1. November 24, 2012 Rose M. Carter, Q.C. Bennett Jones LLP Adjunct Professor, Faculty Medicine and Dentistry University of Alberta Rocky Mountain Internal Medicine Meeting

2. Environmental The use of environment, including seclusion or a time out room, to involuntarily confine a person and to restrict freedom of movement Mechanical The use of a device or appliance that restricts or limits freedom of movement, for example, vest restraints, lap belts, pelvic restraints, mittens, geriatric chairs with locked trays and sheets Chemical Any psychotropic drug not require for treatment, but whose use is intended to inhibit a particular behavior or movement College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009) at 3 2 Types of Restraints

3. Physicians are responsible for "taking all reasonable steps to prevent harm to patients" to "respect the right of a competent patient to accept or reject any medical care recommended" Canadian Medical Association, Code of Ethics (2004) 3 Responsibility

4. When necessary to protect the patient other patients, or others lawfully on the premises (staff or other patients) from harm to prevent endangerment to the safe environment of the hospital or facility Conway v. Fleming [1996] OJ No 1242 (Ont Div Ct) 4 When can restraints be utilized?

5. Need informed consent from patients, their families, and/or their legal guardians Ensuring the safety of the patient and others 5 Use of Restraints – Legal Issues

6. Responsibility for use of restraints shared by: all members of the health care team; patients; their families; and/or their legal guardians; the community; regulatory agencies; and governing bodies College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009) 6

7. May be appropriate where a patient is at risk for self-injurious behavior or poses a threat to the safety of medical staff and other patients College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009) 7 Restraints in Hospital Setting

8. CARNA advocates for a policy of least restraint in all client care settings; this requires that nurses exhaust all possible alternatives before using restraints College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009) 8 Amount of Restraint

9. Use of restraints may result in negative consequences: loss of bone and muscle mass; skin breakdown; Immobilization; urinary incontinence; urinary tract infection; Pneumonia; cardiovascular stress; and psychological and psychiatric sequelae such as increased agitation, anxiety, delirium, depression and even death College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009) 9 Negative Consequences

10. Involving of families in providing care Choosing less intrusive treatment options Offering medication to control pain Providing physical activity to diffuse the mood of an agitated pt College & Association of Registered Nurses of Alberta, "Position Statement on the Use of Restraints in Client Care Settings" (Edmonton, 2009) 10 Possible Alternatives to Use of Restraints

11. consider: The patient's response to the restraints/whether the restraint has the desired effect Positioning of the restraint The need for ongoing use of restraints each shift The patient's level of alertness and orientation The affect of the restraints on the patient's and their emotional well-being The patient's need for socialization Any pain or discomfort related to the restraint The opportunities for the discussion of thoughts, feeling and worries regarding the restraint The patient's need Any opportunities for physical activity, re-positioning, and skin care Circulation to extremities to which a restraint is applied University Health Network, Policy and Procedure Manual: Clinical – Patient Restraint Minimization (2005) 11 Monitoring of Patient Under Restraint

12. Section 30 provides the authority to control a person under this Act is authority to control the person without the person's consent to the extent necessary to prevent serious bodily harm to the person or to another person by the minimal use of such force, mechanical means or medication as is reasonable, having regard to the physical and mental condition of the person. NB – Section 30 only applies to patients who fall under the terms of the MHA (those who are detained in a facility pursuant to an admission certificate) RSA 2000, c.M-13, s.30 12 Mental Health Act (MHA)

13. Appropriate to use restraints to protect the patient from suicidal behavior and to protect others R. v. Wittman, 2007 ABPC 89,415 AR 394 13 Case Law

14. the plaintiff was a non-psychiatric in-pt who suffered injuries when she was attacked by a psychiatric in-pt. She sued the hospital for negligence for failing to control the movements of a mentally-ill patient who had known propensities for violence Wellesley Hospital v. Lawson [1978] 1 SCR 893 at 895, 76 DLR (3d) 688 [Wellesley] 14 Case Law

15. SCC noted at common law a hospital, especially one providing treatment for mentally-ill persons, would be under an common law liability if by reason of its failure to provide adequate care and supervision injury occurred to third persons by reason of the conduct or behaviour of a patient Court stated the hospital had an independent duty to supervise and keep under reasonable control patients who the hospital knows or ought to know have propensities do to violent behavior Wellesley Hospital v. Lawson [1978] 1 SCR 893 at 895, 76 DLR (3d) 688 [Wellesley] 15 Case Law

16. the hospital had the authority, and the duty, to control (or restrain) the behavior of the mentally-ill patient if necessary to protect other people from harm. Wellesley Hospital v. Lawson [1978] 1 SCR 893 at 895, 76 DLR (3d) 688 [Wellesley] 16 SCC Concluded

17. every hospital, and every unit with a hospital, will have its own policies regarding the use of restraints 17 Policies and Procedure

18. AHS is in the process of developing a comprehensive policy on the use of restraints during hospitalization The policy is meant to relieve the ambiguity in this area and will apply across the province This policy is set to be released in 2013 18 AHS Future Policy

19. Duty to protect pt from self harm Duty to protect others from a pt who may harm them AHS developing policies and procedures due out in 2013 19 Summary

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