fear of malpractice may well wish to consider which is the greater risk -- being sued for not using a physical restraint or being sued for using it!

Conclusion

With every decision made, there is the realization that while something is gained, something also is lost. Sometimes applying or providing a treatment that is readily available and accessible, such as physical restraints, may seem the easy solution. Examining the moral issues involved can certainly be more difficult. Dealing explicitly with the moral issues, though, as well as attempting to carefully analyze the comparative benefits and risks of various treatment approaches, will only enhance the quality of care provided to elderly patients.

Lorraine C. Mion, RN, MSN, is Research Associate, Division of Restorative and Geriatric Medicine, MetroHealth Medical Center, Cleveland, Ohio 44109.

References

1. Hogstel MO, Gaul AL. Safety or autonomy. Journal of Gerontological Nursing 1991; 17:6-11.

2. Evans JG. Prevention of age-associated loss of autonomy: Epidemiological approaches. Journal of Chronic Diseases 1984; 37:353-363.

3. Rodin J. Aging and health: Effects of the sense of control. Science 1986; 233:1271-1276.

4. Schafer A. Restraints and the elderly: When safety and autonomy conflict. Canadian Medical Association Journal 1985; 132:1257-1260.

5. Strumpf NE, Evans LK. Physical restraint of the hospitalized elderly: Perceptions of patients and nurses. Nursing Research 1988; 37:132-137.

6. Werner P, Cohen-Mansfield J, Braun J, et al. Physical restraints and agitation in nursing home residents. Journal of the American Geriatrics Society 1989; 37:1122-1126.

7. Evans LK, Strumpf NE. Patterns of restraint: A cross-cultural view. Gerontologist 1987; 27:272A-273A.

8. Evans LK, Strumpf NE. Tying down the elderly: A review of the literature on physical restraint. Journal of the American Geriatrics Society 1989;37:65-74.

9. Francis J. Using restraints in the elderly because of fear of litigation. New England Journal of Medicine 1989; 320:870-871.

10. Cotsides: Protecting whom from what? |Editorial~. Lancet 1984; 35:383-384.

11. Strumpf NE, Evans LK. The ethical problems of prolonged physical restraint. Journal of Gerontological Nursing 1991; 17:27-30.

12. Kapp MB. Liability issues and assessment of decision-making capability in nursing home patients. American Journal of Medicine 1990; 89:639-642.

13. Hunt AR. Legal issues involved in the use of restraints: Analyzing the risks. In: Untie the elderly: Quality care without restraints. 1990; Washington, D.C.: U.S. Government Printing Office, Serial No. 101-H. (pp. 197-202).

14. Kapp MB. Ethics vs. fear of malpractice. Generations 1985; Winter, 18-20.

15. Evans LK, Strumpf NE. Myths about elder restraint. Image 1990; 22:124-128.