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The ethics of mechanical restraints.

Robert J. Moss is co-director, Section of Geriatric Medicine, and Clinical Ethics Scholar-in-Residence, Lutheran General Hospital. John La Pluma is director, Center for Clinical Ethics, Lutheran General Hospital, Park Ridge, Ill.

As mechanical restraints have never been proven effective in clinical practice, they should not be used routinely. They should be considered a nonvalidated therapy requiring consent.

Mechanical restraints are leather or cloth devices, bedrails, or geri-chairs, used to modify the behavior of an individual through the limitation of physical movement. They may be applied as many as 500,000 times a day in the United States in acute and long-term care settings, particularly in providing care for persons over the age of sixty.[1] When restraints are used to protect a patient from harm, their use is for therapeutic purposes.

There is considerable uncertainty, however, about whether restraints are safe or effective and whether their benefits outweigh their risks in clinical care. Thus, as Rubenstein and colleagues have noted, the use of mechanical restraints appears to have emerged as a "standard of care by consensus rather than by scientific data."[2] Given that available empirical data suggest that restraints can be inefficacious and dangerous, we contend that mechanical restraints should be considered an investigational or nonvalidated therapy. At the very least, this requires that patients or their reliable proxies give formal informed consent to use of restraints, following full disclosure of their likely risks and benefits. In this context, we Will briefly review current empirical data on restraint utilization and efficacy, and identify the ethical considerations posed for health care professionals when they consider using mechanical restraints in the care of elderly patients.


The incidence of mechanical restraints in the United States varies by setting: 7.4 percent to 22 percent of acute care patients, 3.6 to 5 percent of psychiatric patients, 33 percent of patients in rehabilitation settings, and from 25 percent to 41 percent of patients in long-term care settings may be restrained.[3] In the acute hospital setting, wrist and jacket or chest restraints are most commonly used, particularly on medical and surgical floors. In the hospital, moreover, often more than one restraint is applied simultaneously; up to 20 percent of patients may concurrently be taking major tranquilizers.[4] In extended care settings, lap belts are common, and 40 percent of physically restrained residents also receive psychotropic medications.[5]

Depending on the setting, restraints may be used for different reasons. In the acute setting, the most commonly noted indication is perceived danger to self or others."[6] In one prospective study, nurses restrained patients to allow treatments to be implemented (34%), to prevent patients from wandering (23%), and from falling out of bed (11%), to control violent behavior (11%), to promote sitting balance (11%), and to protect themselves (11%).[7] On the rehabilitation unit, restraints are used to keep the patient in a bed or chair (presumably to prevent them from falling). On the psychiatric ward, the management of violent or "out of control" behavior is the most frequent reason for restraints; it may also be one of the more common reasons for their application in the nursing home. According to the National Nursing Home Survey, restraints are used in managing 33.4 percent of agitated residents, 36 percent of aggressive residents, and 34 percent of residents who wander or pace.[8]

However, the motivation for restraining patients in both the acute and long-term care settings may not always be patient safety. Restraints are frequently applied to protect an institution from liability subsequent to a patient's fall.[9] Such institutions may breach the standard of care if physicians have failed to order restraint use and bedrail elevation, or have allowed a patient to ambulate prematurely. Restraints can sometimes substitute for nursing supervision and care, especially when staffing patterns are inadequate.[10] Nursing staff may also inadvertently use restraints as punishment if they become angered or threatened by a patient. Despite the frequency with which restraints are applied, written documentation of the reasons for their use is absent in over one-third of the medical records examined, and standing "as needed" orders are common.[11]

Risk Factors:

When present upon a patient's admission to an acute care setting, several factors are highly associated with a risk of being restrained. In the hospital, persons over age sixty comprise 50 to 89 percent of those patients restrained;[12] approximately 20 percent of persons over age seventy and 30 percent over age eighty are restrained.[13] Although age may identify a group of individuals at risk for restraints, age alone does not predict who will be restrained. Impaired cognitive functioning, dementia, abnormal mental status examination, postoperative delirium, a psychiatric diagnosis, severity of illness, immobility, and physical dependence have been shown to be significant independent predictors of restraints. Only cognitive impairment and physical impairment have been shown to be risk factors in both the acute care and rehabilitation setting.[14]

Because of their association with severity of illness, restraints may serve to identify patients with underlying conditions that place them at risk for poor outcomes. Restrained patients have twice the length of stay, are more likely to be discharged to a long-term care facility, and are at higher risk for death in the acute care setting than unrestrained patients.[15] In one study, patients who were restrained had an eightfold increased risk of dying in the hospital;[16] as many as 50 percent of patients who die in the hospital are restrained at the time of death.[17]

