Physical Restraints: There Are Alternatives


Your mother lives in a nearby nursing home and she has fallen there a number of times.  She suffers from dementia and osteoporosis.  You are getting worried that the next phone call will bring news that she has broken her hip.  The staff is becoming concerned as well.  They suggest that keeping your mother in a wheelchair and using a physical restraint may be in her best interests.  What should you do?

  • Federal nursing home regulations say, "The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.  Restraints may only be imposed -- "(I) to ensure the physical safety of the resident or other residents, and (II) only upon the written order of a physician that specifies the duration and circumstances under which the restraints are to be used...."
Examples of physical restraints are hand mitts, vests, waist belts, gerichairs, pelvic rollbars, and a relatively new product used across chair arms --"positioning pillows."  Bed rails, chairs, or tables which prevent someone from rising are forms of mechanical restraint.  A locked wheelchair or bed sheets tucked so that a person cannot move also fall into this category.

Many nursing home residents and their relatives are not always aware of the potential detrimental risks of using physical restraints.  Here are some:
  • Decreased appetite
  • Bone demineralization
  • Malnutrition
  • Decreased muscle strength
  • Dehydration and mass
  • Constipation
  • Contracted muscles
  • Incontinence
  • Pressure sores (ulcers)
  • Pneumonia
  • Cardiovascular stress
  • Urinary tract infections
  • Death by asphyxiation
Note that these are only the physical dangers; the psychological impact of being restrained cannot be overlooked.  Restrained individuals may experience a loss of dignity and reduced social contact, and/or may exhibit agitation, hostility, depression, withdrawal and lethargy.

First and foremost, prior to using any physical restraint, it is incumbent upon a nursing facility to thoroughly assess a resident to determine what is causing the problem.  Federal law mandates utilization of specific tools to assess residents and devise care plans for them.  It also requires the facility to consider all less restrictive alternatives first.

