I have written about my mother being treated horribly in the nursing home where she was recovering from ankle surgery and treatment of the elderly is often effected by peoples stereotyped prejudices and judgments about the elderly.
I found the following study quite interesting as it mentions research on forcible restraint of the elderly in nursing homes.
"To become old is to become institutionalized and imprisoned": comparing regulatory frameworks for the use of restraints in long-term care facilities.
Link to this page
"To become old is to become institutionalized and imprisoned": comparing regulatory frameworks for the use of restraints in long-term care facilities."One of the essential functions of human-rights legislation is to protect human beings from the therapeutic good intentions of others. ... To give these human beings [patients] the benefit of informed consent, the rule of law, and such autonomy as they can exercise without harm to others is the proof that we actually believe in human rights." (2) (Michael Ignatieff This page is currently protected from editing until (UTC) or until disputes have been resolved. )
Introduction
Our commitment to human rights is tested when we enact laws and create policies that affect the elderly. As Kazin writes: "We are often sentimental about the old in the abstract but contemptuous con·temp·tu·ous
adj.
Manifesting or feeling contempt; scornful.
--------------------------------------------------------------------------------
con·temptu·ous·ly adv. of them in practice." (3) She continues that "many of us simply expect that to become old is to become institutionalized in·sti·tu·tion·al·ize
tr.v. in·sti·tu·tion·al·ized, in·sti·tu·tion·al·iz·ing, in·sti·tu·tion·al·iz·es
1.
a. To make into, treat as, or give the character of an institution to.
b. and imprisoned im·pris·on
tr.v. im·pris·oned, im·pris·on·ing, im·pris·ons
To put in or as if in prison; confine.
security penitentiary, near San Francisco; “escapeproof.” [Am. Hist.: Flexner, 218]
Altmark, the
German prison ship in World War II. [Br. Hist. that is experienced by the elderly is restraint; (5) indeed, some elderly persons regard the imposition of restraints as a routine part of care as they grow older. (6)
Restraint is a technique used to control and restrict a person's freedom of movement, and as such it is vulnerable to being misused and/or abused. Regulation can serve as a framework to ensure that the human rights of the elderly are enabled and respected, serves to minimize the potential abuse and misuse of restraints, and may reduce the potential harm to the person who is restrained. Accordingly, in this paper I examine how we, as a society, should regulate the use of restraints to ensure that they are not a routine part of the lives of the elderly. (7) I compare and contrast two regulatory frameworks for the use of restraints in long-term care facilities long-term care facility
n.
See skilled nursing facility. and conclude by suggesting a new regulatory framework.
The Incidence of the Use of Restraints
International research suggests that nine percent of residents of long-term care facilities are restrained in countries such as Iceland, Denmark and Japan, 13.5-17 percent in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , 15-17 in France, Italy and Sweden, 15-26 percent in Australia and 40 percent in Spain. (8) The most common justification for restraint use is that it is necessary to restrain an elderly person to prevent serious self-harm or serious harm to others. But these rationales do not completely explain the high levels of restraint use. Research from the US suggests that restraints are used by health providers for a number of other reasons including: adhering to policies; the health provider's sense of security and comfort; and fear of legal liability. (9) Other, more clinical rationales are said to include: behavioral control; confusion; poor judgment; and controlling agitated ag·i·tate
v. ag·i·tat·ed, ag·i·tat·ing, ag·i·tates
v.tr.
1. To cause to move with violence or sudden force.
2. behavior or wandering. (10)
Certainty, Autonomy, Effectiveness and Abuse--Issues Pointing to the Need for A Regulatory Framework
In most jurisdictions in Canada, and in many international jurisdictions, the use of restraints in health facilities generally is not regulated. (11) It is left to the common-law, professional bodies, and individual institutions to create standards for restraint use.
There are four key arguments that suggest that to continue not to regulate restraints in long-term care facilities does not accord sufficient priority to the rights and needs of the elderly and to the interests of health care providers and society as a whole.
First, lack of regulation creates uncertain law and therefore uncertainty in practice. Under the common-law it is not clear when, why, how and in what circumstances restraints may be legitimately used. It is also not clear what impact the Charter (12) could have on this area. Regulation may create a degree of certainty as to the legality of restraint use and set out in detail the circumstances in which it may be used. It also may create standards for the application and monitoring of restraint use.
Second, an individual's right to autonomy needs to be accorded greater protection, which may be achieved through legislation specific to the issues in this area. When health providers argue that they need to restrain an elderly person to protect him/her from self-harm, such as the possibility of falling, they are acting out of a desire to protect that person. This protective instinct may be legitimate in some cases, perhaps if the person is not competent, but may be overly paternalistic pa·ter·nal·ism
n.
