restraint in the care of older patients: ethical and legal aspects · restraint in the care of...

Restraint in the care of older Restraint in the care of older patients:patients:

Ethical and legal aspectsEthical and legal aspects

Dr David OliverDr David OliverBGS Spring MeetingBGS Spring Meeting

Bournemouth April 2009Bournemouth April 2009

What I want to coverWhat I want to coverI: Why this matters so much right nowII: Definitions and types of restraint (versus protective measures or deprivation of liberty)III: Main moral tensions...IV: Moral arguments and permission/specification (using “four principles” approach)....and how these are reflected in lawV: Alternatives to restraintI won’t critique the empirical evidence. That’s for the debate..

David Oliver - BGS Spring 2009

Restraints and bedrails can be dangerous/harmful and have caused serious injury and death but do we conclude that they should never be used?


Empirical evidence Empirical evidence -- issuesissuesPaucity/quality of interventional studiesRCTs hard to perform (removal, application of restraint)Especially in this vulnerable/acute/confused populationLimitations of observational/quasi-experimental studiesHarms from use of devicesBut denominator?Or control group?Basis for “strong assertions” not too clearThat’s all I am saying on this..


I: Why this mattersI: Why this matters


Why this mattersWhy this mattersPatients over 65 – c 70% bed daysFalls: common cause of admission.Falls: 30-40% safety incidents (NPSA report)Dementia and neuro-psychiatric symptoms common even in non-psychiatric hospitals (e.g. Who cares wins. Dementia Strategy)Delirium 11-40% hospital admissions (RCP Delirium Guidelines. Young and Inouye BMJ 2007)Care homes, 40% residents fall twice or more p.a.Dementia/behavioural disturbance affect 50-70% even in “non EMI” homes (Bowman et al national census 2004. Selbaek G et al 2005)


Why this mattersWhy this mattersFalls....(leading to injury, complaint, litigation, fear of falling, worsened rehab, prolonged stay etc etc)

Median age (hospital) 81Common risk factors, dementia, delirium, agitation, postural instability, visual impairmentMedication – especially psychotropic (systematic review Woolcott 2008, Hartikainen2008. Common over-use – e.g. Dementia Inquiry 2009)


Why this matters: Location of Why this matters: Location of fallsfalls (NPSA Report 2007) (90% (NPSA Report 2007) (90% unwitnessedunwitnessed in this in this

and other reports)and other reports)

32%

28%

18%

10%

9%2%1%

fall whilst mobilising

fall from bed

fall circumstancesunclearfall from chair

fall from toilet orcommodefall in bathroom orshowerfall other


Why this matters Why this matters –– policy/law/guidancepolicy/law/guidanceNPSA Report on falls 2007 (and bedrail guidance)Health Care Commission Standards (now to CQC)Dementia StrategyGrowing public concern around dignity, safetyMore complaining/litigious cultureSafeguarding vulnerable adultsMental Capacity Act 2005 (including guidance on restraint use). Scottish Adults with Mental Incapacity Act.Bournewood Ruling and deprivation of liberty safeguards 2009


II. Definitions and types of II. Definitions and types of restraintrestraint


Important distinction (or continuous spectrum?)

Protective Measures

Restraint

Deprivation of Liberty


Types of restraintTypes of restraint Draft RCN Guidance 2008Draft RCN Guidance 2008

Physical:Physical: Being held by one or more personsBeing held by one or more personsChemical:Chemical: (e.g. sedation) (n.b. National Dementia Enquiry)(e.g. sedation) (n.b. National Dementia Enquiry)Psychological:Psychological:–– e.g. being told repeatedly to sit down/avoid a particular e.g. being told repeatedly to sit down/avoid a particular

activityactivity–– Having everyday objects taken away (aids, clothes etc)Having everyday objects taken away (aids, clothes etc)

Mechanical:Mechanical: (Overt and Covert)(Overt and Covert)–– Specifically designed/prescribed devices e.g. lap belts, Specifically designed/prescribed devices e.g. lap belts,

mittens, chairmittens, chair--top trays.top trays.–– Use of everyday equipment e.g. wedging furniture, Use of everyday equipment e.g. wedging furniture,

bedclothes, soft or low chairsbedclothes, soft or low chairs–– Alarms/tagging/monitoring/surveillance?Alarms/tagging/monitoring/surveillance?–– Bedrails?Bedrails?


