Is It Ever Acceptable To Use Restraints

Restraint and the Law

In different countries and in different regions, the regulations and rules around restraint differ. Sometimes even within one facility, the guidelines can differ from unit to unit depending on the patient groups. In this article, we are aiming to outline some of the issues around restraint and ways that proper seating can help reduce some of the risks around this contentious issue. Please bear in mind that you must follow the guidelines set out in your own place of work and comply with your internal, regional or national laws and regulations around restraint.

In 2016, we read about a case in Northern Ireland where an elderly gentleman with dementia was tied to his chair by two care home employees and left unattended for at least two hours.

This was a horrific ordeal for the gentleman and a tragic situation for his family to learn, who were absolutely devastated when they discovered what happened, days after the incident had occurred. On examination they found bruises and marks on his arms. This obviously caused the gentleman great pain and distress, and the incident affected his personality afterwards, leaving him nervous and withdrawn. The care home in question has since closed and the member of staff found guilty of assault.

Unfortunately this is not an isolated case. Often with late stage dementia patients and patients with other neurological conditions; they can pose a safety risk to themselves and to others. They might impulsively try to stand up whilst forgetting that they cannot weight bear, therefore they are a high falls risk. Another key concern is when patients might become agitated and lash out, as they risk injuring themselves or others. As a result of this, we see restraint being used more often, and most commonly, the use of belts/lap belts as a safety measure.

When a patient is individually assessed and matched with a chair to meet their needs, often the need for restraint is reduced and incidence of falls from chairs can be lower.

Consider this Situation

Your elderly mother has dementia. She now lives in a care home specially catering for neurological conditions. She uses a wheelchair for mobility. On occasion she has been known to stand up and stumble from her wheelchair. She needs help completing this task but sometimes she forgets that she is not strong enough to stand up on her own. Just a few days ago she unfortunately had a nasty fall, which resulted in an open head wound and a trip to the Emergency Department. You were devastated when you saw the after effects of this fall and vowed you would do whatever possible to ensure it doesn't happen again. You talk to the staff at the care home about the various options to prevent this and keep her safe, which include restraint.

Weigh up the pros and cons of the situation:

• Restraint is holding your mother in her chair against her will, impeding her independence, dignity and possibly increasing agitation.
• Without restraint, you're terrified that your mother will fall again, inflicting further pain and suffering.
• It is a difficult, emotional situation with no easy answer.

The Issue of Restraints

Restraint is a complex subject. At Seating Matters we know that when patients are matched with seating appropriate to their size and clinical needs, the need for restraint is often reduced.

We have seen the difference a proper chair can make to a patients' quality of life, comfort and safety. If a patient is sitting in an over-sized standard chair which is not tailored to their requirements, they are more at risk of falling out and causing injury or harm. When they are safe, supported and snug within their chair which is designed for falls prevention and is exactly matched to their needs, they can be less agitated, more likely to sit peacefully and be safe, enjoying their surroundings. This can allow the patient a greater sense of independence and dignity, rather than being restrained which can have psychological as well as physical side effects.

The Dangers of Using Restraint

The real danger with restraining a patient is where the use of restraint is abused to the extent where it is used as a result of convenience rather than necessity. Sometimes we hear of extreme examples where shocking and unacceptable levels of restraint are applied to the most vulnerable members of our society. Although it can be abused in some extreme cases, most often it is used by a care giver as a last resort when they wish to protect the patient from doing physical harm to themselves or other patients. Sometimes the care giver may know of no other way to prevent such harm, and therefore they see a temporary restraint as the least harmful option.

What is Considered Restraint?

While definitions may vary from region to region, generally, that which restricts free movement of the patient can be considered restraint. In terms of specialist seating, the following things can be considered as restraint:

Lap Belts
In our experience, we have witnessed many cases where belts have been unnecessarily prescribed. There could be significantly less requirement for belts if patients were seated properly in a chair suited to their physical dimensions which keeps them feeling safe and secure. By belting them into a chair, they are restricted to remain in their chair and their independence and function are adversely affected. We only recommend belts are used during transportation or after a thorough risk assessment.

