1 The Ethics of Restraining the Mentally Ill in Nursing Homes Maggie Dunning Medical University of South Carolina Nursing 385: Professional Nursing and Nursing Practice
2 The Ethics of Restraining the Mentally Ill in Nursing Homes Totally dependent on his relatives for care, Percival Guthrie is a 58-year-old man with a history of organic brain syndrome. Although he is in good physical condition, his family can no longer take care of him due to his forgetfulness, wandering behavior, sleep pattern disturbances, and growing need for supervision and personal care (Veatch, & Fry, 1987). His family hopes that he will be happy in a nursing home and receive the proper attention and care that they can no longer give him. Recognizing his need for extra care, a new RN assigned to Mr. Guthrie agrees to place his room near the nurses station and promises his family to help him while he adjusts to his new living situation. However, it seems that adjustment is harder than expected. Mr. Guthrie begins to wander into other patients rooms, talk loudly, and frequently yell for his relatives. He becomes more and more agitated and spends his nights roaming through the halls, going into other patients rooms, and engaging in loud, boisterous behavior. Other times, Mr. Guthrie sits in his armchair all night and urinates himself. His unkempt appearance, the smell of urine emanating from his room, and abnormal behavior are deeply disturbing to the other patients, the nursing staff, and all of the visitors (Veatch, & Fry, 1987). The consensus among the nursing staff is that his liberty must be restrained to ensure that everyone has a satisfying nursing home atmosphere (Veatch, & Fry, 1987). Agreeing with the nurses, the physician prescribes a combination of chemical and physical restraints to control Mr. Guthrie s behavior on an as needed basis. After Mr. Guthrie wanders into another patient s room, the supervising charge nurse tells the new RN to administer physical and chemical restraints immediately. Given Mr. Guthrie s good
3 physical condition, the new RN is reluctant to take this action and does not believe this action is justified. The new RN is in a difficult situation and faces a severe ethical dilemma. By making this decision, she feels her personal and professional values of advocacy and responsibility might be at risk. As a nurse, she is an advocate for the rights, safety, and health of Mr. Guthrie, and she has a responsibility to his family to follow through on her promise to take care of him. Does she obediently administer the physical and chemical restraints or think of other options that could potentially benefit all of the concerned parties? Her decision will not only affect Mr. Guthrie but also the nursing home establishment, nursing staff, patients, visitors, and Mr. Guthrie s family. Unfortunately, if the new RN refuses to follow orders, a conflict of ideas and ethical principles may arise between her and the nursing home physician and staff. The new RN must clarify the ethical dilemma, gather information relative to the specific case, identify the possible courses of action, and choose the best option to resolve the dilemma (class notes and powerpoint). Clarifying the Ethical Issue and Gathering Information In this situation regarding Mr. Guthrie, the dilemma is whether or not to use restraints and sedatives on a demented patient; however, the given justification for restraining and sedating Mr. Guthrie is based on maintaining a pleasant nursing home environment. In this case, it seems that autonomy and beneficence are two competing ethical maxims. The new RN must consider many different issues and gather pertinent information that will help her resolve her dilemma. First and foremost, it is essential to
4 understand the nursing home s policy as well as the legal standards and guidelines regarding the use of restraints. Upon admission to a nursing home, it is the ethical norm that caregivers inform the patient and their relatives about various options when physical restraint is being considered (Gastmans, & Milisen, 2006). Information should be provided as objectively as possible about treatment possibilities, their nature and aims, their pros and cons, and their effects and risks (Gastmans, & Milisen, 2006). The least restrictive measures should always be tried first. Even mentally incompetent persons should be involved as much as possible in the decision-making process (Gastmans, & Milisen, 2006). Due to the fact that Mr. Guthrie has organic brain syndrome, his autonomy and competency might be in question. If he is not an autonomous individual, family members and caregivers should attempt to make decisions in accordance to Mr. Guthrie s authentic interests (Sjostrand, & Helgesson, 2008). In regards to social and political implications, the use of coercion and restraints against a patient or family s will may mean that the general trust in the healthcare system withers and people will hesitate seeking care if they have medical problems (Tannsjo, 2004). Moreover, some healthcare facilities may not have the money and resources to adequately care for complex patients that need extra attention. A shortage of manpower could influence the decision to use methods of physical restraint (Gastmans, & Milisen, 2006). In a nursing home setting, fixed structure and ritual are essential for the therapeutic needs of its patients. Caregivers often have the impression that restraint use affords them a measure of control and decreases the chance of chaos (Gastmans, &