Increased the awareness of restraints Increased the awareness of restraints The Provision states The Provision states ““ Residents have the Residents have the right to be free from right to be free from ……any physical or any physical or chemical restraint imposed chemical restraint imposed for the for the purposes of discipline or convenience purposes of discipline or convenience and not required to treat the residentand not required to treat the resident’’s s medical symptomsmedical symptoms””

US Omnibus Reconciliation Act US Omnibus Reconciliation Act 19871987


US 1987 OBRA guidelines restraints US 1987 OBRA guidelines restraints include:include:

Physical or mechanicalPhysical or mechanicalVest RestraintsVest RestraintsMitts, Wrist RestraintsMitts, Wrist RestraintsGeriatric Geriatric cchairs hairs –– lap top trays &lap top trays &cushionscushionsChair to close to a wallChair to close to a wallBed railsBed railsSheets tucked too tightSheets tucked too tightDrugsDrugs


““GerichairGerichair””David Oliver - BGS Spring 2009

““Posey HuggerPosey Hugger””David Oliver - BGS Spring 2009

““Posey BeltPosey Belt””David Oliver - BGS Spring 2009

““Posey wrist restraintPosey wrist restraint””David Oliver - BGS Spring 2009

Posey Posey ““deluxedeluxe””David Oliver - BGS Spring 2009

““Posey VestPosey Vest””David Oliver - BGS Spring 2009

““Sleep restraintSleep restraint””David Oliver - BGS Spring 2009

¾¾ length bedrailslength bedrailsDavid Oliver - BGS Spring 2009

““If an item is used as a mechanism to If an item is used as a mechanism to control behaviour, the item may be control behaviour, the item may be considered a restraint. If on the other hand considered a restraint. If on the other hand a patient/ resident is incapable of moving a patient/ resident is incapable of moving him or herself the device should not be him or herself the device should not be viewed as a restraintviewed as a restraint””..

Australian guidelines for Australian guidelines for the prevention of falls in the prevention of falls in hospital and in care homes hospital and in care homes 20052005


Protective MeasuresProtective MeasuresObligation to carry out risk assessments and minimise accidents“Routine” use of protective measures more controversialSome measures should be routine (e.g. HSE report on scalding injuries from too-hot water and need for mixer valve with temperature restrictor)Electronic tagging for wandering?Bed and chair alarms to prevent/detect falls?So “protective measures” sounds benign but could be more restrictive than restraint in some cases


Deprivation of Liberty Safeguards (Amendment to Mental Capacity Act)

“A combination of factors – type, duration, effect and degree – are what constitutes a

deprivation of liberty “Restraint/Restriction Deprivation of Liberty

Doors are locked but the patient is given access to go out

Doors are locked but patient rarely goes out

Patient is prevented from leaving unless they are escorted for safety reasons

Patient never leaves ward without escort and there are rarely escorts available

Staff exercise some control over the patient Staff extensively control the care and movement of a patient around the ward and what they can do

Family / carers request discharge Discharge refused and no negotiation with family / carers

Contact with others is limited by visiting hours Contact with others is severely limited because of additional rules

Patient has some choice and control over daily living activities

Loss of control over daily living activities because of continuous supervision and control.


III: Main moral tensionsIII: Main moral tensions


Framework for decisionFramework for decision--making making (after (after TallisTallis))

Ethical considerations

Legal and regulatory considerations. (nation-specific)

Evidence-Base for Practice

…

Personal values, experience, professional training

Organisational culture values/priorities, resources

Cultural values (including professional group, patient, family, media/society , nationality)

Professional decision-making constrained by...


