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Australia’s aged care system is undergoing a necessary transformation — one that places the rights and dignity of older people front and centre. At the heart of this is the need to minimise restrictive practices, including the use of chemical restraint.
While regulatory obligations around chemical restraint fall squarely on the shoulders of aged care providers (providers), the role of general practitioners (GPs), who prescribe the medications, is vital. But too often, providers and GPs are speaking different languages, and the result is frustration, confusion, and ultimately risk to the older person.
Chemical restraint: it’s about intent, not just the medication
Chemical restraint refers to the use of medication not to treat a condition, but to influence an individual’s behaviour. Under Commonwealth aged care legislation, “chemical restraint” is defined as “a practice or intervention that is, or that involves, the use of medication or a chemical substance for the primary purpose of influencing an individual’s behaviour”. This means that antipsychotic medications used for behavioural symptoms of dementia (rather than for the treatment of a psychiatric diagnosis) are considered chemical restraint.
The key challenge? Medications have many effects. For example, opioids prescribed for pain may also calm agitation. Is that restraint? According to the Aged Care Quality and Safety Commission (Commission), if the primary purpose for its prescription is behaviour management, then yes. But assessing “intent” isn’t always straightforward, and this is where clinical governance and strong relationships become essential.
Clinical governance: it’s everyone’s business
Clinical governance is more than compliance. It’s how we ensure safe, person-centred care. This includes minimising restrictive practices, using any form of restraint only as a last resort, gaining informed consent, monitoring impacts, and clear documentation.
Good clinical governance is not only the responsibility of providers. GPs are also expected to play their part. The Medical Board’s Code of Conduct highlights that doctors share responsibility for safety, quality, and risk management. That includes how they prescribe and how they document the reasons behind these decisions.
Why many GPs are frustrated
GPs often feel caught in the middle. They’re being asked to justify medication decisions in detail, often in formats created by providers, without additional funding or time.
A major pain point is the broad definition of “psychotropic medication”, which, as per the Commission, includes any drug that can affect the mind, emotions and behaviour. This includes antiemetics, antidepressants, and even anti-dementia drugs (Aged Care Quality and Safety Commission). GPs are understandably puzzled: why should they have to document their reasoning that metoclopramide isn’t a chemical restraint?
There’s also the wider backdrop of GP burnout, Medicare reforms and increasing regulatory demands. According to the RACGP 2024 Health of the Nation Report, regulatory burden is one of the top stressors for GPs, and those working in aged care are subject to an additional layer of regulation.
Failure of governance: the Reeves story
The Royal Commission into Aged Care Quality and Safety spotlighted the tragic case of Terry Reeves, a man with dementia who was placed in respite care and subjected to both chemical and physical restraint. There was no clear consent, no proper documentation and little attempt to use alternatives. The Commission found the care was substandard and unjustified. This case was less about bad intentions and more about poor systems.
A better way forward
Thankfully, solutions exist, and some providers are already leading the way. Jewish Care Victoria, for example, appointed Dr Simon Grof (co-author) as its Chief Medical Officer. His role includes liaising with GPs, providing clinical updates and helping GPs navigate the regulatory landscape. Other providers have geriatricians or consultant pharmacists on-site to support prescribing decisions and help reduce psychotropic use. GPs also play an important role on medication advisory committees.
These partnerships not only reduce risk but improve outcomes for older people. Research shows that interdisciplinary collaboration can reduce the use of restraint and improve the safety and quality of care.
Making the system work for older people and clinicians
This isn’t about ticking compliance boxes. The Strengthened Aged Care Quality Standards (Standards) recognise the complexity of older people’s needs and the central role of primary care. The Standards emphasise the importance of shared responsibility in clinical care. GPs and providers should agree on responsibilities, protocols and how to collaborate.
With a shrinking GP workforce and fewer junior doctors entering general practice, it’s more important than ever to create aged care models that support GPs rather than burden them.
It also means embedding aged care into early medical training so the next generation of doctors understands the regulatory environment that is foundational to the provision of aged care in Australia.
The bottom line
Chemical restraint is a difficult topic but it’s also a powerful lens for understanding how GPs and providers must collaborate more closely. If we want to deliver truly person-centred care, we can’t operate in silos. Clinical governance only works when everyone is engaged.
Ultimately, good aged care isn’t just about keeping the rules. It’s about doing what’s right, together.
Dr Simon Grof is a geriatrician with Eastern Health and chief medical officer of Jewish Care Victoria.
Dr Melanie Tan is an independent clinical governance and medico-legal consultant.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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When dealing with the elderly, we sometimes forget that they bring a lifetime of experiences with them- not always good. Most of the World War II veterans and affected civilians are gone, but there will still be others whose minds start to relive various horrific experiences as they lose the ability to suppress the bad memories. And those who were psychotic in their 20’s may still be psychotic in their 80’s. Is it kind to withhold antipsychotics from people who are getting “flashbacks” of being bombed when someone in the kitchen drops a saucepan? Those who are searching incessantly for the “lost child” who drowned 80 years ago?
By all means have lots of skilled staff but not everyone can be “talked down” .
Of course our seniors must be treated with respect and dignity, but group aged care involves a range of unavoidable compromises.
Aged care facilities are group homes, and workplaces.
The better the staffing ratios, training and experience of the staff, the higher the costs (and therefore the lower the accessibility to lower income people).
My point: no matter how well-trained, insightful and vigilant the staff are, distraction/de-escalation strategies will not always work. If staff feel that they, and/or other residents are at risk from a particular person’s behaviour, the solution can’t always be to call the ambulance: if this is a long-term behaviour pattern, psychotropic medication may be the best solution, accepting that 1:1 24 hour skilled care is not possible.
Working in emergency telemedicine outside office hours, I frequently have to assist skeleton nursing staff during night shift, when day-night reversal has patients living with dementia roaming. Calling the ambulance to take them to ED in the middle of the night is NOT a better solution for people who have already been screened for delirium
Many of us would appreciate better guidelines about when and how to use psychotropics, rather than just repeating the accusation that “intent” to control behaviour is some sort of failure.
As a GP, who has been working in Aged Care for many years, I am becoming increasingly frustrated with the lack of communication and coordinated care between nursing staff, management, pharmacy and us.
MAC, who don’t have a GP representative, make decisions and often not passed onto until a nurse pulls us up on changes. For example: no imprest box and no Afterhours medications now available, vaccines given by pharmacists sometimes notify us, but often incomplete, and physiotherapy regularly attended our patients, now rarely.
Case conferencing is always a valuable communication between the service providers, but as no funding for the others, they are less interested, despite the value of comprehensive, coordinated care for the resident, our patient.