A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities. in other circumstances. Competent individuals are free to choose paths that may lead to self-harm. Risks are a part of life and to deny the elderly the chance to take risks can be to deny their autonomy. If autonomy is to be limited for protection of self or others then it must be limited within a clearly articulated regulatory framework, otherwise it may violate the Charter or human rights law.
Third, regulation may reduce the levels of restraint use by limiting opportunities for health providers to misuse restraints. Often health providers will use restraint because an elderly person is agitated, wandering, or unsteady and they fear that the person will fall. They consider that restraints are an effective tool to reduce that risk. (13) However, recent research suggests that fall rates are the same whether restraints are used or not and that the severity of the outcome of the fall may be increased when restraints are used. (14) Similarly, agitation may increase, rather than decrease. (15) Restraints may therefore not actually achieve the ends that health providers hope they will. Regulation may create clearer evidence based criteria for restraint use that may reduce the opportunities to misuse restraints.
Similarly, restraints are not necessarily safe interventions--restraint use carries with it its own risks, particularly for the elderly. If physical restraints Physical restraint refers to the practice of rendering people helpless or keeping them in captivity by means such as handcuffs, shackles, straitjackets, ropes, straps, or other forms of physical restraint. are not applied properly, and the person who is restrained is not monitored regularly and effectively, injuries, even death, can ensue en·sue
intr.v. en·sued, en·su·ing, en·sues
1. To follow as a consequence or result. See Synonyms at follow.
2. To take place subsequently. . (16) In addition, immobility immobility
standing still and disinclined to move, as in an animal suddenly blinded; responds to other stimuli unless immobility is part of a dummy syndrome when all stimuli are ignored. caused by restraint use can contribute to the development of pressure sores pressure sore
n.
See bedsore. , as well as the development or worsening wors·en
tr. & intr.v. wors·ened, wors·en·ing, wors·ens
To make or become worse.
Noun 1. worsening - process of changing to an inferior state
decline in quality, deterioration, declension of other conditions. (17) Chemical restraints also have side effects Side effects
Effects of a proposed project on other parts of the firm. . These include symptoms such as dizziness dizziness: see vertigo. , sedation Sedation Definition
Sedation is the act of calming by administration of a sedative. A sedative is a medication that commonly induces the nervous system to calm.
Purpose
The process of sedation has two primary intentions. , and increased agitation, which may contribute to an increased risk that the person will fall, may reduce the person's capacity (18) or cause ill health. (19) Regulation can set standards for safe and appropriate restraint use, especially for those with multiple health conditions who are more vulnerable to adverse effects caused by restraint, like the elderly.
Fourth, regulation may reduce or prevent abuse of the power to restrain by health providers. In an institutional environment where there may be a profound power imbalance between the elderly person and staff or when the elderly person lacks capacity, misuse or abuse of such a powerful tool is not unheard of Not heard of; of which there are no tidings.
Unknown to fame; obscure.
- Glanvill.
See also: Unheard Unheard . In the face of the potential for abuse, regulation is necessary to protect those who are most vulnerable.
Those jurisdictions that do not currently have regulations limiting and monitoring restraint use should enact law that specifically addresses this issue. However, the regulation of restraint use in health facilities is complicated by the fact that restraints are used in a variety of environments, by a variety of health providers, some of whom are trained professionals and some of whom are not, on a variety of people with differing needs, who are from a variety of cultural, religious, ethical, social and ethnic backgrounds and who all have different personal histories. In the next section I examine models of regulation for restraint use that have been implemented or suggested in two jurisdictions to see whether lessons can be learned and direction taken from these models.
Regulatory and Legislative Frameworks for Restraint Use in Long-term Care Facilities
There are two main types of regulatory frameworks evident in legislation that address the use of restraints in health facilities: facility-focussed regulatory frameworks (British Columbia British Columbia, province (2001 pop. 3,907,738), 366,255 sq mi (948,600 sq km), including 6,976 sq mi (18,068 sq km) of water surface, W Canada. Geography
); and patient-focussed regulatory frameworks (proposed in New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. ). Each of these frameworks indicates different terminal values in health systems. (20) Facility-focussed frameworks focus on institutional compliance with procedural norms that aim to achieve safe, consistent systems within institutions, in accordance with the quality improvement and safety model that to a certain extent dominates health system management discourse at this time. Patient-focussed frameworks aim to maximize observance of and respect for the human rights of individuals in health care systems, in accordance with a more patients rights centred approach, which postulates the patient at the centre of the model of care.
