Following a stroke, Mrs. Smith, an eighty-two year-old nursing home resident, spent an evening in the ICU. She became confused and agitated, pulling out her IV line. After reinserting it, the night nurse placed Mrs. Smith in soft wrist restraints. She continued to struggle, broke free of them, and pulled the line out again. The nurse asked the physician to do something about Mrs. Smith's agitation, so the physician prescribed a sedative.

If a hospital patient or nursing home resident seems likely to injure him or herself, caregivers often use physical or chemical restraints to prevent serious health and quality-of-life consequences. The essential ethical concern is that people who do not agree to restraints will experience them as humiliating and dehumanizing, regardless of potential benefit. It is difficult to square the ethical values of autonomy and human dignity with the use of restraints. The fact that caregivers are well intentioned in seeking to prevent a patient from injury does not overcome the patient's feeling of subjection to the will of others. Forced immobilization may cause physical or psychological harm or emotional trauma to the patient.

For the past several years, health care professionals in various facilities have been rethinking the use of restraints. Key to the use of restraints is informed consent, requiring adequate information about risks, benefits, and alternatives to restraints, since most patients for whom restraints are considered already have some cognitive impairment. Evaluation of patients' or decision makers' ability to understand the issues is critical.

The Health Care Financing Administration (HCFA) views the use of restraints as high risk and problem prone (see HCFA Standard: "Restraints for Acute and Surgical Care," A769-799, Interpretive Guidelines 482.13 (e) and (f), A180-196). Because of their impact on patient dignity, rights, and well-being, the Guidelines suggest that restraint policies be developed by interdisciplinary groups, identify specific staff roles and responsibilities, and require documentation that includes reasons for restraint and instructions for specific use. Alternatives are urged, with the least restrictive one as the primary goal. Restraints should not be implemented as part of general practice or an alternative to proper care and personal attention, and never for the staff's convenience. Their use must always be individualized, unless a carefully developed protocol exists for selected patients. Overall, the objective is a reduction in the use of physical and chemical restraints.

Policies and procedures for restraint use in hospitals or other health care facilities with inpatient psychiatric units or outpatient mental health treatment clinics may be different than those established for the general patient population.

If Mrs. Smith is agitated and disoriented, the importance and purpose of the IV line and any other procedures should be explained to her carefully and clearly. An effort should be made to maintain a consistent staff presence, since new faces and voices may be upsetting. The presence of loved ones and family members, especially at night, might reassure the patient. An assessment should be made of the possible causes of her agitation. Other steps that could be taken include ensuring uninterrupted sleep, judicious use of lights (especially at night), reducing noise, staying within Mrs. Smith's visual field when talking, and avoiding arguments. If she remains agitated, staff should ask how serious it is if the IV line is dislodged and has to be replaced and whether there might be some other way to provide the necessary treatment.

According to Advocate's Mission, Values, and Philosophy, appropriate use of restraints stems from the value of equality, which affirms the respect, integrity, and dignity of all people. As compassionate caregivers, associates embrace the whole person and respond to emotional, ethical, and spiritual concerns, as well as physical needs in our commitment to unselfishly care for others.

The following practices comply with HCFA's standards:

1. Restraints used only on a short-term basis and as a last resort after trying other alternatives.
2. Staff should be properly trained to use restraints.
3. Other treatment plans obviating the use of restraints should be considered.
4. Decision for restraints should come as a result of collaborative and informed decision making among caregivers, patients, and families, in accordance with a carefully developed care plan.
5. Never resort to restraints as a substitute for monitoring and surveillance, or as a convenience for staff.
6. When restraints must be used, attention to patient comfort and safety are of primary importance.
7. If applied for behavioral management (emergency situations in which patients are threats to themselves or others) evaluate restraint use after one hour, then every four hours for adults or every two hours for children, and write new orders after twenty-four hours. Restraints that are part of the treatment (for example, IV boards post-surgery) should also be periodically reassessed.
8. Fully document restraint orders by a physician, including the clinical justification for restraints, the methods to be used in monitoring their use, and the process for reassessment.