Reduce use of physical restraints in eldercare

The use of physical restraints in eldercare may seem like a lesser evil but it is fraught with adverse consequences and also often unnecessary

The news about a proposed model of nursing home care with no restraints for the Jade Circle project ("Peacehaven nursing home gets nod"; ST, July 7) is a breath of fresh air.

It is certainly a progressive step that will mark a milestone in Singapore's long-term care sector.

A friend, who is not familiar with the local healthcare landscape, was surprised to know that physical restraints are still used in the care of patients. Indeed, from the perspective of a lay person, could restraints ever be compatible with the caring profession?

One fundamental reason for using restraints is in the case of patients who cannot cooperate with treatment, such as during the administration of intravenous fluids and antibiotics, or the use of urinary catheters and feeding tubes.

As these interventions are invasive and intrusive, patients who are confused, commonly from delirium or dementia, attempt to remove them. Physical restraints are thus applied to their arms to prevent patients from removing the tubes and intravenous cannulas.

Another common scenario, particularly in the geriatric care setting, occurs when patients with unsteady gait and a high risk of falls attempt to ambulate - that is, walk or move about - on their own.

Given the risk of falls, restraining them physically appears to be an effective and convenient way to prevent falls which may result in serious fractures and injuries. As such, it seems physical restraints can be justified on grounds of necessity and on being a lesser evil, given the dire consequences that may ensue without restraints.

But physical restraints are fraught with adverse consequences.

ETHICAL CONCERNS

For patients who are already uncooperative and confused, they worsen confusion, agitation and precipitate aggression. Frail older patients who already suffer from gait instability will lose their ability to ambulate with limited opportunities to walk.


ST ILLUSTRATION: MANNY FRANCISCO

Importantly, restraints thwart patient autonomy and can break the spirit. Excess dependency is created and the overall physical and psychological well-being of the patient suffers.

Important ethical issues arise as well. Think of a patient with advanced dementia, who may have difficulty eating properly, and who has his arms in restraints to ensure that he does not remove his feeding tube. Does this not conjure the impression of force-feeding against his will?

Or are restraints justified because he might otherwise die from dehydration and malnutrition?

Think of another scenario: A patient, with a high risk of falls, who is strapped down to his bed to stop him from walking unsupervised. Are the restraints justified because they contribute to his own safety?

These scenarios raise questions of whether we should value safety and risk management more than respect for the patient's autonomy and dignity. Sometimes, one has to prioritise one over the other.

On the other hand, common or frequent use of restraints also risks sliding down a slippery slope where callous and unthinking use can promote a laissez faire culture which justifies restraints loosely on grounds of efficiency and convenience, with little regard for the person, especially in situations of manpower constraints.

In an environment that prioritises task over person, the dignity and well-being of patients - particularly the frail and those with dementia and mental illness - are most vulnerable to being violated.

So, can we really practise safe and effective eldercare without physical restraints?

We have stellar examples of restraint-free care from countries like the United States where implementation of the Omnibus Budget Reconciliation Act of 1987, which declared that nursing home residents have the right to be free from restraints, resulted in the marked reduction of their use. Closer to home, Japan, too, prohibits the use of restraints in its eldercare facilities.

These initiatives have taught us that when restraints are not an option, creativity in care flourishes. Not only do patients benefit, but staff also derive greater work satisfaction, resulting in higher rates of retention.

However, restraint-free care requires a systematic and organised effort that is both ground-up and top-down to change beliefs, practices and mindsets.

It entails nothing less than a culture change to help staff recognise the deficiencies of the status quo and to want to take ownership of the change process.

RESTRAINT-FREE MODEL IN S'PORE

With funding support from the Ministry of Health, Khoo Teck Puat Hospital started a dementia unit (Care for the Mentally Infirm Elder or Camie) in 2012, which has maintained a physical restraint-free record for more than four years.

Although the intention was to be restraint-free from the outset, it did not materialise until several months later, with the addition of extra staff to attend to patients who tried to get out of bed at night.

A major obstacle to restraint-free care lies in limited manpower, particularly in the night. However, we did not need substantial manpower increments. A modest increase in the night staffing complement by one nurse marked the turning point.

In addition, the use of technology by way of pressure sensor mats or passive infrared sensors around the bed helped to alert the staff if the patient attempted to get out of bed, thereby allowing them to attend to him promptly to avert falls.

There were other lessons learnt, especially in the need for a less medicalised and more person-centred care environment that goes beyond treating the patient to knowing the person more intimately. This included understanding the patient's life history, preferences and habits, emphasising the primacy of nurturing trusting relationships as well as caring beyond the custodial and physical. Innovative care practices have evolved in the process.

For a patient who repeatedly pulls on his catheter that is attached to an obtrusive urine bag, substituting a tap-like valve for the bag allows the catheter to be "hidden" under the garments and obviates the need to restrain his hands.

Another example involves engaging volunteers and family members to help feed - slowly and patiently - patients with advanced dementia, who may otherwise require feeding tubes inserted to augment their nutritional needs.

Such care practices are better caught than taught. New members of the unit learn through role-modelling more experienced staff and, with time, change their mindsets and practices when they witness that restraint-free care is indeed possible.

We conducted an evaluation of Camie restraint-free care versus conventional geriatric care and found compelling benefits in patients' overall well-being, mobility and function. There was a reduction in challenging behaviour despite less use of psychotropic medication and, most significantly, without an increase in rate of falls.

Ageing with physical and cognitive decline and increased dependency are existential issues that affect all of us, the same way a new birth and growing into adulthood do. If we do not resort to restraints in the care of young children who cannot comply with medical treatment, there is little reason for us to do the same to frail older persons.

Long-term care for older persons has been associated with negative stereotypes for too long, with physical restraints being the ultimate symbol of despair and the loss of freedom. Providing restraint-free care can go a long way in preserving the dignity of older persons and changing the image of eldercare to one that is more humane and hopeful.

With a rapidly ageing population and an increasing need for eldercare services, there is no better time to start than now. Perhaps only then will we make progress towards the ideal expressed by the English poet William Wordsworth: "Come grow old with me, the best is yet to be."

• The writer is director, geriatric centre, and senior consultant at Khoo Teck Puat Hospital.

A version of this article appeared in the print edition of The Straits Times on July 19, 2017, with the headline 'Let's stop tying down old people'. Print Edition | Subscribe