HL MenckenHL Mencken

““For every complex problem, there is a For every complex problem, there is a solution which is simple, obvious and solution which is simple, obvious and wrongwrong””


Strong opinionsStrong opinions…….(e.g. .(e.g. bedrails)bedrails)

‘‘The more backward the ward, the The more backward the ward, the more bedrailsmore bedrails’’ ((HazellHazell 1990)1990)

‘‘Indignity and inherent dangersIndignity and inherent dangers’’ (Miller (Miller 1989)1989)

‘‘Institutionalisation of the worst kindInstitutionalisation of the worst kind’’(RCN 1992)(RCN 1992)

‘‘Dangerous and unethicalDangerous and unethical’’ ((JehanJehan 1999)1999)

‘‘DegradingDegrading’’ (Gray and Gaskell 1990)(Gray and Gaskell 1990)


Assertions are not arguments!Assertions are not arguments!e.g. for bedrails, a relative evidence vacuum e.g. for bedrails, a relative evidence vacuum filled with strong opinionsfilled with strong opinionsStaff sometimes uncritically take opinions in Staff sometimes uncritically take opinions in published papers as published papers as ““gospelgospel””Critique of empirical evidence Critique of empirical evidence for for effectiveness may helpeffectiveness may helpBut for ethics, so might a proper But for ethics, so might a proper examination examination of the moral arguments....of the moral arguments....


Damned if you do, damned if Damned if you do, damned if you donyou don’’t?t?


Main Moral Tension Main Moral Tension (Kai and (Kai and SamettSamett2007 2007 GastmansGastmans and and MilisenMilisen 2006 . JME. Older People. 2006 . JME. Older People.

SenSen P. 2007. Forensic Psychiatry)P. 2007. Forensic Psychiatry)

Use of restraints (overt or covert) is an Use of restraints (overt or covert) is an infringement of autonomy and dignityinfringement of autonomy and dignity of of patient and therefore is patient and therefore is maleficentmaleficent

VsVsActing (Acting (paternalisticallypaternalistically) in the patient) in the patient’’s s presumed presumed best interest is part of duty of best interest is part of duty of carecare(Mutually exclusive position?)(Mutually exclusive position?)……


3 key elements in the case 3 key elements in the case againstagainst restraint restraint ((Healey and Oliver Healey and Oliver

2008 Age Ageing2008 Age Ageing))

1.1. ““Dangerous and HarmfulDangerous and Harmful””–– So we need to examine the evidence and So we need to examine the evidence and

risk/benefit analysisrisk/benefit analysis22. . ““In any case, ineffectiveIn any case, ineffective””–– So we need to examine the empirical evidence So we need to examine the empirical evidence

and its limitationsand its limitations3.3. ““Morally impermissibleMorally impermissible””–– So we need to examine the moral argumentsSo we need to examine the moral arguments


3 Key arguments 3 Key arguments forfor use? Not use? Not easy to find supporter but would easy to find supporter but would

go...go...1: 1: ““Paternalistic Paternalistic duty of careduty of care to protect the patient to protect the patient from harmfrom harm””

2: 2: ““Use of restraint Use of restraint proportionateproportionate to the potential to the potential degree of harmdegree of harm””

MoresoMoreso if the person is confused and doesnif the person is confused and doesn’’t t appreciate riskappreciate risk

3: 3: ““Wider duty to Wider duty to avoid complaints/upsetavoid complaints/upset from from family members or legal action for failure to protect family members or legal action for failure to protect from harmfrom harm””


Other scenarios?Other scenarios?

Protecting other patients/residents from harm?Protecting from self-harm (rather than risk)?Or inadvertent sabotage of own treatment?Patients with mental capacity?


