When there’s a possibility that patients may harm themselves or others, physical or chemical restraint may be required. However, the use of restraints is not without risk and their use must be carefully considered.
Using restraints can lead to increased physical harm, psychological trauma, distrust in the medical system, and damage in the physician-patient relationship. Injuries to patients and staff, sudden unexpected death, and cardio-respiratory problems can all be associated with the use of restraints.
Best practices on restraints generally emphasize that institutions should strive to be restraint free. Restraints should be considered extraordinary measures and used only when alternative interventions fail and in compliance with applicable legislation and hospital/institution policies governing the use of restraints.
What can physicians do to help ensure patient safety and reduce the risks? Physicians can take steps such as clearly communicating with patients or families about restraint use and effectively monitoring restrained patients. Legislation and best practices on the use of restraints also offer guidance.
Restraint legislation
Physicians should be familiar with any relevant legislation governing the use of restraints in their jurisdiction.
Under the common law, a physician owes a duty of care to their patient to take any necessary steps to protect the patient from harm during treatment. The courts have also recognized the right and duty to protect others from a potentially dangerous patient.
Legislation governing the use of restraints in common law jurisdictions (all provinces except Québec) does not generally affect the common law duty and right to restrain or confine a patient when immediate action is necessary to prevent serious bodily harm to the patient or to others.
In Ontario, for example, the Patient Restraint Minimization Act stipulates that a hospital may apply restraints if necessary to prevent harm to the patient or others, to enhance the patient’s freedom or enjoyment of life, and if it is part of a treatment plan authorized by the patient or their substitute decision-maker. The legislation outlines important considerations in the use of restraints including the adequate monitoring of patients. It also emphasizes the importance of trying alternative methods, staff training, and appropriate record-keeping.
In Québec’s An Act to make the health and social services system more effective, requirements are similar, stipulating that force, isolation, mechanical means or chemicals may not be used to place a person under control, except to prevent the person from inflicting harm upon themselves or others. Further, the use of such means must be minimal and resorted to only exceptionally, and must be appropriate having regard to the person’s physical and mental state. All Québec institutions must adopt procedures for how the use restraints is applied and that are consistent with the published ministerial guidance.
Understanding the impact of racial bias
Racial bias in healthcare settings can significantly impact the use of patient restraints. Studies have shown that in emergency departments and psychiatry units, racialized groups, particularly Black patients, are more likely to be restrained than white patients.1, 2 This disparity can stem from unconscious biases held by healthcare providers: unconscious attitudes or stereotypes that affect our understanding, actions, and decisions.
Racial stereotypes and biases may cause healthcare providers to unconsciously perceive (and treat) racialized individuals as more aggressive or threatening. In a fast-paced environment where decisions are made quickly, these biases can lead to the excessive use of restraints rather than de-escalation techniques.3, 4
Racialized patients experience a higher rate of police transport to the ED. The presence of police transport may create the perception of a threat and may influence decisions on restraints, which may lead to escalation of distress and agitation.1
Safety and managing risk
Most hospital/institution policies dictate that a physician order is required for restraints and that restraint orders are reassessed every 24 hours. Some institutions mandate a debriefing shortly after a patient has been restrained.
To help ensure patient safety and reduce risks when using restraints:
- Where practical and the circumstances permit, speak with the patient or substitute decision-makers, clearly and calmly explaining why and how restraints are to be used.
- Document in the medical record those discussions, the information relied on, and the rationale to make the clinical decision to use restraints as well as the type of restraint.
- Follow guidelines on the use of restraints, complying with laws, regulations, and hospital/institution policies.
- The restraint should be proportionate to the physical strength and ability of the patient and used for the shortest time that is necessary.
- Institutions should have appropriate resources, staff training, equipment, and policies and procedures to effectively monitor restrained patients.
Additional reading
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