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Chemical Restraint Neil Petrie Consultant Pharmacist September 2016 How do you define “Chemical Restraint” • There is no legal definition of this term – National Health Act or – Aged Care Act 1997 – Accreditation standards for Residential Aged Care. • It is mentioned in – Mental Health Act 1986, the Disability Act 2006 How do you define “Chemical Restraint” __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ Think of instances where “Chemical Restraint” was used? Medication Situation Chemical Restraint • Chemical restraint is the control of a person’s behaviour through the intentional use of any medicine – Prescribed, Over the counter, Complementary or Alternative medicines • May be considered a chemical restraint – when no medically identified condition is being treated – where the treatment is not necessary for a condition – to over-treat a condition. Definition • Key factor that differentiates restraint from other forms of care or medical treatment is that it is always applied intentially to restrict the movement or behaviour of a person • The appropriate use of drugs to reduce symptoms in the treatment of medical conditions such as anxiety, depression or psychosis DOES NOT constitute restraint. What leads to Restraint? To control an episode of behaviour To prevent falls To protect from injury To maintain treatment regimes Meet request by families May be considered a Restraint unless Type of Medication Antipsychotic Anticonvulsants/ Mood stabilisers Anxiolytics ie benzodiazepines Antidepressants Accepted Medically Identified Conditions Psychosis, delusions, hallucinations, Schizophrenia, Bipolar disorder Seizures, Neurological disorders, Bipolar disorder PRN short term for acute relief of anxiety in diagnosed psychiatric illness Depression, anxiety disorder Sedatives/Hypnotics Where requested by resident to sleep What do you think of this statement? “This medicine is being used for Behaviour Management and is NOT being used as a restraint”. One large organisation has asked staff to place this sticker next to all antipsychotics!!!!!!!!! Doctor records in notes after prescribing risperidone “This is not a chemical restraint” Residential Aged Care Use The use of Chemical Restraint in Aged Care may be particularly insidious for two reasons 1. Actual use is relatively undetected and is not specifically monitored. 2. Potential side-effects can be both substantial and severely detrimental Chemical Restraint It is sometimes considered when care staff are concerned about a residents behaviour. We need to consider what is in the patient’s best interest. Expected benefits need to be weighed up against risks Considered high risk along with Removing mobility aids and Bed rails Decision to Use Involves obtaining consent Least restrictive form Last resort Should enable the resident to function better Prevention is always the priority Consent Consent should be obtained Resident The person responsible for consent It should be documented It should be regularly reviewed. Can be withdrawn at any time. except in an emergency or where the law provides otherwise. Consent - Important Note A family member or legal representative does not have the legal power to require that a resident be restrained. This is a clinical decision made by appropriately qualified people. Must document the reason for restraint use Must document the process in making this decision Those deciding are legally accountable for any consequences. Accreditation If chemical restraint is used there are processes to ensure it is being used within guidelines and that it is reviewed and monitored by appropriately qualified health professionals Assessment module compilation June 2014 Outcomes Standard Guidelines Although are not strictly legally binding but are also relevant 2.13 Behaviour Management The needs of residents with challenging behaviours are managed effectively. The focus of this expected outcome is ‘results for residents’. Expected outcome 2.7 Medication Management When using pharmacological interventions, the aim is to settle distress, without affecting clarity of consciousness or compromising quality of life. Chemical restraint should only be used when all other options have been exhausted. If chemical restraint is used there are processes to ensure it is being used within guidelines and that it is reviewed and monitored by appropriately qualified health professionals Assessment module compilation June 2014 Australian Government Australian Aged Care Quality Agency Expected outcome 3.9 Choice and decision making Before any medical treatment or procedure is carried out, staff must obtain consent from the resident/representative. The consent must be informed, competent, uncoerced and continuing. The Agreement The resident has the right to and shall be provided with, adequate and appropriate care, services and accommodation without confinement or restriction unless permitted by law. Be free of unnecessary medication and unnecessary restrictive treatments Common Law Rights Laws of assault and false imprisonment are also relevant. Locking a person in a room or using medication to prevent a person’s movement is considered by the law to be false imprisonment Common Law Rights If psychotropic medication is used on a resident without her/his informed consent, unless its use can be shown to be necessary, then the chemical restraint may be illegal. Medicolegal Pitfalls Failure to recognize a medical cause for agitation or assumed psychosis Inadequate monitoring of vital signs after sedation Failure to recognize potential lethal cardiac adverse effects from medications given Failure to comply with state laws regarding patient competency and confinement When should psychotropic medications be used? Treat a psychiatric condition or When it is necessary to avoid self-injury or Injury to others Suitably Trained People The use of chemical restraint should be reviewed regularly by sufficiently trained person Doctor Nurse Pharmacist When is it not justified? It should not be used to manage behaviour such as Wandering Pacing Uncooperativeness Sleeplessness As a disciplinary measure – For convenience of staff Care Strategies Develop a data base of care strategies Remembering that care plans are individualised. Regular care plan review Consider a Behaviour Management Committee To develop a team environment for best practice To encourage “Proactive Care” as opposed to “Reactive Care”. To promote communication and consultation Management Responsibilities 1. Develop policies and practices 2. Initiate prevention programs 3. Promote communication and consultation 4. Establish and maintain review processes 5. Ensure education and training support 6. Keep informed of best practice The Health Service should Have regular medication audits To obtain a snapshot of the use of restraint To provide information for further action Be peer reviewed involving General practitioners Director of nursing Pharmacist See NPS Audit Coroners Case Case in South Australia “harsh and unsympathetic staff were too quick to seek pharmaceutical solutions to a dementia patients behaviour problems” Recorded reasons for use included “John is a little restless” “Given for settling tonight” Usually no suggestion of threatening behaviour Keep Informed about best practice National Prescribing Service Dementia Action Alliance Dementia Behaviour Management Advisory Service 1800 699 799 Myths about Restraint Myth – “It doesn’t really bother old people to be restrained.” Reality – studies show that older people report feeling fear, distress, humiliation, frustration and agitation when restrained. Belinda Evans – Elder Rights Myths about Restraint (cont) Myth – “The old should be restrained because they are more likely to fall and seriously injure themselves.” Reality – Residents under restraint, often: suffer injuries such as falls or strangulation resulting from struggling to be released; experience confusion and cognitive decline; suffer loss of functional capacity, for example, muscle tone and balance. Belinda Evans – Elder Rights Myths about Restraint (cont) Myth – “If we don’t restrain we could be sued.” Reality – Failure to restrain (after appropriate assessment) has seldom resulted in a successful liability case. However, liability has been found where restraint has been applied inappropriately. Belinda Evans – Elder Rights Useful Information Summary Consider the reason for administering Consent is important Clearly document Monitor the outcome. If we spent as much time trying to understand behaviour as we spent trying to manage or control it, we might discover that what lies behind it is a genuine attempt to communicate Source: Goldsmith, M (1996) Slow Down and Listen to their voices – Journal of Dementia Care 4(4)