Effectiveness and Complications;

Although restraints may be intended to treat aggressive behavior and prevent patient injury, there is little data to suggest they are effective. Residents who were restrained in a nursing home setting were found to exhibit the same or more agitated behaviors than residents who were not restrained.[18] The incidence of falls among home-bound, unrestrained elderly patients is not greater than the incidence of falls among institutionalized, restrained elderly patients.[19] Moreover, hospitals and long-term care institutions that have limited their use of restraints have reported no increase in the frequency of patient falls. [20] Bedrail use has not been shown to prevent falling out of bed in the acute hospital setting. In one retrospective study of 120 acute hospitals, two-thirds of "getting out of bed injuries" occurred in patients who were trying to climb over elevated bedrails.[21] With bedrails raised, the severity of injury was greater, as patients fell from greater heights. Cross cultural studies have shown a 50 percent greater hospital fall-fracture rate in the United States and Canada than in England, where the restraint rate is eightfold less, suggesting that restraints may not prevent falls.[22]

Although seldom reported in surveys, significant complications can be directly associated with the use of restraints (for example, death by strangulation, limb injury, skin trauma).[23] Less well-defined physical, psychological, and clinical complications, however, are more difficult to link directly to their use. Immobility from restraints may cause compromised circulation, decreased vital capacity, contractures, muscle weakness, nerve compression, and incontinence.[24] In one prospective study, being restrained longer than four days was highly associated with the development of pressure sores and nosocomial infections.[25] The psychological consequences of humiliation and loss of dignity can lead to depression, a paradoxical increase in agitation, and behavioral problems similar to the constellation of symptoms seen in torture-related syndromes.[26] In one survey of restrained patients, one-third were angered and demoralized by restraints.[27]

Reasonable, practical alternatives to restraints are difficult to find. One is to hire more nursing personnel or sitters to engage or observe patients in acute and long-term care settings. We believe this approach could be made cost-effective through fewer nosocomial infections, shorter lengths of stay, and reduced comorbidities, but our hypothesis is untested. Other alternative methods may include decreasing environmental hazards, discontinuing unnecessary psychoactive medications, purchasing low-adjustable beds and utilizing behavioral therapies or video cameras to monitor those patients likely to fall.

Patients who fall should be assessed not only for complications, but for the underlying etiology of the fall, and for their risk for future falls. Underlying causes should be corrected to reduce the risk of falls. Caregivers should emphasize gait training and physical therapy when appropriate. Finally, patients with behavioral problems should be assessed for underlying cognitive impairment, delirium, or primary functional psychiatric disease, with emphasis again on treating the primary disorder to reduce agitated behavior.

A Nonvalidated Therapy:

Since mechanical restraints pose known medical risk and there is insufficient validation of both their safety and efficacy, their use in clinical practice should be understood as an application of an investigational or nonvalidated therapy. To be sure, many efficacious clinical therapies have been inadequately tested by contemporary standards, but have proven effective in clinical practice. Nevertheless, the application of a nonvalidated therapy should be governed by the spirit and ethical principles that govern research, which are embodied in the process of informed consent.[28]

Informed consent has generally not been pan of the prescription and application of mechanical restraints.[29] Adequate information, reasonable understanding, and voluntariness comprise informed consent to therapy, but the standard for informed consent to nonvalidated therapy must be higher. Patients with full decisionmaking capacity must understand and volitionally accept a detailed disclosure of the potential benefits and risks of restraints, together with their therapeutic goals.[30] Patients without full decision-making capacity should have well-intended proxies who meet the same high standard. Proxy consent should be obtained from reliable family members, or agents with durable power of attorney or legal guardianship before restraints are applied.

Ensuring informed consent for restraints can be problematic because those who are at greatest risk for being restrained are also those who are cognitively impaired. The elderly may be particularly vulnerable in the long-term care setting, where slower reaction time, sensory impairments, polypharmacy, increased physical dependency, and the lack of financial and caregiver supports all may discourage providers from engaging residents in the informed consent process.[31] In the acute hospital setting, patients who refuse to be restrained are often sedated and restrained anyway.[32] If informed consent is taken seriously, however, caregivers must acknowledge the right of a competent patient or his or her proxy to dissent and to refuse restraints.

The decision to use restraints without the patient's consent may be legally restricted. The Illinois Mental Health Code, for example, states that restraints can be used only Kith written prescription of the physician and only if the patient is in danger of causing himself or others harm.[33] And the Fourteenth Amendment guarantees freedom from harm and unnecessary restraint. The less likely a patient is to cause harm to himself or others, the more significant is the infringement on the patient's legal rights by restraints.