IV: Developing an ethical IV: Developing an ethical frameworkframework

And how this is reflected in lawAnd how this is reflected in law


Prima facie ethical principlesPrima facie ethical principles……(I am (I am not going to critique not going to critique ““principlismprinciplism”” here here –– it works for examining our it works for examining our

arguments)arguments)

Respect for patient Respect for patient AutonomyAutonomy (self(self--determination)determination)

BeneficenceBeneficence–– Duty of care to maximise Duty of care to maximise

benefit to patientbenefit to patient

NonNon--maleficencemaleficence–– Duty to minimise the risk of Duty to minimise the risk of

harmharm

JusticeJustice–– Equity in resource allocationEquity in resource allocation–– Equal rights to treatment/careEqual rights to treatment/care


To turn these principles into practical To turn these principles into practical rules for actions in specific circumstances rules for actions in specific circumstances

i.e..i.e..““specificationsspecifications”” and and ““permissionspermissions””

Consider Consider scopescope of decisionof decision--making (for making (for individuals, institutions, policyindividuals, institutions, policy--makers etc)makers etc)If any of these prima facie norms are to be If any of these prima facie norms are to be infringedinfringed, then need to consider , then need to consider ““balancing rulesbalancing rules”…”…for balancing one norm for balancing one norm against anotheragainst another


Balancing RulesBalancing Rules ((Beauchamp and Beauchamp and Childress)Childress)

1. 1. ““Better reasonsBetter reasons can be offered to act on the overriding than can be offered to act on the overriding than infringed norminfringed norm””2. 2. ““The moral objective justifying the infringement must have The moral objective justifying the infringement must have a a realistic prospect of achievementrealistic prospect of achievement””3. 3. ““The infringement is necessary in that The infringement is necessary in that no morally no morally preferable alternativepreferable alternative actions can be substitutedactions can be substituted””4. 4. ““The infringement selected must be the The infringement selected must be the least possible least possible infringementinfringement needed to achieve the primary goalneeded to achieve the primary goal””5. 5. ““The agent (i.e. doctor/nurse) must seek to The agent (i.e. doctor/nurse) must seek to minimise any minimise any negative effectsnegative effects of infringementof infringement””6. 6. ““Must Must act impartiallyact impartially in regard to all affected parties and in regard to all affected parties and not influenced by morally irrelevant informationnot influenced by morally irrelevant information””Let us apply this to the realLet us apply this to the real--life use of life use of restraintsrestraints……


Why might physical restraints/bedrails be Why might physical restraints/bedrails be used in used in ““real lifereal life””??

1.1. Patient has Patient has askedasked for devicefor device2.2. Beneficent Beneficent aim of preventing falls/injuries aim of preventing falls/injuries in people who might in people who might roll or slide roll or slide out of bed out of bed or chairor chair3.3. Beneficent aim of Beneficent aim of preventing falls/injuries preventing falls/injuries in people who are in people who are agitated & unsteady agitated & unsteady and who keep trying to leave bed or chair.and who keep trying to leave bed or chair.4.4. Prevent Prevent disturbed, wandering disturbed, wandering patients from patients from endangeringendangering / / harmingharming themselves or sabotaging own treatment (e.g. fluids)themselves or sabotaging own treatment (e.g. fluids)55…….. Or harming/worrying Or harming/worrying other patientsother patients/residents/residents6.6. They consume so much staff attention that They consume so much staff attention that care of others care of others compromised (i.e. compromised (i.e. ““opportunity costsopportunity costs””))7.7. Routine Routine custom and habit custom and habit (e.g. with bedrails) rather than any (e.g. with bedrails) rather than any conscious management decision conscious management decision ––i.e. casual/unthinking applicationi.e. casual/unthinking application8.8. Staff and skills are Staff and skills are inadequate inadequate to manage problems restraintto manage problems restraint--free free 9.9. PatientsPatients’’ relativesrelatives are insistingare insisting10.10. Deliberately Deliberately abusive or punitive abusive or punitive measuremeasure11.11. In someone who In someone who doesdoes have mental capacity have mental capacity to refuse to refuse


