commentary REEXAMINING MEDICAL RESTRAINTS
BY MICHAEL BRAZOS FIELDER, MD My greatest regret as an intern was pre- scribing medical restraints. Inherently controversial, restraints are often used on patients, against their will, to per- form a procedure or to provide neces- sary care. This goes against the fidu- ciary model of the patient-physician relationship. One of my personal ex- periences ordering medical restraints provides an opportunity to reflect on this problematic intervention. My 72-year-old patient had just
suffered a severe infarct of his thala- mus. I was his doctor when he arrived at the emergency department. It was evident this poor man’s entire world had fallen apart. He was confused and crying out a woman’s name repeatedly. He could not swallow or articulate his pain, and his blood pressure was as stubbornly unstable as his mood. For nourishment, he needed na-
sogastric tube (NG) feedings, but he would pull the tube out when left un- attended. To keep his NG tube in, I or- dered medical restraints. His son had his medical power of attorney. When I finally contacted him to discuss his father’s wishes regarding the NG tube or end-of-life care, the son refused to make any decisions over the phone
until he could visit in person in two or three weeks. Day after day, I renewed the pa-
tient’s restraint order. Always I would find him in the same condition — arms spread by his side, tied to the bed, writhing in agony. He would fight the nursing staff’s attempts to suction the purulent mucus from his nose. On day seven of his stay when I asked him how he was doing, in a rare moment of clarity, he meekly replied, “Not well.” Later that evening, a consulting spe- cialist notified me the patient had died before he could see him. My patient had died tied to a bed in restraints, and I had placed the order. The experience was life-changing.
Since that day, I resolved to reexam- ine the necessity and risks of medical restraints. Restraints are a last resort in patients with altered mental status who would otherwise harm them- selves if left unattended. While it is true restraints keep some patients safe, they are not a benign intervention. Re- straints used in patients with altered mental status can exacerbate their condition, according to a 2015 report in Journal of the American Geriatrics Society. The report cites increased stress and cortisol levels in physically
restrained animals. In humans, such stress might decrease immunity and prolong hospitalization. Invariably placed against a pa-
tient’s will, restraints damage the pa- tient-physician relationship. Typically, restrained patients are more challeng- ing for nurses, medical assistants, and doctors. Health professional exaspera- tion is common, and it becomes easy to renew restraining orders without careful consideration. Restraints can cloud medical decisionmaking and adversely affect patient care. Ultimately, I learned that prescrib-
ing restraints should not be taken lightly. While at times necessary for patient safety, restraints have the po- tential to harm patients and the pa- tient-physician relationship. Health professionals should fre-
quently reevaluate the need for re- straints and consider alternatives whenever possible. If a patient is in critical condition, every effort should be made to contact the designated de- cisionmaker to discuss end-of-life care. Above all, the experience taught me to do my utmost to preserve the dignity of my patients. I hope you will join me in my pledge to never let a patient die in restraints. n
MICHAELBRAZOS FIELDER,MD, is a second-year resident in family medicine at The
University of Texas at Austin Dell Medical School. SWATI AVASHIA, MD, an assistant professor of medicine at the UT-Austin Dell Medical School, contributed to this commentary.
Restraints should not be taken lightly. May 2016 TEXAS MEDICINE 15
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