Some medical activities are legitimately conducted not for the patient's benefit, but for the benefit of others.[34] The fields of preventive medicine, public health, and occupational medicine all employ such practices: for example, mandatory immunizations and infectious disease reporting have come from balancing an individual's right to privacy against society's need to protect its health as a whole. Although restraints have not been shown to reduce aggressive or agitated behaviors, it is possible that they indirectly benefit others by protecting them from such behavior.

Is it ethically permissible to restrain a patient for the benefit of others? When another identifiable individual is at risk of serious morbidity or mortality, or the public welfare appears in jeopardy, we believe that overriding the refusal of restraints by a competent patient or his or her proxy is ethically permissible. The ethical principle of preventing harm to identifiable others supersedes the patient's right to refuse. The negative fights of an individual to be free of interference end as he or she violates the autonomy of another. When restraints are applied for the benefit of others, physicians must balance professional responsibility to individual patients with their societal and legal responsibility to protect the public health.

There is no ethical justification for the application of restraints as a punitive measure when caregivers are angered or threatened by a patient. Such practice is abusive. It is unethical for health professionals to remain passive when they witness the abuse of patients with treatments ordinarily used for therapeutic purposes. Professionals have a unique expertise in evaluating the signs and symptoms of patient injury; this expertise can and should be used to interrupt or prevent mistreatment.

The use of restraints should be consistent with the overall goals of therapy. When restraints are used to allow other treatments to continue, several goals of therapy may compete or conflict.[35] For example, the goals of optimizing function and rehabilitation may conflict with the goal of protecting a patient from falls.

If the goal of therapy is to prolong life, to restore a patient with an acute or chronic illness to health, or to improve decision-making capacity, using restraints to prevent interference with life-sustaining treatments is consistent with treatment goals. Conversely, restraining a patient near the end of life to provide nutrition and hydration conflicts with the goal of preventing pain and suffering, and can be inconsistent with treatment goals. In this situation, several questions about goals need to be addressed: Is the burden of administering intravenous or tube feedings great? Is the patient rejecting feedings? Would overcoming this rejection unjustifiably infringe on patient autonomy? If the answers are "yes," the use of restraints should be discontinued.

Restraints can cause suffering directly through physical discomfort, patient anxiety, loss of integrity, and feelings of social isolation, and indirectly by allowing death-delaying treatments to continue when they may be undesired or ineffective. Preserving a patient's sense of control may often be more important than treating a superimposed acute illness, even when it is technically reversible, or providing food and fluids with tube feedings, when they alone delay death. While competent patients can balance these considerations for themselves, incompetent patients cannot. Restraining terminally ill patients who cannot participate in decisionmaking vitiates the comfort measures that are needed near the end of life. Offering restraints to patients in place of proper medical evaluation, nursing care, and compassion is unethical.

We present the following recommendations about using restraints in clinical practice.

* Mechanical restraints should not be used routinely in either the acute or long-term care settings. No compelling clinical data exist to validate restraint efficacy or safety. Until data become available to merit their use, restraints should be deemed investigational, and prospective trials should be carried out in acute and long-term care settings.

* Restraint use should be governed by the doctrine of informed consent. If patients are unable to consent, reliable proxy consent should be obtained, by telephone if necessary, with full disclosure of risk and benefit and with regard for the virtue of compassion and the principle of respect for persons. Only in cases of violent assault or for the immediate protection of staff is informed consent unnecessary, and then only until a physician has examined the patient and made an independent assessment.

* When restraints appear to be warranted, the least restrictive restraint should be ordered; periodic review and renewal of a specific and time-limited doctor's order is morally mandatory. The indication should be clearly documented in the medical record, with a follow-up visit planned and the nursing staff instructed in the proper application of restraints.

* Underlying disturbances of gait, mobility, behavior, and cognition should be sought and alternative therapies to decrease the risk of falling should be considered in restrained patients.

* When constructing limited treatment plans for patients, the benefits and risks of restraints as investigational interventions should be weighed. Restraints are generally not indicated when patients are near the end of life, or when the goals of therapy are to promote patient comfort.


This work was supported by the Lutheran General Hospital and the Lutheran General Medical Group, Park Ridge, Illinois.


1. Lois Evans and Neville Strump, Tying Down the Elderly: A Review of the Literature on Physical Restraints, "Journal of the American Geritric Society 36 (1089): 65-74.

2. Howard Rubenstein et al., "Standards of Medical Care Based on Consensus Rather Than Evidence: The Case of Routine Bedrail Use for the Elderly," Law, Medicine, and Health Care, 11 (1983): 271-76.

