Patient Restraints

M. SUHRON
Sample Case
 stages of Alzheimer's Disease
– Cognitive impairment
• Memory

• Understanding

• Reasoning

• Emotions

 “ Pengembara “and “helper”

 Perilaku kekerasan
 Fungsi keseimbangan terganggu
“restraint”: definition

 Perangkat atau protokol untuk membatasi

mobilitas pasien yang membatasi gerakan
pasien, imobilisasi kepala / ekstremitas
pengasingan
 [ Medis / pengekangan farmakologis ]
2 Kategori

 Perangkat atau protokol yang

diperlukan untuk pengobatan

 Perangkat atau protokol tidak

diperlukan untuk pengobatan
"perlindungan" kenyamanan
Professional actions

 Tindakan profesional terjadi dalam

konteks sosial

 Konteks sosial tunduk pada batasan

hukum . Oleh karena itu mungkin
tepat untuk memulai dengan
beberapa pertimbangan hukum
 Indikasi restrain
 Seseorang melakukan serangan ketika tanpa
persetujuan dari orang lain ,
 Berlaku memaksa sengaja untuk orang lain ,
langsung atau tidak langsung
 Mencoba atau mengancam , dengan tindakan
atau gerakan
Some provincial statutory
provisions
 Dalam Undang-Undang ini : "
penyalahgunaan" berarti penganiayaan
sengaja dewasa yang menyebabkan orang
dewasa ( A) fisik , bahaya mental atau
emosional , atau ( B ) kerusakan atau
kehilangan aset , dan termasuk intimidasi ,
penghinaan , penyerangan fisik ,
kekerasan seksual , overmedication ,
Kenapa di restrain
 ( A) pengekangan fisik,
 ( B ) cacat fisik yang membatasi
kemampuan mereka untuk mencari
bantuan , atau
 ( C ) suatu penyakit cedera atau kondisi
lain yang mempengaruhi kemampuan
mereka untuk membuat keputusan
tentang penyalahgunaan atau kelalaian
The View from the Ethical Window
 Relevant Ethical Principles

Beneficence Autonomy and Respect

Non-Malfeasance Fidelity

Impossibility Equality and Justice

ETIC
Legitimate Infringement
Pelanggaran yang sah
Cont..

 Physician or hcp in charge

 Duly empowered proxy
 [Role of relevant Legislation]
Standard ethical indications:
Principled practice
 Danger to self
– Beneficence, non-Malfeasance, Fidelity

 Danger to others
– non-Malfeasance, Fidelity

 Necessary to achieve legitimate

therapeutic aim
– Fidelity
Convenience vs. practical necessity
 Convenience
 Practical necessity
– Danger
• to self
• third party
– Hcp as agent of institution
– Duty to warn / alert
• administration
• patients / substitutes Fidelity
• authorities
• public
General procedures
 Ethically based requirements
– Necessity
• Impossibility
• Beneficence
• non-Malfeasance
– Least intrusive alternative
• Autonomy
• Fidelity
– Informed consent if possible (pt. or substitute)
• Autonomy
• Equality
• Fidelity
Standard ethical protocols
 By authorised professional
 Not for convenience or punitive
– Legitimate infringement, Equality, Fidelity, Beneficence
 Continuously assessed, monitored and re-evaluated
– Fidelity, non-Malfeasance
 Evaluated within one hour by physician or independent
qualified hcp
– Fidelity, non-Malfeasance
– One-hour rule standard in most jurisdictions
• Autonomy, Fidelity, non-Malfeasance
 Training of staff
– Fidelity, non-Malfeasance
 Simultaneous use of restraint
and seclusion
 Higher level of necessity
• Impossibility, Fidelity, Legitimate infringement, Least
intrusive alternative
 Greater level of care
• Fidelity, non-Malfeasance
– Continuous monitoring face-to- face with hcp or
– Continuous monitoring through video and audio
with pickups in close proximity to patient

Sample website: www.hcfa.gov/quality/4b2.htm

Some basic considerations
 Is restraint a matter of convenience?
 Is restraint a matter of necessity?
 Who identified the necessity?
 What is the place of the restraint in
– the specific treatment plan
– the overall protocol
– in the professional / institutional culture
 Has there been
– review
– consultation
 Other Restraints

Chemical restraints are subject to the same

considerations as physical restraints – with the added
caution of pharmacological interaction.
The End
Informed consent
 Parties
– Patient
– Proxy decision-makers
 Standards
– Reibl v. Hughes
– Fleming v. Reid
– Ciarlariello v. Schacter

.
 Autonomy and respect for
persons
 Everyone has the right to be treated
not as an object but as an
autonomous decision-maker who is
entitled to respect as an individual.
[
Equality and justice
 All persons are the same insofar as
they are persons, and should be
treated equally. Differential treatment
should be based solely on ethically
relevant differences.
Beneficence
 Everyone has a duty to try and
maximize the good.
Non-Malfeasance
 Everyone has a duty to try and
minimize harm.
Fidelity
 The existence of a duty entails a
corresponding obligation to fulfil the
duty to the best of one’s ability.
Impossibility
 No-one can have a duty to do what is
impossible under the circumstances
that obtain.
 Limiting condition
– The impossibility is not due to an
inappropriate action on part of the
individual her/himself.
Principle of Legitimate
Infringement: basic version
 The fundamental rights of the
individual person are
conditioned by the equal and
competing rights of other
persons.
 Principle of the Least
Intrusive Alternative
 A right may be infringed only for ethically
proportionate reasons.
 The infringement must be demonstrably
necessary to achieve the otherwise
legitimate aim.
 The infringement must infringe the
relevant right only to the degree
necessary to achieve the otherwise
legitimate aim.