Facility-Focussed Regulatory Frameworks--British Columbia
In British Columbia, the regulatory framework for restraint use is set out in s. 25 of the Health Care (Consent) and Care Facility (Admission) Act. (21) This states that operators of care facilities (22) must not use physical, chemical or other means of restraint to restrict the freedom of movement of an adult who lives in that facility unless: all alternatives have been exhausted; the restraint is as minimal as possible; the patient/substitute decision-maker and a physician approve a plan devised by another health care provider agreeing that it is in the patient's best interest or for the protection of others; and the need for restraint is periodically reassessed. Restraint may be used in an emergency without consent if it is necessary to preserve the person's life or to prevent serious physical harm to others as long as he/she is restrained no longer than necessary, and is monitored and reassessed at regular intervals. The operator must record restraint use in the patient's clinical record.
The Adult Care Regulations (23) also provide a regulatory framework for the use of restraints in long-term care facilities. Restraints must not be used for punishment or discipline or for the convenience of staff, but may be used if all alternatives to the use of restraint have been exhausted, the restraint is as minimal as possible, the restraint is approved by the resident or his/her substitute decision-maker, restraint is documented in the care plan, staff are trained, and there are written policies and procedures Policies and Procedures are a set of documents that describe an organization's policies for operation and the procedures necessary to fulfill the policies. They are often initiated because of some external requirement, such as environmental compliance or other governmental acceptable to the Medical Health Officer.
Patient-Focussed Regulatory Frameworks--New Zealand
The New Zealand Law Commission reviewed the current legislative framework in New Zealand for the use of coercive co·er·cive
adj.
Characterized by or inclined to coercion.
--------------------------------------------------------------------------------
co·ercive·ly adv. physical force on disadvantaged groups in the health and disability sector in its report Protections Some Disadvantaged People May Need. (24) It accepts that on occasion coercive powers to apply physical force need to be available to health or welfare officials but concludes that his power is not currently available in New Zealand law. Accordingly, it recommends the introduction of a new section into the Protection of Persons and their Property Act (25) to give the Family Court the power to hear applications for the use of physical restraints and to authorise restraint use. (26) The Commission also suggests that the Family Court periodically review restraint orders. The Commission recommends that the powers of District Inspectors of Mental Health (27) monitor the rights of compulsory psychiatric patients be expanded to include monitoring of the rights of persons in respect of whom coercive orders have been made wherever they may live.
New Zealand already has a national standard to inform the development of institutional policies as to when and how physical restraints should be used. (28) Facilities are audited to determine whether they have institutional policies that comply with general and specific national standards, including the restraint standard, and may not be licensed if they do not comply. (29)
Evaluating the Frameworks from British Columbia and New Zealand
In this section I evaluate the regulatory frameworks having regard to three criteria: autonomy, adherence and monitoring systems.
i. Autonomy
The proposed New Zealand system focuses on the rights and needs of individuals rather than facility compliance. Assuming that the Family Court has the time and expertise to evaluate the appropriateness of restraint for each individual, an independent assessment can be made of whether restraint unduly compromises the rights of incompetent individuals or is necessary to protect the individual or to protect others from serious, imminent and reasonably certain harm. This system would appear to limit the opportunities for restraint to be abused or misused. However, there seem to be two serious difficulties: New Zealand's proposed mechanism promises to be reasonably resource intensive, at least initially; and it does not appear to address issues relating to relating to relate prep → concernant
relating to relate prep → bezüglich +gen, mit Bezug auf +acc competent patients and when it is clinically and legally appropriate for restraints to be used for this group. Resource issues are not necessarily fatal objections to such a scheme. As a society we offer costly protections to other groups subject to coercive mechanisms, such as the mentally ill and prisoners, and we should do no less for the elderly. The New Zealand system also has the potential to clog family court processes. It may create the risk that restraint approval by the courts becomes a pro forma As a matter of form or for the sake of form. Used to describe accounting, financial, and other statements or conclusions based upon assumed or anticipated facts.
The phrase pro forma process.
In contrast, although the system in British Columbia focuses on institutional compliance with statutory requirements and thus is facility focussed, the legislation itself is patient-focussed. Patients or surrogate surrogate n. 1) a person acting on behalf of another or a substitute, including a woman who gives birth to a baby of a mother who is unable to carry the child. 2) a judge in some states (notably New York) responsible only for probates, estates, and adoptions. decision makers (if the patient is not competent) must give consent to restraints being used unless the emergency provisions apply. The legislation also sets out criteria within which restraints may be used, limiting the opportunities for misuse or abuse and thus prioritizing the autonomy of the patient.
ii. Adherence
One of the greatest challenges faced by regulators, particularly in the health sector, is creating regulation that is likely to be adhered to by the public, or in this case health providers. As Eastman and Peay note:
People use law; law does not use people. Law is
not an actor, only an instrument of human actors
whose interest is not in how the law thinks people
act, but how they do act; people are not passive
participants of the law--they use it, abuse
it and stretch it in order to stay creatively within
it and/or to frustrate its objectives. People interact
with law. (30)
The British Columbia framework encourages adherence by the operators of long-term care facilities, because it is not procedurally cumbersome. Facilities need not make applications for each individual to the court for permission to restrain, they must merely comply with the set of specific criteria set out in the legislation in order for restraint use to be lawful.