SoSo……back to argument 3... back to argument 3... –– i.e. i.e. ““Restraint Restraint use is use is always always morally impermissiblemorally impermissible””

There There areare permissionspermissions and circumstancesand circumstances……Where the person has Where the person has requested requested the device or...the device or...Or Or lack autonomous capacitylack autonomous capacity to appreciate riskto appreciate riskAnd where they And where they areare at serious at serious risk of injuryrisk of injuryAnd where degree of restraint And where degree of restraint proportionateproportionate to degree of to degree of possible harmpossible harmAnd restraint is a And restraint is a ““last resortlast resort”” after other after other alternativesalternatives fully fully exploredexploredAnd is And is reviewed regularlyreviewed regularly and and applied safelyapplied safely

Protection of Protection of staff/other residentsstaff/other residents is morally more greyis morally more grey……Moral responsibility to advocate for better staffing levels?Moral responsibility to advocate for better staffing levels?Though Though scope scope of personal/of personal/insitutionalinsitutional moral responsibility moral responsibility cannot extend to factors which you/the institution cannot cannot extend to factors which you/the institution cannot control/influencecontrol/influence


Mental Incapacity Act UK 2005. Five Key Mental Incapacity Act UK 2005. Five Key principlesprinciples

A presumption of capacity A presumption of capacity unless proved otherwiseunless proved otherwise;;The right for The right for support in decisionsupport in decision--makingmaking. All appropriate . All appropriate help should be given before any conclusion that someone help should be given before any conclusion that someone cannot make their own decisions;cannot make their own decisions;Individuals retain the right to make what might be seen as Individuals retain the right to make what might be seen as eccentric or unwise decisionseccentric or unwise decisionsBest interestsBest interests –– must be the aim of anything done on behalf must be the aim of anything done on behalf of people without capacity. There is a checklist of factors for of people without capacity. There is a checklist of factors for use in deciding what is in a personuse in deciding what is in a person’’s best interests.s best interests. A person A person can also put his wishes into a written statement. can also put his wishes into a written statement. CarersCarers and and family members gain a right to be consulted family members gain a right to be consulted The intervention The intervention least restrictive to basic rights and least restrictive to basic rights and freedomsfreedoms should be applied. should be applied.


Mental Capacity Act and Mental Capacity Act and RestraintRestraint

““The use or threat of force where an incapacitated The use or threat of force where an incapacitated person resists and any restriction of liberty of person resists and any restriction of liberty of movement whether or not the person resistsmovement whether or not the person resists””““Restraint is only permitted if the person using it Restraint is only permitted if the person using it believes it is necessary to believes it is necessary to prevent harmprevent harm (to the (to the incapacitated person)incapacitated person)””““And if the degree of restraint is And if the degree of restraint is proportionate proportionate to to the degree of harmthe degree of harm””


Proportionality...Proportionality...David Oliver - BGS Spring 2009

A misunderstanding of A misunderstanding of ““Respect for Respect for autonomyautonomy”” is the main source of the is the main source of the

““strong opinionsstrong opinions””

i.e. i.e. ““selfself--determinationdetermination”” as opposed to as opposed to personhood/ human dignitypersonhood/ human dignityMany of the assertions in the literature about Many of the assertions in the literature about ““infringement of autonomyinfringement of autonomy”” ignore thisignore thisNeed to distinguish Need to distinguish ““normativenormative”” autonomy autonomy (i.e. (i.e. the overall principle of right to selfthe overall principle of right to self--determination determination and respect for personhood)...and respect for personhood)...from from ““empirical autonomyempirical autonomy”” i.e. whether one i.e. whether one

actually has the capacity to do thisactually has the capacity to do this


Empirical (actual) autonomyEmpirical (actual) autonomyMay be impaired due to: May be impaired due to: Cognitive impairment (can the person appreciate how unsteady Cognitive impairment (can the person appreciate how unsteady they are, how high the risk of falls, the fact that they have they are, how high the risk of falls, the fact that they have fallen before, the chance of serious harm from falls?)fallen before, the chance of serious harm from falls?)AlsoAlso……..NauseaNauseaPainPainAnxietyAnxietyUnfamiliar environmentUnfamiliar environmentIrrational fearsIrrational fearsDepressionDepressionFamily pressureFamily pressureLack of information/communicationLack of information/communicationHopelessnessHopelessnessFatigueFatigueCarer StressCarer StressObligations to OthersObligations to OthersSense of meaninglessness/existential crisisSense of meaninglessness/existential crisis


