FEBRUARY 28, 2000 VOLUME 7, NUMBER 35
The Nursing Home Reform Act of 1987 mandated changes in American nursing care. Chief among those changes: patients may not be restrained (either physically or chemically) unless it is medically necessary. How has that mandate fared in practice?
Frail (usually elderly) nursing home patients may be unable to walk, or even to support their own weight. Among those patients who are able to stand, gait and balance may be so compromised that there is a constant risk of falls.
The purpose behind most restraints, particularly so-called “soft” restraints like vests that tie patients to their chairs, or tables that make it impossible to stand (and that can not be easily removed by a confused, weakened elderly patient) is to prevent the patient from getting out of a chair or bed, and thereby to avoid falls and resultant injuries. The problem with those restraint devices, according to a growing portion of the elder care community, is that they actually endanger rather than protect patients.
Restraints have been cited as the causative factor in numerous deaths and injuries of patients. A frail elderly patient who is constantly trying to escape from restraints may be in danger of slipping part way out of the restraint system, and patients have even been strangled by the “protective” device.
Furthermore, according to advocates for the elderly, the mere fact of being restrained can lead to increased anxiety and confusion, and may itself be the cause of future increases in the use of restraints, including tranquilizers for the resulting agitation. The frail patient’s adverse reaction to restraints can become the cause of further loss of mobility, strength, dignity and self-control, accelerating the patient’s decline and resulting in an earlier death.
One powerful force behind the use of physical restraints is the demand by families for what is perceived as protection of elderly patients. Legitimately concerned and well-meaning family members often demand that facilities tie up elders to prevent the possibility of falls. Because the danger of restraints may not be apparent to family members, the facility has a special duty to not only resist the use of restraints but also to help educate patients’ families.
Does the 1987 law prevent the use of restraints? No, but it does call for restraints to be used only for legitimate medical needs of the patient, and not for the convenience of the facility or the comfort of family members.
A small but growing number of American nursing homes have moved toward elimination of restraints altogether. One leader in this movement is the Kendal Corporation of Pennsylvania, which has operated restraint-free nursing homes in four states beginning in 1973. The Kendal Corporation, in fact, operates a nationwide educational and advocacy program, called “Untie the Elderly,” in which it promotes the elimination of restraints in other nursing facilities as well. The program offers a videotape on the use of restraints in nursing homes and a compelling and practical handbook for use by nursing homes considering eliminating the use of restraints. The “Untie the Elderly” program also operates a website, with more information about its program and training materials.
Another excellent resource on the use of restraints in nursing homes is the National Citizen’s Coalition for Nursing Home Reform (NCCNHR), which has long advocated for reduced use of restraints and increased emphasis on patient’s rights. NCCNHR has published a short Fact Sheet on the use (and overuse) of restraints. More details (including NCCNHR’s excellent books Avoiding Physical Restraint Use: New Standards in Care and Nursing Homes: Getting Good Care There) can be ordered from the organization’s site.