In contrast, one of the problems with the Law Commission's proposed framework for New Zealand is that it requires long-term care facilities to be pro-active and make an application to the courts seeking authorization to use restraints on an individual. Alternatively, health providers must encourage the family (presuming pre·sum·ing
adj.
Having or showing excessive and arrogant self-confidence; presumptuous.
--------------------------------------------------------------------------------
pre·suming·ly adv. there is one) to apply to the courts for such an order. However, inaction in·ac·tion
n.
Lack or absence of action.
--------------------------------------------------------------------------------
inaction
Noun
lack of action; inertia
Noun 1. is a powerful force. Provider/facility/family costs associated with making applications to the family court in adherence to law are an issue that may also discourage adherence, for example, the costs of legal representation, expert evidence etc. Similarly, health providers and/or facilities in New Zealand may try to avoid legal mechanisms (whether because of fear, ignorance, dislike of red-tape or a reluctance to enter the legal system and to attract further institutional monitoring). Providers and facilities may therefore choose to rely on common law doctrines or, as the proposed New Zealand system does not address the use of chemical restraints, it creates the risk that health care providers will use chemical restraints as an alternative to physical restraints. In contrast, the framework from British Columbia addresses emergency restraint use, thus removing the common-law from the equation, and it also covers all forms of restraint use.
iii. Monitoring
Monitoring how services are provided is a crucial step in ensuring that individuals receive treatment or health care that is safe. When the services in question are those that can cause serious harm and perhaps more importantly can be abused it is important that such monitoring is independent of the health providers who provide the service. Yet ultimately the framework in British Columbia seems to rely upon self-policing by institutions. Although the Medical Health Officer must approve an institution's restraint policy, it is not clear that this policy is regularly reviewed after approval is given. No independent agency enters facilities to review restraint use. Therefore, the capacity of this framework to police restraint application on individuals is non-existent, and abuse or misuse is not likely to be identified and stopped.
In contrast, the monitoring system currently in place, through national standards, and that proposed by the New Zealand Law Commission, will enable monitoring at both ends of the spectrum. Institutional compliance is audited independently as part of a certification process to ensure that standards are met and facilities take responsibility for guiding staff. The welfare of the individual who is being restrained is also monitored by an independent agency to ascertain the person's safety, the effectiveness of the intervention and to ensure that the person's rights are being impinged upon to the least possible extent. If the rules are obeyed and monitoring is effective, the incidence of abusive, inappropriate or unsafe restraint use could decrease under this model.
Hybrid Framework
Both of the regulatory responses described above have both positive and negative features. If policy makers wish to privilege individual autonomy to its greatest extent, and minimize the incidence of misuse and abuse of restraints, I suggest a hybrid framework drawing from the strengths of both frameworks. Briefly, in this hybrid model blanket authorization for restraint use is set out in legislation but is subject to stringent conditions. Health providers who use restraints on their patients are required to keep excellent records, setting out when, why and how restraints were used and what strategies were used to make restraint an option of last resort. Health providers/facilities must report each incidence of restraint use to a monitoring agency. That agency will actively monitor an individual's experiences with restraint, as well as whether the facility has formulated a policy to ensure that restraint is used and applied in a manner that maximizes the resident's safety. The monitoring agency should be independent and have the power to make random inspections. The hybrid model is both facility and patient focussed and may contribute to autonomy, minimizing restraint use and reducing the likelihood that restraints are used in an abusive or inappropriate manner.
Conclusion
Regardless of the model chosen, what is certain is that a robust regulatory and monitoring framework surrounding the use of restraints in long-term facilities, and indeed in all healthcare facilities, is important to safeguard the autonomy of the elderly and to minimise abuse and misuse.
It is also important to acknowledge that regulation is only part of the answer. Barham and Barnes note:
[The law] can define the circumstances in which
action to limit the autonomy of citizens can be
legitimated, and the procedural rights available
to citizens to challenge such limitations, but it
cannot require action to enable the practice of
citizenship. (31)
If, as a society, we wish to free the elderly, as much as possible, from the use of restraints there are at least two remaining problems that the law cannot address: resource issues; and the perceptions and attitudes of health providers, families and the general public.
