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THE risks of using physical restraints in nursing homes outweigh the benefits, and data on the full extent of the harm being caused by this practice is needed, says a leading expert.
Professor Joseph Ibrahim, head of the Health Law and Ageing Research Unit at Monash University’s Department of Forensic Medicine, co-authored a study that found there have been five deaths from physical restraints in Australian nursing homes over a 13-year period, but he told MJA InSight that what researchers really needed was access to information on the number people being restrained and the associated injuries.
“There isn’t a central reporting body for it, so when we produce an article like this one, which says there’s been a small number of deaths, people say ‘well, that’s okay because it rarely happens’. But that’s missing the point: we don’t know the proportion of serious injuries from physical restraints.
“We need to know how many people are actually restrained in any way and talk about whether that’s acceptable, rather than turning a blind eye or rationalising by saying that we’re acting in the person’s interest, and their best interest is to stop them walking because they might fall.”
The study, published in Age and Ageing, was based on deaths reported to coroners in Australia between 2000 and 2013, and the number of fatalities attributable to physical restraints was likely to be an underestimate, the authors said.
They found that the median age of residents who died was 83 years, and all residents had impaired mobility and had restraints applied for falls prevention. Neck compression and entrapment by the restraints was the mechanism of harm in all cases, resulting in restraint asphyxia and mechanical asphyxia, respectively.
“Although there are few deaths occurring due to physical restraint, the seriousness of the outcome, and questionable efficacy of restraint use for falls prevention, should prompt policy and practice reform towards a restraint-free model of care”, the authors wrote.
“The prevalence of physical restraint use for people with dementia in residential care varies from 12–49%,” they wrote.
Professor Ibrahim said that nursing homes justify physical restraints because they believe they reduce harm from falls by preventing patients from moving around and leaving the facility.
“The problem is that restraints get people more agitated and what we continue to ask is ‘what are the downsides of physical restraints, and would you rather fall or be restrained?’
“We think, on balance, most people would prefer not to be restrained.”
He said that the continued practice of physical restraints in some residential homes stems from fear – fear from relatives, and fear from nursing home staff who don’t want a fall to happen on their watch.
“So, this is based on fear of harm without any consideration that the restraint itself causes harm, and I honestly don’t understand that.”
Professor Ibrahim said that physical restraints were viewed by nursing homes as being more subtle than straitjackets and were similar to a seatbelt.
“But what they don’t recognise is that if you want to get up, or you’re busting to go to the loo, and you stand up with a seatbelt on, then you can fall while attached to chairs.”
Professor Ibrahim said he had experienced backlash to his research on this topic, which reflected a bigger problem of how society viewed ageing and dying.
“The minute you’re old, you’re not allowed to play, walk and everyone wants to protect you. They want to protect what they think is your physical health, but our argument is that there is no point in being healthy if you can’t do anything.
“Would you rather be sitting on a couch doing nothing or going out and doing something that you enjoy, with a fall at the end of it? Which would you choose? And some people will choose to sit quietly, but I think the assumption that that’s what everyone wants to do is wrong.”
Professor Ibrahim added that there needed to be an open and frank discussion about the common perception that old age is a time to die quietly without unsettling anyone.
“I’d rather have a messy death that meant I was enjoying my life, than sitting in a room day after day waiting to die ‘nicely’. Dying nicely only really suits the survivors.”
He said that a general assumption was that a nursing home was a place where old people go to wait for death to happen.
“We’re really trying to dispel all of that and the only way, with our background, is to go through the academic literature and try and create a debate.”
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restraints shall be used if it is necessary. but when using necessary restraints, the staff should make sure that it do not cause and risk of injury or death. if the staffs who used restraint belts or bed rails in the above death cases had properly used it, if they had put cushions between the bed rail and the resident it would not have lead to the neck strangling. so here the cause of death is not the use of necessary restraint but it is due to the improper or careless use of restraint. then the justification may arise that the reason is under-staffing. there is often a trend to blame on under-staffing for all issues in hospitals and nursing homes. i must say, under-staffing has nothing to do with the above death incidents. how much time it require for a staff to put those belts properly? how much time it require for the staff to put a cushion between the resident and the bed rail to avoid neck strangling between the bed rails? only a few seconds. the staff have not done it properly. even if there was 1000 staffs on duty on that day in that nursing home, the same thing will happen if it is not done properly. only a single staff will perform that duty. that single staff could have done it properly to avoid the death. so everything rests on the common sense of the staff to do a thing properly after considering the possible risks involved in an act.
