November 24, 2012

Rose M. Carter, Q.C.Bennett Jones LLPAdjunct Professor,Faculty Medicine and DentistryUniversity of Alberta

Rocky Mountain Internal Medicine Meeting

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• Environmental• The use of environment, including seclusion or a time out

room, to involuntarily confine a person and to restrict freedom of movement

• Mechanical• The use of a device or appliance that restricts or limits

freedom of movement, for example, vest restraints, lap belts, pelvic restraints, mittens, geriatric chairs with locked trays and sheets

• Chemical• Any psychotropic drug not require for treatment, but

whose use is intended to inhibit a particular behavior or movement

College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009) at 3

Types of Restraints

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• Physicians are responsible • for "taking all reasonable steps to prevent harm to

patients"• to "respect the right of a competent patient to accept or

reject any medical care recommended"

Canadian Medical Association, Code of Ethics (2004)

Responsibility

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• When necessary to protect • the patient• other patients, • or others lawfully on the premises (staff or other patients) from

harm to prevent endangerment to the safe environment of the hospital or facility

Conway v. Fleming [1996] OJ No 1242 (Ont Div Ct)

When can restraints be utilized?

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• Need informed consent from patients, their families, and/or their legal guardians

• Ensuring the safety of the patient and others

Use of Restraints – Legal Issues

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• Responsibility for use of restraints shared by:• all members of the health care team;• patients;• their families;• and/or their legal guardians;• the community;• regulatory agencies; and • governing bodies

College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009)

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• May be appropriate where a patient is at risk for self-injurious behavior or poses a threat to the safety of medical staff and other patients

College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009)

Restraints in Hospital Setting

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• CARNA advocates for a policy of • least restraint in all client care settings; • this requires that nurses exhaust all possible alternatives

before using restraints

College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009)

Amount of Restraint

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• Use of restraints may result in negative consequences:• loss of bone and muscle mass;• skin breakdown;• Immobilization;• urinary incontinence;• urinary tract infection;• Pneumonia;• cardiovascular stress; and• psychological and psychiatric sequelae such as increased

agitation, anxiety, delirium, depression and even death

College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009)

Negative Consequences

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• Involving of families in providing care• Choosing less intrusive treatment options• Offering medication to control pain• Providing physical activity to diffuse the mood of an

agitated pt

College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009)

Possible Alternatives to Use of Restraints

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• consider: • The patient's response to the restraints/whether the restraint has the

desired effect• Positioning of the restraint• The need for ongoing use of restraints each shift• The patient's level of alertness and orientation• The affect of the restraints on the patient's and their emotional well-

being• The patient's need for socialization• Any pain or discomfort related to the restraint• The opportunities for the discussion of thoughts, feeling and worries

regarding the restraint• The patient's need • Any opportunities for physical activity, re-positioning, and skin care• Circulation to extremities to which a restraint is applied

University Health Network, Policy and Procedure Manual: Clinical – Patient Restraint Minimization (2005)

Monitoring of Patient Under Restraint

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• Section 30 provides • the authority to control a person under this Act is authority

to control the person without the person's consent to the extent necessary to prevent serious bodily harm to the person or to another person by the minimal use of such force, mechanical means or medication as is reasonable, having regard to the physical and mental condition of the person.

• NB – Section 30 only applies to patients who fall under the terms of the MHA (those who are detained in a facility pursuant to an admission certificate)

RSA 2000, c.M-13, s.30

Mental Health Act (MHA)

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• Appropriate to use restraints to protect the patient from suicidal behavior and to protect others

R. v. Wittman, 2007 ABPC 89,415 AR 394

Case Law

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• the plaintiff was a non-psychiatric in-pt who suffered injuries when she was attacked by a psychiatric in-pt.

• She sued the hospital for negligence for failing to control the movements of a mentally-ill patient who had known propensities for violence

Wellesley Hospital v. Lawson [1978] 1 SCR 893 at 895, 76 DLR (3d) 688 [Wellesley]

Case Law

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• SCC noted • at common law a hospital, especially one providing

treatment for mentally-ill persons, would be under an common law liability if by reason of its failure to provide adequate care and supervision injury occurred to third persons by reason of the conduct or behaviour of a patient

• Court stated the hospital had an• independent duty to supervise and keep under reasonable

control patients who the hospital knows or ought to know have propensities do to violent behavior

Wellesley Hospital v. Lawson [1978] 1 SCR 893 at 895, 76 DLR (3d) 688 [Wellesley]

Case Law

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• the hospital had the authority, and the duty, to control (or restrain) the behavior of the mentally-ill patient if necessary to protect other people from harm.

Wellesley Hospital v. Lawson [1978] 1 SCR 893 at 895, 76 DLR (3d) 688 [Wellesley]

SCC Concluded

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• every hospital, and every unit with a hospital, will have its own policies regarding the use of restraints

Policies and Procedure

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• AHS is in the process of developing a comprehensive policy on the use of restraints during hospitalization

• The policy is meant to relieve the ambiguity in this area and will apply across the province

• This policy is set to be released in 2013

AHS Future Policy

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• Duty to protect pt from self harm• Duty to protect others from a pt who may harm

them• AHS developing policies and procedures due out in

2013

Summary

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