Let's look at some common reasons for restraint usage and some alternative measures.
  • Poor posture--sliding in seat:
Seating should be customized to the individual, drawing from a wide variety of special cushions, pillows, and postural supports which are available.  The resident should not have to sit for long durations, and different types of chairs should be provided.  Seating should be as comfortable as possible; wheelchairs--the most common "seat" provided--don't [always] meet this criteria!
  • Gait Problems/unsafe mobility:
Nursing staff should consider whether hearing and visual deficits, medication side effects, blood pressure, a lack of exercise, or medical illness (infections, pain) are to blame for a resident's instability.  The environment must not be overlooked: Is the resident's furniture too large or unstable?  Is her bed or chair too high?  Is the lighting adequate?  Are the waxed floors slippery or causing a glare?   Also, do the resident's shoes fit properly and do they have skid-proof soles?  Is her cane and walker in good repair?
Besides treating, correcting or minimizing the effects of these problems, nursing home staff can learn about the resident's lifelong habits in order to anticipate when the resident will need assistance in getting to the bathroom or obtaining a snack, for example.  Residents should be provided with meaningful activities suited to their needs and cognitive abilities.  This, plus varying locations where the resident sits (i.e. quiet and busy areas) may reduce the chances of the resident getting up unaided.
  • Wandering:
Staff should assess why the resident is wandering, looking at his past social history and personal habits.  Boredom, thirst, pain, fatigue, over stimulation or the need to use the bathroom should also be considered.  Staff should attend to and empathize with the emotional needs expressed by the individual.
Some alternatives include providing comfortable rocking chairs to meet the need for motion; allowing the use of personal furniture and possessions to make one's room recognizable and home-like; eliminating the use of a PA system, which can be stressful and confusing to residents.  Also: structured, familiar daily activities; an exercise program; opportunities that can provide residents with a sense of purpose; audio or videotapes of the person he might be seeking.
It is important that the restless resident be permitted to wander.  Staff should ensure that the inside environment is as hazard-free as possible, and provide a safe enclosed outside area to walk with benches in the shade.
Stop signs, theater ropes and partitions as well as "camouflage" like towel racks, mirrors, and wallpaper can be employed to discourage wandering residents from going through doors that they shouldn't.  All staff (not just nursing personnel) should be alerted to watching for residents who wander.
  • Agitated and/or aggressive behavior:
The agitated/aggressive resident should be approached from the side in a calm, gentle, non-threatening manner.  Staff should respect the resident's need for personal space and stay physically distant until the resident calms down.  Validating the resident's feelings and initiating reminiscence can be effective interventions, whereas arguing, reasoning, or using reality orientation are unlikely to help.  Change the environment by reducing stimulation, rearranging the seating, and/or playing soothing music.
Bearing in mind that "frustration breeds aggression," staff should assess the cause or "triggers" for such behavior, focusing on what immediately precedes it.  They should ask the resident what is wrong and explore whether bodily discomfort such as thirst, hunger, pain, constipation, or fever are the culprits.  Was the resident's sleep cycle disrupted?  Are medications having side effects?  Is the resident hypoglycemic?  Is a high noise/activity level around the resident provoking the agitation?
Other helpful approaches include identifying specific things that comfort the resident when she is agitated; always explaining procedures to the resident before they are performed; providing a regular, structured schedule; limiting the number of primary care givers; and offering ongoing in-services for staff to discuss effective interventions to deal with these difficult behaviors.
  • Interference with vital medical treatment:
When a resident disrupts life support measures, nursing staff should first check the IV or tubing site for irritation.  Next, alternatives such as providing hydration by mouth instead of a feeding tube, or inserting a gastrostomy tube instead of a naso-gastric tube should be considered.  Evaluate whether permitting incontinence or initiating a bladder training program might be the preferable alternative to a urinary catheter.
Other interventions can include covering IV tubing with long sleeves, covering gastrostomy tubing with flextone binders, and/or providing the resident something else to pull and manipulate such as a knotted towel.
Most importantly, the staff, family and physician should discuss the resident's rights to dignity, comfort and autonomy, and what this resident wants.  They will need to try to ascertain whether the resident is removing the tube to convey refusal of treatment.
Let's return to the dilemma above.  As you can see, the question of whether to use a physical restraint often involves a choice between two "evils":  the risk of the unrestrained resident falling and coming to serious harm, or the emotional and physical risks associated with restraint usage.  The decision is not an easy one.  It is best made by well-informed residents who comprehend the various risks and can communicate their wishes.  When this is not possible, families should make the decision in consultation with the physician and primary care nurses, all the while focusing on what they believe the resident would want.

For further information contact the Ombudsman Program at 703-324-5861.


References:
  • "Omnibus Budget Reconciliation Act of 1987"
  • "Avoiding Physical Restraint Use: New Standards in Care" by the  National Citizens Coalitions for Nursing Home Reform
  • "Eliminating Restraints Resource Manual" by The Vermont Free-to-Be Project, 8/90 excerpts from above.

    [As of 2004, the Omnibus Budget Reconciliation Act of 1987 is current law.]

If the resident opts for a restraint, the assessment must show the presence of a specific medical symptom that requires its use, that those symptoms are being treated, and how the use of restraints will assist the resident in reaching his or her highest level of physical and psychosocial well-being.

On the other hand, there have been situations in which residents wanted a rest
raint, because it increased their sense of physical security.  Federal guidelines require that residents (and their families) should be told of the potential negative outcomes of restraint use.  A self-releasing device fastened with velcro was appropriate in at least one situation.

(Use a different example in which safety isn't the main factor?  Say she has disrupted other residents with wandering into their rooms?  For someone so frail-looking, she has surprising energy--always up and about and moving.)

Physical restraints are defined as "any manual method or physical or mechanical device, material, or equipment...that the individual cannot remove easily which restricts freedom of movement or normal access to one's body."

[One resident, who objected to the side rails of her bed being up, told the Ombudsman, "I feel like a monkey in a cage."]



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