(Legitimate) paternalism(Legitimate) paternalism““heteronomyheteronomy”” –– defined as defined as ““any controlling any controlling influence over the will other than motivation by influence over the will other than motivation by moral principlesmoral principlesJS Mill On LibertyJS Mill On Liberty““Paternalism may be defined as the interference Paternalism may be defined as the interference with a personwith a person’’s liberty of action justified by s liberty of action justified by reasons referring exclusively to the welfare, good, reasons referring exclusively to the welfare, good, happiness, needs, interests or values of the person happiness, needs, interests or values of the person being coercedbeing coerced””R R DworkinDworkin 19721972““SoftSoft”” Vs Vs ““HardHard”” PaternalismPaternalism

J FeinbergJ Feinberg


Conditions for legitimate Conditions for legitimate paternalism paternalism (Beauchamp and (Beauchamp and

Childress)Childress)

1. 1. ““A patient is at risk of a significant A patient is at risk of a significant preventable preventable harmharm””2. 2. ““The paternalistic action will probably The paternalistic action will probably prevent prevent the harmthe harm””3. 3. ““The projected The projected benefits outweigh the risksbenefits outweigh the risks””4. 4. ““The The leastleast--autonomy restrictive alternative autonomy restrictive alternative that that will secure the benefits and minimise the risks is will secure the benefits and minimise the risks is adoptedadopted””


Questions about Questions about ““autonomyautonomy”…”…

Are health Are health professionalsprofessionals tootoo respectfulrespectful of respect for of respect for autonomy or confidentiality at the expense of a duty autonomy or confidentiality at the expense of a duty of care to ensure patient safety (i.e. of care to ensure patient safety (i.e. libertarianlibertarian))Or are Or are patientspatients’’ relatives relatives too too inclined inclined to compromise to compromise freedom and autonomy and to infantilise older people freedom and autonomy and to infantilise older people in favour of physical in favour of physical ““safetysafety”” without thinking about without thinking about other harms? (i.e. other harms? (i.e. paternalisticpaternalistic))Do the Do the professionals understand professionals understand what what autonomyautonomyactually means?actually means?Do Do lay people lay people actually respect autonomy in older actually respect autonomy in older people or have they subconsciously decided that people or have they subconsciously decided that ““different rules applydifferent rules apply”” if you are old if you are old –– just as if you just as if you are a child?are a child?


Restraint is an infringement of Restraint is an infringement of personal freedom? personal freedom? ((VassalloVassallo et al)et al)

66

35

0

10

20

30

40

50

60

70

Agreement %

health care professionals patients and relatives

P<0.0001


Restraining methods are acceptable Restraining methods are acceptable at the discretion of health care at the discretion of health care professionals? professionals? ((VassalloVassallo et al)et al)

43

91

0102030405060708090

100

Agreement %


P<0.0001


Differences in Acceptability:Differences in Acceptability:Bed or chair alarms Bed or chair alarms ((VassalloVassallo))

74

86

68

70

72

74

76

78

80

82

84

86

Acceptability %


p=0.052

Alarms that alert staff that a patient is getting out of bed or chair (having a ringing alarm)


Differences in Acceptability: Differences in Acceptability: Nursing patients on the floor Nursing patients on the floor

((VassalloVassallo))

64

190

10

20

30

40

50

60

70

Acceptability %


p=<0.0001

Nurse patient on a mattress placed on the floor


Mentally Competent Mentally Competent Individuals?Individuals?