Lap Trays/Tables
Lap Trays are very useful to enable self feeding from the comfort of the patients chair, however if not removed once lunch or dinner time is over, these can be considered a restraint as they impede the free movement of the patient in the chair.

Tilt in Space
Tilt in space can be a useful function in order to easily redistribute pressure and to improve positioning and comfort. If abused and a patient is left in tilt for long periods of time without the ability to remove themselves from tilt, it could be considered counterproductive and therefore a restraint. The use of tilt should be prescribed in appropriate circumstances and closely monitored and managed. Often a 5 minute tilted position is sufficient in order to redistribute pressure and re-oxygenate tissues to reduce the risk of developing pressure injuries, after which the patient can be tilted back to a normal upright sitting position

Risk Assessment

There is no easy or quick answer to the question of using restraint. It should always be risk assessed on an individual case by case basis. The rules around restraint are very complex and are different in each geographical area we encounter. What needs to be reduced is the use of unnecessary restraint where it is being used out of convenience rather than necessity. Excessive use of restraint leads to risks of negative physical and emotional side effects for the patient.

In all situations the least-risk option should be considered, i.e. consider the use of tilt in space to reduce agitation in the chair, versus not using tilt in space and the client becomes agitated and steps out of the chair, risking a serious injury from a fall. When restraint is approved for use it must be closely monitored to determine the effect it has on the patient both physically and psychologically.

5 Top Tips to Consider Appropriate Use of Restraint

If the use of restraint is being considered to keep a patient or loved one safe, consider why and seek to fix the root of the problem, not just address the symptom which is a short term fix.

Restraint is not the only answer. Ask yourself these key questions about their current situation

• Is the seat width of their chair too wide? If so they could be feeling unstable, uneasy and as a result, restraint may be being used unnecessarily to keep them seated and 'safe' in their chair. The general rule of thumb is that leaving a 1 inch gap between the outermost part of their hip and the arm of the chair is sufficient.
  
  
• Is the seat height too high so their feet don't touch the floor? It is often necessary to load the feet on the floor or a footplate for several key reasons. Firstly, 19% of our body weight goes through our feet so it is essential for pressure management in order to redistribute pressure throughout the body but also to 'ground' the person in the chair so they feel stable and secure. When we have something beneath our feet we can feel more secure and safe as a result. Stability is important and when a patient does not have that sense of 'grounding' or stability they might seek sensory feedback by trying to find the floor, leading to an increased risk of falls.
  
  
• Are they likely to feel safe in the chair they are in? You can often tell just by looking at the chair whether it is a good fit for the patient or over sized, and you can often read facial expressions if the patient is non verbal, to determine whether they could be content or anxious and worried about the possibility of falling or sliding from their chair.
  
  
• Are they agitated in their chair? Are they constantly moving, trying to get a better sitting position or trying to stand up? Do they look like they are in pain? Improving their level of comfort can reduce agitation, allowing them to sit peacefully and rest.
  
  
• Can they sit up straight independently or is their body falling to the side, or sliding forward? They might require some additional postural support to maintain a mid-line postural position. If their posture is affected by muscle weakness, a spinal condition like scoliosis, or gravity, they are likely to be uncomfortable and at risk of falls and sliding out of the chair.

Reduce Restraint and Prevent Falls with the Atlanta Chair

The Atlanta™ from Seating Matters has been called a 'Magic Chair' in the past by clinicians. With its deep reclined seat and back angle recline, it creates a very safe and comfortable position for patients. It comes with an adjustable angle leg rest for optimum comfort. In some cases, patients with conditions such as Huntington's disease have experienced a reduction in involuntary movements in the past and numerous patients with dementia have shown a reduction in agitation when using this chair properly. It is a fantastic chair to consider for any patient who presents as a falls risk.