5 Milisen, 2006). In all clinical settings, nurses must apply values and norms as guidelines for their actions. Courses of Action Since the charge nurse ordered restraints and sedation immediately, the time frame for the new RN s course of action is limited. After quickly gathering the appropriate data, the new RN should identify possible courses of action. In favor of beneficence, the new RN could return Mr. Guthrie to his room, apply the physical restraints, and administer sedatives immediately. The negative implications of this action include: reinforcing negative and paternalistic attitudes toward demented patients, physical risks, and traumatic psychosocial experiences for the patient, relatives, and caregivers (Gastmans, & Milisen, 2006). Advantages include ensuring the patient s own safety, the protection of society and people in the immediate surroundings, and the potential restoration of the patient s autonomy (Sjostrand, & Helgesson, 2008). A mental disorder can in fact severely impair a person s decision-making capacity; therefore, it is reasonable to suppose that coercion is in the patient s actual interest, and the restoration of autonomy can be a possible goal (Matthews, 2000). In contrast to direct obedience, the new RN can refuse to sedate and restrain Mr. Guthrie based on her own moral convictions and previous views of social norms. She may feel that it is morally and ethically wrong to threaten the autonomy of a patient for the comfort of others and the maintenance of a pleasant atmosphere. An advantage of refusing any action is that Mr. Guthrie retains his autonomy for a temporary period of time. Conversely, the new RN is directly refusing to implement prescribed physician
6 treatments and follow orders from the charge nurse. With this refusal, her job and professional career may be in danger. If the new RN does not apply restraints and administer medication, another nurse will. For Mr. Guthrie, the delay in treatment may result physiological harm and could endanger his own safety as well as the safety of others. The fact that Mr. Guthrie has not harmed himself or others in the past does not affect his potential to inflict harm or endanger himself in the future. Lastly, the new RN can take an alternative course of action instead of the two extremes. After receiving the order from the charge nurse, the new RN can ask to quickly reassess Mr. Guthrie to determine if both medication and physical restraints are still necessary. If his and other s safety and security are at risk, the RN should administer treatments immediately to prevent injury. Once order is maintained and Mr. Guthrie is stable, the RN can approach the charge nurse and discuss possible future alternatives to sedation or restraints. It is possible to suggest a treatment plan where benefits can be weighed against the shortcomings, methods can be individualized to Mr. Guthrie s condition, and open discussion can begin with all those involved including Mr. Guthrie himself and his family. Underlying causes of the patient s wandering, yelling, and incontinence can also be addressed. The advantages of this approach combine promoting patient and community safety and opening up options to ensure Mr. Guthrie s overall dignity and wellbeing. By reassessing the patient, unnecessary use of sedation and restraints can be avoided; however, taking time to assess the patient a second time can increase potential risks. Resolving the Dilemma
7 When analyzing the different courses of action, the nurse should choose the one with the best possible ethical outcome. In this case, neither beneficence nor autonomy should serve as primary guiding ethical principles. Mr. Guthrie should not be restrained or sedated to help the staff maintain order or provide a pleasant nursing home atmosphere for other patients and visitors. The restraint of psychiatric patients can only be implemented if, without such treatment, serious harm is likely to result to the health of the patient; it must no be given in the interest of other people (Tannsjo, 2004). When it comes to healthcare interventions, interests other than the patient s own should be considered secondary (Sjostrand, & Helgesson, 2008). In regards to autonomy, patients with severe psychiatric illness may not realize that they are suffering from a disease which can distort their comprehension of the world and impair their ability to make rational, autonomous treatment choices (Sjostrand, & Helgesson, 2008). Due to his mental illness, Mr. Guthrie no longer has the ability to make choices about all aspects of his care, so the duty to act in his best interest falls on his family, the doctor, and the nurses. Some patients who suffer from mental disorders are dangerous to others and can be influenced by their disease to harm themselves (Tannsjo, 2004). It is possible that Mr. Guthrie is one of these people; therefore, the primary ethical consideration is nonmaleficence. The new RN should choose the course of action that avoids harm and hurt to anyone. The last course of action has the greatest potential to fulfill total nonmaleficence. The short-term outcomes include protecting the other patients as well as Mr. Guthrie. Discussions of alternatives could lead to the conclusion that physical restraints are unnecessary, which would prevent long-term
8 physical and psychological risks of prolonged restraint use. The new RN should push the nursing home to start analyzing the ethics of chemical and physical restraints. In the clinical world of today, healthcare facilities are moving away from the use of physical restraints and looking for alternatives that serve the same purpose.
9 References Gastmans, C, & Milisen, K. (2006). Use of physical restrain in nursing homes: clinicalethical considerations. Journal of Medical Ethics, 32(3), Retrieved from http:/www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2564468&tool=pmcen trez Matthews, E. (2000). Autonomy and the psychiatric patient. Journal of Applied Philosophy, 17, 59-70. Sjostrand, M, & Helgesson, G. (2008). Coercive Treatment and Autonomy in Psychiatry. Bioethics, 22(2), 113-120. Tannsjo, T. (2004). The convention on human rights and biomedicine and the use of coercion in psychiatry. Journal of Medical Ethics, 30. doi: 10.1136/jme.2002.000703 Veatch, R, & Fry, S. (1987). Case Studies in Nursing Ethics. Philadelphia: J.B. Lippincott Company.