3. Evans and Strumpf, "Tying Down the Elderly"; J. Dermot Frengley and Lorraine Mion, "Incidence of Physical Restraints on Acute General Medical Wards," Journal of the American Geriatric Society 34 (1986): 565-68.

4. Lorraine Mion et al., "A Further Exploration of the Use of Physical Restraints in Hospitalized Patients," Journal of the American Geriatric Society 37 (1989): 949-56.

5. Evans and Strumpf, "Tying Down the Elderly."

6. Laurence Robbins et al., "Binding the Elderly: A Prospective Study of the Use of Mechanical Restraints in an Acute Care Hospital," Journal of the American Geriatric Society 35 (1987): 290-96.

7. Mion et al., "A Further Exploration."

8. National Nursing Home Survey: 1977 Summary for the United States, DHEW Publication No. (PHS) 79-1794 (Washington, D.C.: U.S. Government Printing Office, 1979).

9. Rubenstein et al., "Standards of Medical Care."

10. David MacPherson et al., "Deciding to Restrain Medical Patients," Journal of the American Geriatric Society 38 (1990): 516-20.

11. Robbins et al., "Binding the Elderly."

12. Frengley and Mion, "Incidence of Physical Restraints"; Jean Morrison et al., "Formulating a Restraint Use Policy," Journal of Nursing Administration 17 (1987): 3942.

13. Robbins et al., "Binding the Elderly"; Frengley and Mion, "Incidence of Physical Restraints."

14. Mion et al., A Further Exploration."

15. Frengley and Mion, "Incidence of Physical Restraints."

16. Robbins et al., "Binding the Elderly."

17. Robbins et al., "Binding the Elderly." Frengley and Mion, "Incidence of Physical Restraints."

18. Paula Werner et al., "Physical Restraints and Agitation in Nursing Home Residents," Journal of the American Geriatric Society 37 (1989): 1122-26.

19. Rubenstein et al., "Standards of Medical Care."

20. Colin Powell et al., "Freedom from Restraint: Consequences of Reducing Physical Restraints in the Management of the Elderly," Canadian Medical Association Journal 141 (1989): 561-64; G. A. Hollingsworth, "Nursing Home Reduces Restraints in Keeping with its Philosophy," Dimensions, November 1986, pp. 39-40.

21. Rubenstein et al., "Standards of Medical Care."

22. Frengley and Mion, "Incidence of Physical Restraints,"

23. L Katz, E Weber, and P Dodge, Patient Restraints and Safety Vests: Minimizing the Hazards," Dimensions in Health Service 58 (1981): 10-11; Arthur Dupe and Erik Mitchell, Accidental Strangulation from Vest Restraints," JAMA 256 (1986): 2725-26.

24. Sandra Selikson, Karla Damus, and David Hamerman, "Risk Factors Associated with Immobility," Journal of the, American Geriatric Society 36 (1988): 707-12.

25. Richard Lofgren et al., "Mechanical Restraints on the Medical Wards: Are Protective Devices Safe?" American Journal of public Health 79 (1989): 735-38.

26. Anne Goldfeld et al., "The Physical and Psychological Sequelae of Torture: Symptomatology and Diagnosis," JAMA 259 (1988): 2725-29.

27. Mion et al., "A Further Exploration."

28. Robert Levine, Ethics and Regulation of Clinical Research, 2d ed. Baltimore: Urban & Schwarzenberg, 1986).

29. Paul Appelbaum, "The Right to Refuse Treatment with Antipsychotic Medications: Retrospective and Prospective," American Journal of Psychiatry 145 (1988): 413-19.

30. Levine, Ethics and Regulation of Clinical Research.

31. Sandra Berkowitz, "Informed Consent, Research, and the Elderly," The Gerontologist 18 (1978): 237-43; Richard M. Ratzan, "`Being Old Makes You Different': The Ethics of Research With Elderly Subjects," Hastings Center Report 10, no. 5 (1980): 32-42.

32. Paul Appelbaum and Loren Roth, "Involuntary Treatment in Medicine and Psychiatry," American Journal of Psychiatry 141 (1984): 202-5.

33. Task Force on the Mental Health Code, Guidelines for Implementation of the Mental Health Code and Related Mental Health Legislation (Sec. 2-108, Illinois State Medical Society, 1988).

34. Mark Yarborough, "Continued Treatment for the Fatally Ill for the Benefit of Others," Journal of the American Geriatric Society 36 (1988): 63-67.

35. A. Shafer, "Restraints and the Elderly: When Safety and Autonomy Conflict," Canadian Medical Association Journal 132 (1985): 1257-60.
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Author:Moss, Robert J.; La Puma, John
Publication:The Hastings Center Report
Date:Jan 1, 1991
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