Chemical restraint or lethal injection?

THE Tasmanian Mental Health Act defines chemical restraint as a “medication given primarily to control a person’s behaviour, not to treat a mental illness or physical condition”.

Acute agitation or behavioural disturbance is a common presenting problem to Australian emergency departments and hospitals. Sedative medication is used to manage the agitation and, in some cases, treat a mental illness or physical condition. However, in many cases, it is, by definition, a form of chemical restraint used to control a patient’s behaviour.

The implicit goal of chemical restraint at the hands of health care providers is to ensure the safety of the patient and those trying to care for them during a period of acute agitation that makes informed consent and adequate assessment difficult, if not impossible.

To ensure best practice and prioritise safety, one would think chemical restraint education and guidelines would be consistent and evidence-based across Australia.

They are not. There is no national guideline or standard.

Below are some examples of the variations across Australian states and territories in sedation or chemical restraint guidelines:

• Management of patients with acute severe behavioural disturbance in emergency departments (NSW Health, 2015) – the first line choice for parenteral sedation is droperidol.
• Guidelines: the management of disturbed/violent behaviour in inpatient psychiatric settings (West Australian Department of Health, 2006) – general advice with no specific recommendations on sedative choices.
• Sedation of acutely agitated adult patients prior to transportation: a guide for medical practitioners (WA Therapeutics Advisory Group, 2006) – first line choice (for parenteral sedation) is midazolam, haloperidol or clonazepam.
• Sir Charles Gairdner Hospital – nurse practitioner mental health clinical protocols (WA, 2011) – first line choice (for parenteral sedation) is clonazepam or haloperidol.
• Emergency chemical restraint – medication options (Safer Care Victoria, 2012) – first line options for parenteral sedation are olanzapine, midazolam, haloperidol or midazolam–haloperidol combination.
• CMG 37 – management of combative and agitated patients (ACT Ambulance, 2015) – parenteral sedation: midazolam or ketamine sedation.
• Management of patients with acute severe behavioural disturbance in emergency departments (Queensland Health, 2016) – first line choice for parenteral sedation is droperidol.

While there has been a concerted effort to move towards a universal consensus guideline, notably between Queensland and NSW, it is obvious that significant variation in chemical restraint practice remains.

This variation can lead to increased risk and the following four cases of deaths related to acute chemical restraint should be a wake-up call for all health care providers charged with the provision of this emergency duty.

The 2007 death of David Lee (page 70) was due to excessive sedation from midazolam infusion in Port Hedland hospital. He had schizophrenia and was under the involuntary status of the Mental Health Act. A follow-up report (page 13) concluded that a lack of adequate staffing should not be justification for using excessive chemical restraint measures.

A very similar case of a chemical restraint-related death was noted here in 2009 in WA (page 22), when an Indigenous man with schizophrenia was excessively sedated with midazolam infusion. The cause of death was pulmonary embolus, but it is likely that this was a result of prolonged immobilisation as a result of the excessive sedation, its resultant pulmonary aspiration syndrome and need for intensive care unit level admission.

In 2010, in Townsville, Lyji Vaggs died after chemical restraint with olanzapine and then midazolam for acute agitation in the mental health unit of the main hospital. Unlike Lee in WA, there was adequate staffing during the admission of Mr Vaggs, including police.

In 2015, David Dungay died in the psychiatric unit of the Long Bay prison after being physically restrained and then administered midazolam via injection. He had been diagnosed with schizophrenia while in prison and was improving on appropriate medication. The coronial inquest into his unnatural death is still pending.

These four men were all Indigenous and either under care of the prison system or the local mental health act.

The use of midazolam infusion has never been supported by any official guidelines in Australia and the origins of its use for acute behavioural disturbance remain a mystery. While the use of midazolam injection is supported by several guidelines, it is my opinion that it carries significant risks in inherently risky situations, such as the acutely agitated patient.

The push to remove midazolam from clinical guidelines for this high risk patient group should be supported, as Queensland Health and NSW Health have done in past 2 years.

We can do better. We must do better if patients are to trust that safe care is our priority, rather than variable care.

It is grimly ironic that midazolam has been used as a lethal injection substitute for capital punishment in the United States, since thiopentone sourcing has become problematic.

Dr Minh Le Cong works for the Royal Flying Doctor Service in Queensland and is the chief editor of the PHARM (Prehospital and Retrieval Medicine) blog site and podcast, the FOAM4GP blog site and the Ketamine Leadership Academy blog site.

 

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