It is strange that in all these comments, and the article itself, there is no mention of the safety and well being of the staff caring for patients. Employers have a duty to provide a safe place to work and having staff hit or pushed over does not meet OH&S standards. I do wonder at the acceptance of physical and verbal abuse by the staff of RCAFs as part of their job – the “they don’t understand what they’re doing” attitude. Until every worker in health facilities can go to work feeling safe, I don’t think we can honestly say that restraints are evil.
‘Would you rather be sitting on a couch doing nothing or going out and doing something that you enjoy, with a fall at the end of it? Which would you choose?’ In my opinion this absolutely sums it up – we seem, as a community, to forget about the importance of autonomy for the frail aged. Atul Gawande’s quote in ‘Being Mortal’ about wanting autonomy for ourselves and safety for those we love is very pertinent. Unfortunately, the fear of blame (by relatives, the coroner, aged care facility accreditors, etc) if someone does fall is well-founded in Australian society; hopefully articles such as this will drive the conversation that might slowly change this culture.
In a culture that values autonomy and individuality highly, it is incongruous that we do not allow this for our aged. We impose restraints because we can neither afford 1:1 care nor accept the harms that are a natural consequence of freedom.
Of course it is even more challenging to discuss those who are restrained chemically and physically because of the risks of their behavior towards others.
I agree with one of the commenting persons that current staffing is NOT sufficient to prevent injury to patients. Two aides for fifty patients is very common in my state. I have worked in nursing homes so I know first hand how much work is involved. Utopia has staff to patients ratio that allows for wandering and one on one care.
These are insightful comments. There is a body of literature on the deleterious effects of the use of restraints in aged care settings and it is a complex issue. There are some situations here it is necessary. There are many different types of restraint chemical, physical, mechanical, seclusion etc. Using restraint with restraint i.e. as a last resort is the best approach, using whatever else can be used that is less restrictive is the best way to go. Staffing levels, lack of education, zero risk tolerance all increase the use of restraint. People in care and their families need choice about the use of restraint or not also I believe. Some family and the patient may be OK with the risk of a fall if the person is mobile and less agitated.
The evidence shows that physical and mechanical restraint increases the risk of delirium in older adults and those with cognitive impairment, see http://www.anzsgm.org/documents/PS13DeliriumstatementRevision2012.pdf .
Physical and mechanical restraint have for decades been associated with metabolic acidosis, which has a high incidence of cardiac arrest. See http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1999.tb00164.x/pdf. There is a great deal of evidence that demonstrates this risk, and the risk of again increasing delirium through these actions.
The above evidence is in addition to the risk of asphyxiation.
We are very focussed on tasks when caring for older people, and this is a necessity given the physical and cognitive changes that occur with aging and also associated chronic illnesses including dementia. Task focus is also where most of the funds are allocated. We do not spend quality time with these humans, and we do not adequately engage in activities that distract and tire; we do not adequately train our staff in skills required to do this.
We would be repulsed at the thought of tying up a busy and curious child, and do our best to tire them out every day with physical and mental challenges. Until there is a shift in how we see and value the quality of life in older adults in the demographic we are discussing, staff will continue to be challenged by behaviours and will continue to resort to physical, mechanical and chemical restraint.
I presume everybody that makes a comment at least works or have worked recently in an age care facility.
The situation is much more complex than having a blank rule as we are treating individuals and aim to provide person centered care.
Developments in restraints have come a long way too. You cant compare a concave mattress(a restraint that needs to follow the same stringent paperwork and regular review) on a low low bed to a leg slider restraint. Let alone comparing physical restraints to chemical restraints.