Right to freedom of movement enshrined in Human Rights Act 1998, which protects individuals from arbitrary restrictions on their liberty.Any form of restraint which restricts competent

individuals’ freedom, without their consent or other overriding justification, could be in breach of the Act. An overriding justification could arise in exceptional cases where a competent person has to be restrained because their activities would cause harm to others.Competent patients of any age have rights to risk their own health but are justifiably restrained if they represent a significant harm to other people.


Restraint to protect others (Legal position. Restraint to protect others (Legal position. Mason and McCallMason and McCall--Smith. BMA guidanceSmith. BMA guidance) ) But could But could

apply apply ““balancing rulesbalancing rules””

Professionals have a common law right to use restraint to prevent harm to a person in their care or to another person. They should also intervene if the individual seriously compromises the therapeutic environment. Restraint should always be the minimum necessary to prevent harm.Responses to any threat of violence must be reasonable and proportionate to the risk. Where there is a foreseeable need to manage violent patients, this needs to be planned for and staff should be trained in appropriate skills.


V:Other points of lawV:Other points of law


Negligence TestsNegligence Tests

Duty of Care (see Bolam and Bolitho_

BreachReasonably foreseeable and preventableIdentifiable harm(See Oliver et al QSHC 2008 for review of NHSLA cases)


Human RightsHuman RightsArticle 3. Right to Prohibition of torture“No one shall be subjected to torture or to inhuman or degrading treatment”

Article 5. Right to liberty and security“Everyone has the right to liberty and security of

person. No one shall be deprived of his liberty save in specific exceptions.”


BournewoodBournewood ruling ruling (European court of human rights re (European court of human rights re autistic man who consented to inpatient treatment but clearly autistic man who consented to inpatient treatment but clearly

lacked capacity)lacked capacity)

Identifying deprivations of libertyThe court gave some directions on what would contribute to deprivation of an individual’s liberty: these were:

– Use of restraint or sedation to admit a person who is resisting– Professionals exercising complete control over care and movement for a

significant period– Professionals controlling assessments, treatment– being prevented from leaving residence – Request by other carers for the person to be discharged being refused– Individual unable to maintain social contacts since restrictions placed on

access to other people– Individual loses autonomy due to continuous supervision or control


Deprivation of Liberty Safeguards (Amendment to Mental Capacity Act)

A combination of factors – type, duration, effect and degree – are what

constitutes a deprivation of liberty

Restraint/Restriction Deprivation of Liberty

Doors are locked but the patient is given access to go out

Doors are locked but patient rarely goes out

Patient is prevented from leaving unless they are escorted for safety reasons

Patient never leaves ward without escort and there are rarely escorts available

Staff exercise some control over the patient Staff extensively control the care and movement of a patient around the ward and what they can do

Family / carers request discharge Discharge refused and no negotiation with family / carers

Contact with others is limited by visiting hours Contact with others is severely limited because of additional rules

Patient has some choice and control over daily living activities

Loss of control over daily living activities because of continuous supervision and control.


VI: Alternatives to restraint?VI: Alternatives to restraint?


AlternativesAlternativesDavid Oliver - BGS Spring 2009

Alternatives e.g.Alternatives e.g.David Oliver - BGS Spring 2009

Alternatives

Multifaceted interventions in hospitals and care homes can reduce falls rates (Oliver D et al BMJ 2007. Oliver D et al Reviews Clin Geront 2008. Cochrane Update 2009. Australian Safety Council Guidelines 2005/9)

Some evidence around injury prevention (flooring/hip protectors etc)Some evidence around single interventions such as medication review and adjustment (Zermansky 2006. Vitamin D and Calcium e.g. Boonen S 2007, Bischoff-Ferrari 2006)

Better management of agitation/restlessness (e.g. RCP Delirium Guidelines)


In Conclusion…


restraint in the care of older patients: ethical and legal aspects · restraint in the care of...

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