Moving to an institutional environment where restraint use is at a minimum requires an investment in the care of the elderly. Alternative mechanisms used to reduce the need for restraint use, such as special beds and diversion therapy, are not without cost and these costs may be significant in an area that has traditionally attracted little support and funding from government. It also may be significant for private facilities that must return a profit to investors in the facility.
But perhaps the most significant issue in the restraint conundrum conundrum A problem with no satisfactory solution; a dilemma is the attitudes, perceptions and beliefs of providers, patients, families and the public. Ageism ageism Geriatrics A bias or belief that may be held by a health care provider that depression, forgetfulness, and other disorders are a normal part of aging and that older individuals will not benefit from treatment of mental disorders. Cf elderly. and the protective mantra mantra (măn`trə, mŭn–), in Hinduism and Buddhism, mystic words used in ritual and meditation. A mantra is believed to be the sound form of reality, having the power to bring into being the reality it represents. that accompanies it must be addressed through a shift in societal perceptions accomplished by education and increasing awareness of the rights of the elderly. As Michael Ignatieff states:
... human rights alone are not enough. ... we
need extra resources, especially humour, compassion,
and self-control. These virtues must in
turn draw on a deep sense of human indivisibility,
a recognition of us in them and them in us,
that rights doctrines express but in themselves
have no power to instil in the human heart. (32)
Effective regulation is but a first step to allow the elderly to be free from the expectation that to become old is to be institutionalized, imprisoned, and stereotyped as incapable and in need of protection. (33)
(1.) C. Kazin, "'Nowhere to Go and Choose to Stay': Using the Tort of False Imprisonment false imprisonment, complete restraint upon a person's liberty of movement without legal justification. Actual physical contact is not necessary; a show of authority or a threat of force is sufficient. The person falsely imprisoned may sue the offender for damages. to Redress Involuntary Confinement of the Elderly in Nursing Homes and Hospitals" (1998/1999) 137 U. Pa. L. Rev. 903 at 903.
(2.) Michael Ignatieff, The Rights Revolution (House of Anansi PressHouse of Anansi Press is a Canadian publishing company, founded in 1967 by writers Dennis Lee and Dave Godfrey. The company specializes in finding and developing new Canadian writers of literary fiction, poetry, and non-fiction.
..... Click the link for more information.: Toronto 2000) at 39.
(3.) Kazin, supra A relational DBMS from Cincom Systems, Inc., Cincinnati, OH (www.cincom.com) that runs on IBM mainframes and VAXs. It includes a query language and a program that automates the database design process. note 1.
(4.) Ibid at 904.
(5.) When I use the terms "restrained" or "restraint" in this paper I mean physical restraints, including a health provider holding a resident, the use of equipment and furniture, and environmental factors, including contained environments, seclusion seclusion Forensic psychiatry A strategy for managing disturbed and violent Pts in psychiatric units, which consists of supervised confinement of a Pt to a room–ie, involuntary isolation, to protect others from harm , or strategies to reduce the levels of social contacts or stimulation. I also include chemicals that are used to control a person's behaviour or limit their freedom of movement.
(6.) These are the results from a small qualitative assessment of elderly persons who were physically restrained in an acute hospital after surgery. See, R. Gallinagh, et al. "Perceptions of Older People Who Have Experienced Restraint" (2001) 10:13 Brit brit also britt
n.
1. The young of herring and similar fish.
2. Minute marine organisms, such as crustaceans of the genus Calanus, that are a major source of food for right whales. . J. Nurs. 852.
(7.) I focus on the elderly as restraints are often used on the elderly, a group that may suffer greater harms from restraint use because of their age.
(8.) G. Ljunggren et al., "Comparisons of Restraint Use in Nursing Homes in Eight Countries" (1997) 26 Suppl. Age & Aging 43.
(9.) K.S. Dunn, "The Effect of Physical Restraints on Fall Rates in Older Adults who are Institutionalized" (2001) 27:10 J. Geron. Nurs. 41 at 42; and Julie Braun & Elizabeth Capezuti, "The Legal and Medical Aspects of Physical Restraints and Bed Siderails and Their Relationship to Falls and Fall-related Injuries in Nursing Homes" (2000) 4:1 DePaul J. Health Care L. 1 at 7-8.
(10.) Ibid.
(11.) British Columbia, Ontario and Quebec have regulatory schemes.