Low low beds have replaced bed rails safely in most cases but are more dangerous if not left in the lowest position if the patient is unattended.
Leg sliders are more safe than lap belts, but it needs to be applied correctly and used appropriately. Carers need enough training to manage restraints. In my experience the complications of not applying the restraints correctly or as advised causes the problem in most cases.
The ultimate factor determining patient safety and preventing complications are staffing numbers(1-1 would be ideal but who will be funding it), good communication between staff, doctor and family so everybody understands the implications and proper ongoing staff training( especially non medical care workers). Effective restraints in the extreme cases are usually the only workable alternative after every other resource have been exhausted.
There will always be a a role for some forms of physical restraint where the risk is felt to outweigh the harms. No point making sweeping statements as averages wont necessarily apply to individual situations.
Need to identify what types of restraints resulted in asphyxiation and redesign them to reduce the risk.
Minimal trauma fractures are common and frequently implicated in deaths and cause a good deal of suffering too – to disallow one means to reduce these where it is felt to be appropriate and effective may do harm not good.
Sometimes there may be a better solution but no money to purchase it – can only do what one feels is lowest risk at time with resources available.
1. The definition of restraint and restriction need to be clearly defined. If restraint involves tying someone down then I feel this mostly an ill advised circumstance. If restraint involves a waist strap or a device similar to seatbelt aimed a stopping someone from tipping forward in their chair , then I believe the risks and benefits need to be considered. Some definitions of restraint could include raising the bed rails and such a simple act may not be divisively restrictive , but might prevent someone from falling out of bed at night .
2. A traumatic death whether asphyxiation or fracture become coronial inquests , which most everybody prefers to avoid. The fear of the inquest process is driving some of these activities. Osteoporosis related causes of death are unreported in my opinion , as having fracture as a cause creates an inquest that no one wants (including the coroner). The threat of inquest leads to biased statistical reporting (we don’t get a clear picture). For me , I have been told to not put # femur as the cause of old lady’s death , when a healthy independent old woman, falls at home, 3 months prior , has appropriate surgery and rehab , but never recovers sufficiently to return home and is ultimately death within months (better to call this “old age” to avoid the inquest of saying it was the # femur that killed her ).
Of course no-one wants to be restrained and it is all well and good to stop using restraints – but we would then in fairness also need to prevent lawyers and litigious relatives suing facilities for “damages” (and fund higher carer ratios as per the previous comment)
I suspect that many people who argue strongly against restraints in all situations have never actually worked as an aged care worker in a dementia facility….
Moreover, the community at large needs to have this discussion well before restraints are needed – as the people on whom they are likely to be used are (by then) often not competent to make their own wishes clearly known…. and relatives’ wishes are not always in harmony with the person under discussion.
it reminds me of another form of restraint. My mother was in the early stages of dementia, and the residential care facility was preventing her from going for walks down the street, which was all she wanted to do. They were concerned that she may have an accident crossing the road, or get lost. I accepted that these were real risks, but to my mind they were outweighed by her feeling of desperation when she was locked in and denied her freedom, as if she had been jailed. Even though I had Power of Attorney (including under the Medical Treatments Act) I had a huge battle with the facility to allow her her freedoms again. Fortunately for Mum I won the argument, and she had some further months of enjoying this activity, until her health further deteriorated and it was no longer an option. I could understand the concerns of the facility, and their fear of being found liable for any untoward outcome, but there seemed to be no recognition of my mother’s rights in any of this. And what of those people who have no-one to advocate for them?
Physical restraints seem also to be a very crude tool that may be overriding people’s rights. I would personally hate to be tied down, and I imagine that many of the residents would feel the same way, regardless of frailty or dementia. There has to be a better way.
How can he conclude that the risks outweigh the benefits when he doesn’t have the data on the benefits, and only partial data on the risks?
When society is prepared to pay the wages for one-on-one care in all aged care facilities, then physical restraint cane be consigned to history as a means of protecting residents from falls and assault by fellow residents