(12.) Canadian Charter of Rights and Freedoms The Canadian Charter of Rights and Freedoms (also known as The Charter of Rights and Freedoms or simply The Charter) is a bill of rights entrenched in the Constitution of Canada. It forms the first part of the Constitution Act, 1982. , Part I of the Constitution Act, 1982, being Schedule B to the Canada Act Canada Act, also called the Constitutional Act of 1982, which made Canada a fully sovereign state. The British Parliament approved it on Mar. 25, 1982, and Queen Elizabeth II proclaimed it on Apr. 17, 1982. 1982 (U.K.) 1982, c.11.
(13.) Dunn, supra note 9 and Braun & Capezuti, supra note 9.
(14.) Dunn, supra note 9; M. Arbesman & C. Wright, "Mechanical Restraints mechanical restraint Physical restaint A device used on a person to restrict free movement–eg, seatbelt, straitjacket–camisole, vest, or physical confinement Indications Unsteadiness, wandering, disruptive behavior, often 2º to psychiatric , Rehabilitation rehabilitation: see physical therapy. Therapies and Staffing Adequacy for Risk Factors For Falls in Elderly Hospitalized Patients" (1999) 24:3 Rehabilitation Nursing 122; L. Evans, et al. "A Clinical Trial to Reduce Restraints in Nursing Homes" (1997) 45 J. Am. Geriatric Soc. 675; L. Bradley, C. Siddique & B. Dufton "Reducing the Use of Physical Restraints in Long-term Care Facilities" (1995) 21:9 Geron. Nurs. 21; R. Lofgren, et al. "Mechanical Restraints on the Medical Wards: Are Protective Devices Safe?" (1989) 79:6 J. Pub. Health 735; M. Tinetti, E. Liu & S. Ginter, "Mechanical Restraint Use and Fall-related Injuries Among Residents of Skilled Nursing Facilities skilled nursing facility
n. Abbr. SNF
An establishment that houses chronically ill, usually elderly patients, and provides long-term nursing care, rehabilitation, and other services. " (1992) 116:5 Annals of Internal Medicine Annals of Internal Medicine (Ann Intern Med) is an academic medical journal published by the American College of Physicians (ACP). It publishes research articles and reviews in the area of internal medicine. Its current editor is Harold C. Sox. 369.
(15.) Gallinagh et al., supra note 6. Similarly, benzodiazepines Benzodiazepines Definition
Benzodiazepines are medicines that help relieve nervousness, tension, and other symptoms by slowing the central nervous system.
Purpose
Benzodiazepines are a type of antianxiety drugs. , hypnotics and anti-psychotic medications, all commonly used to chemically restrain the elderly have as side effects the possibility of increased agitation.
(16.) The physical risks of restraint use for the elderly include: occurrence and worsening of pressure sores; infections; incontinence; fecal impaction fecal impaction
n.
An immovable collection of compressed or hardened feces in the colon or rectum.
--------------------------------------------------------------------------------
Fecal impaction
Obstruction of the rectum by a large mass of feces (stool). ; functional impairment from lack of movement; cardiac stress; nutritional impairment; bone resorption Bone resorption is the process by which osteoclasts break down bone and release the minerals, resulting in a transfer of calcium from bone fluid to the blood.
The osteoclasts are multi-nucleated cells that contain numerous mitochondria and lysosomes. due to demineralization demineralization /de·min·er·al·iza·tion/ (de-min?er-al-i-za´shun) excessive elimination of mineral or organic salts from tissues of the body.
--------------------------------------------------------------------------------
de·min·er·al·i·za·tion
n. ; electrolyte electrolyte (ĭlĕk`trəlīt'), electrical conductor in which current is carried by ions rather than by free electrons (as in a metal). losses; injuries that result in increased morbidity and mortality Morbidity and Mortality can refer to:
Morbidity & Mortality, a term used in medicine
Morbidity and Mortality Weekly Report, a medical publication
See also
Morbidity, a medical term
Mortality, a medical term
; and, on rare occasions, accidental strangulation strangulation /stran·gu·la·tion/ (strang?gu-la´shun)
1. choke (2).
2. arrest of circulation in a part due to compression. See hemostasis (2).
--------------------------------------------------------------------------------
stran·gu·la·tion
n. . See discussion in V. Dawkins, "Restraints and the Elderly with Mental Illness: Ethical Issues and Moral Reasoning Moral reasoning is a study in psychology that overlaps with moral philosophy. It is also called Moral development. Prominent contributors to theory include Lawrence Kohlberg and Elliot Turiel. " (1998) 36:10 J. Psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.
--------------------------------------------------------------------------------
psy·cho·so·cial
adj.
Involving aspects of both social and psychological behavior. Nursing 22; Dunn, supra note 9 at 42. See also, H. Archibald Kaiser, "Restraint and Seclusion in Canadian Mental Health Facilities: Assessing the Prospects of Improved Access to Justice" (2001) 19 Windsor Y.B. Access Just. 391 at 395-96; S. Miles & P. Irvine, "Deaths Caused by Physical Restraints" (1992) 32 The Gerontologist ger·on·tol·o·gy
n.
The scientific study of the biological, psychological, and sociological phenomena associated with old age and aging.
--------------------------------------------------------------------------------
ge·ron 762.
(17.) Ibid.
(18.) Medications used for restraints may have a sedating effect and may increase confusion, therefore reducing the person's mental capacity.
(19.) Psychotropic medications List of medications which are used to treat psychiatric conditions on the market in the United States. A
Abilify - antipsychotic used to treat schizophrenia, bipolar disorder, and agitation
are commonly used as chemical restraints. These are drugs that affect brain activities associated with mental processes and behaviour. There are four broad categories of psychotropic medications: anti-psychotic drugs, anti-depressant drugs, anti-anxiety drugs (including benzodiazepines) and hypnotics, all of which have serious side effects. The side effects are also more common in the elderly and may be more severe. Benzodiazepines may cause more daytime drowsiness drows·i·ness
n.
A state of impaired awareness associated with a desire or inclination to sleep. Also called hypnesthesia.
--------------------------------------------------------------------------------
drowsiness Medtalk Semiconsciousness; grogginess, sleepiness ; therefore falls and related accidents may be more common. Confusion, anxiety, depression, amnesia amnesia (ămnē`zhə), [Gr.,=forgetfulness], condition characterized by loss of memory for long or short intervals of time. It may be caused by injury, shock, senility, severe illness, or mental disease. , and, more rarely, delusions Delusions Definition
A delusion is an unshakable belief in something untrue. These irrational beliefs defy normal reasoning, and remain firm even when overwhelming proof is presented to dispute them. , disorientation disorientation /dis·or·i·en·ta·tion/ (-or?e-en-ta´shun) the loss of proper bearings, or a state of mental confusion as to time, place, or identity. , agitation, aggression, and hallucinations Hallucinations Definition
Hallucinations are false or distorted sensory experiences that appear to be real perceptions. These sensory impressions are generated by the mind rather than by any external stimuli, and may be seen, heard, felt, and even may increase. Addiction is also a serious risk. Hypnotic hypnotic /hyp·not·ic/ (hip-not´ik)
1. inducing sleep.
2. an agent that induces sleep.
3. pertaining to or of the nature of hypnosis or hypnotism. medications have similar side effects to benzodiazepines. The side effects of anti-depressants include, excessive sedation, blurred near vision, confusion, disorientation, and orthostatic hypotension Orthostatic Hypotension Definition
Orthostatic hypotension is an abnormal decrease in blood pressure when a person stands up. This may lead to fainting. (which can cause a predisposition predisposition /pre·dis·po·si·tion/ (-dis-po-zish´un) a latent susceptibility to disease that may be activated under certain conditions.
--------------------------------------------------------------------------------
pre·dis·po·si·tion
n.
1. to fall). Anti-psychotics may have a sedating effect, may increase confusion and/or agitation, and may cause rigidity rigidity /ri·gid·i·ty/ (ri-jid´i-te) inflexibility or stiffness.
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clasp-knife rigidity , tremors, and a change in gait. The manufacturers recommend that elderly persons prescribed anti-psychotics be regularly monitored.
(20.) Nuala Kenny, What Good is Healthcare? Reflections on the Canadian Experience (Ottawa: CHA n. 1. Tea; - the Chinese (Mandarin) name, used generally in early works of travel, and now for a kind of rolled tea used in Central Asia.
A pot with hot water . . . made with the powder of a certain herb called chaa, which is much esteemed.
- Tr. J. Press, 2002).
(21.) The Health Care (Consent) and Care Facility (Admission) Act--Supplement, R.S.B.C. 1996 C. 181. Section 25 is not yet in force.
(22.) Ibid. This is defined in s. 2 to include community care facilities, private hospitals, hospitals and facilities designated by regulation as care facilities.
(23.) Adult Care Regulations B.C. Reg. 536/80 sections 10.9, 10.10 and 10.11.
(24.) New Zealand, Law Commission, Protections Some Disadvantaged People May Need: Report 80 (Law Commission: Wellington, 2002), online at: The Law Commission
(date accessed: 20 January 2003) [Law Commission].
(25.) Protection of Personal and Property Rights Act 1988 (N.Z.), 1988/4. This is New Zealand's adult guardianship legislation.
(26.) Law Commission, supra note 24 at 19. Court orders allowing restraint use must be expressed precisely, the purpose must be set out in the order and the order must not be capable of being construed to justify a greater degree of restraint than in necessary to achieve the purpose of the order. The Family Court may impose conditions on its order. For example, that restraint may be used only as long as necessary for the care of the patient or the protection of others. Also coercive powers must be exercised so as not to compromise the dignity, privacy or self-respect of the person concerned.
(27.) District Inspectors of Mental Health are appointed pursuant to section 94 of the Mental Health (Compulsory Assessment and Treatment) Act 1992 (N.Z.), 1992:46 [MH(CAT)]. They monitor the conditions of, and respond to complaints from, patients who are subject to compulsory treatment orders.
(28.) New Zealand Standard 8141:2001 Restraint Minimization and Safe Practice (Wellington: Standards New Zealand, 2001) [Restraint Minimization Standard]. The standard incorporates the following components: cultural recognition, particularly of cultural safety and recognizing the philosophy of Te Whare Tapa tapa: see bark cloth. Wha (the four cornerstones of Maori health); assessment, to be undertaken by suitably skilled persons in partnership with the resident and his/her family and includes the individuals personal and cultural needs, triggers and precursors and other factors and to be regularly reviewed; risk and quality management systems to develop institutional policies and improve communication with staff; compliance with legal and professional standards, including human rights, natural justice, and the Health and Disability Commissioner (Code of Health and Disability Services Consumers Rights) Regulations 1996 (N.Z.), 1996/78; respect for dignity and privacy; consumer support and communication during and after the restraint, including debriefing de·brief·ing
n.
1. The act or process of debriefing or of being debriefed.
2. The information imparted during the process of being debriefed.
Noun 1. ; staff training and competency assurance; an institutional approval process for various types of restraint, where residents, family, internal and external health providers, cultural advisors and specialist input when required, will consider education, competency and evaluation requirements for staff, indications for use, policies and procedures, monitoring and observation requirements, documentation, evaluation and review frequency and maintenance frequency (for equipment); monitoring during restraint use including the provision of food and nourishment nour·ish·ment
n.
Something that nourishes; food. , personal hygiene personal hygiene person n → Körperhygiene f and toileting, clothing, medications, exercise and activity and cultural safety; evaluation and review to ascertain whether an individual plan was followed, it was the least restrictive intervention, de-escalation techniques were tried, what impact the restraint had on the individual, family and staff and that adequate support was provided; quality review of restraint use at six-month intervals; and specific requirements for the use of seclusion under MH(CAT), ibid.
(29.) Section 9 of the Health and Disability Services (Safety) Act 2001 (N.Z.), 2001/93 requires that all health care services (hospital care, residential disability care and rest home care) must (among other requirements) meet all relevant service standards. The Health and Disability Services (Safety) Hospital Care, Residential Disability Care and Rest Home Care Standards Notice 2002 (N.Z.), 2002/24 approved the Restraint Minimization Standard, ibid. Existing facilities have two years to comply with the standard from 1 October 2002. External auditors The examples and perspective in this article or section may not represent a worldwide view of the subject.
Please [ improve this article] or discuss the issue on the talk page. will audit each facility for compliance at approximately two yearly intervals. If they do not comply with the standards they may lose their license.
(30.) Nigel Eastman & Jill Peay, "Law Without Enforcement: Theory and Practice" in Nigel Eastman & Jill Peay, eds., Law Without Enforcement: Integrating Mental Health and Justice (Oxford & Portland, Ore.: Hart publishing, 1999) 1 at 25.
(31.) Peter Barham & Marian Barnes, "The Citizen as a Mental Patient" in Law Without Enforcement, ibid., 133 at 144.
(32.) Ignatieff, supra note 2 at 39.
(33.) Kazin, supra note 1.
Fiona McDonald is a doctoral candidate at Dalhousie UniversityDalhousie University (dălhou`zē), at Halifax, N.S., Canada; nonsectarian; coeducational; founded 1818 by the 9th earl of Dalhousie. Except for a few years between 1838 and 1845, Dalhousie did not function as a university until 1863.
..... Click the link for more information., Halifax, Nova Scotia For other uses, see Halifax.
Halifax, Nova Scotia may refer to any of the following:
Halifax Regional Municipality, capital of Nova Scotia, Canada
The research was supported by the Canadian Institutes for Health Research and the Alberta Heritage Foundation for Medical Research. The author thanks Elaine Gibson, Jocelyn Downie and an anonymous reviewer for their comments on this article. Thanks too, to Archie Kaiser and Elaine Gibson for their comments on the paper on which this article is based. All errors and omissionserrors and omissions n. short-hand for malpractice insurance which gives physicians, attorneys, architects, accountants and other professionals coverage for claims by patients and clients for alleged professional errors and omissions which amount to negligence.
..... Click the link for more information. remain the responsibility of the author.
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