Don’t Tie Me Up To Keep Me Safe!

The use of restraints on confused seniors has always been very close to my heart. Back in the 1990s, as a young nursing student, I was taught to use physical restraints to tie patients to their hospital beds so that they could not walk about, least they sustained a fall or wandered off from the hospital. Back then, it was a common sight to see patients being tied to their hospital beds as long as they were assessed to be at risk to falls and were confused, hence, there was nothing abnormal about the practice of tying patients to their beds. Those who were not confused but at risk to falls would have their cot side put up all the time, preventing them from getting off the beds to walk about (yet walking about is normal for human beings). Thinking about it now, that’s another form of physical restraint, isn’t it? The physical restraints were only released when the patients needed to have a shower / bed-sponge or their 2-hourly turning, after performing those tasks I diligently tied them to the beds again as being taught. I was taught, hence, I thought that I was doing that FOR THEIR SAFETY, least they fall and fractured their already brittle bones. But what I did not realise back then was that my diligence in tying those patients to their beds will actually result in them falling due to the rapid deconditioning of muscles as one stop using their muscles.

Seniors can suffer from confusion due to acute conditions like delirium or chronic conditions like dementia. Once my late-father was hospitalised due to some infections and was suffering from delirium that caused him to be confused. He did not have any other conditions that caused confusion and he was very alert and independent before and after that episode of infection. I remembered walking into the hospital ward, seeing my father being tied to his bed. I was, of course, rudely surprised. That really brought home the message that the use of physical restraints is not right, no matter how justified the situation seemed. I immediately went over to his bed to untie his hands, and while chatting with him, I realised that he was hallucinating about being in his previous workplace and that he had to go and supervise his workers as they were unloading the goods that had just arrived. I reassured him that his workers knew how to do their job well and that he just need to oversee the unloading operations from where he was, and changed the topic of discussion. My father did not press on about ‘the unloading of goods’. I then approached the nurses to enquire about the reason for the use of physical restraints on my father, they replied in a very matter-of-factly and justified manner that “Mr Tan is confused” which insinuated that they were simply carrying out their standard operating procedures (SOPs) for managing confused senior patients and there was nothing wrong with tying confused Mr Tan to his hospital bed. However, I told them that I did not want to see my father being tied up just because he was confused. It was not acceptable to me then and now, after having graduated from nursing school, progressed in  my career, learnt about and met people who knew exactly what person-centred care is and how it was practiced overseas. After a few days of antibiotics treatment, my father’s hallucination and incoherence stopped, so he was allowed to walk about. I noticed that he would normally complain about weakness in his legs upon his discharge from every hospitalisation, at times he would even have to hold on the handrail while walking when he didn’t need to before all his hospitalisations.

Does confining a person to his/her bed/wheelchair for his/her safety and prevent the risk of falls really protect the individual from harm? The answer is a simple NO.

When I read what Francis wrote in Straits Times about the nursing home protocol to get immediate family member to grant consent “for the use of various forms of restraints” for the “safety” of his mother “and would prevent the risk of falls”, it prompted me to write this article to STOP such practices so that both you and I will not be the next victim to this extremely UN-person-centred care approach as we age.  I was heartened to read that he refused to sign the consent form and negotiated for an “‘observe and see’ approach to managing his mother’s condition” as he was knowledgeable about the adverse consequences of the use of restraints as a result of having read Dr Philip Yap Lin Kiat’s article Reduce Use Of Physical Restraints In Eldercare  in Straits Times. In his article, Dr Yap brought up the issue on Ethical Concerns that “common or frequent use of restraints also risks sliding down a slippery slope where callous and unthinking use can promote a laissez faire culture which justifies restraints loosely on grounds of efficiency and convenience, with little regard for the person, especially in situations of manpower constraints” violating the dignity and well-being of the seniors who are being tied.

So, is it possible to provide effective and safe care to seniors without physical restraints?

How many of you, caregivers out there, living with and caring for your parent(s) with dementia actually tie them up at home? In his article, Dr Yap also shared examples of nursing homes in the United States and Japan prohibiting the use of restraints in their eldercare facilities. So when traditional SOPs on physical restraints are no longer viable in a person-centred care environment, care team needs to think and work in an creative and innovative manner. Being creative and innovative by no means imply that they need to be a scientist to create something new or a researcher, all it means is that they need to be knowledgeable about existing technologies and practices in other sectors that could be adapted and/or adopted into the provision of patient care. Dr Yap shared an example on “the use of technology by way of pressure sensor mats or passive infrared sensors around the bed helped to alert the staff if the patient attempted to get out of bed, thereby allowing them to attend to him promptly to avert falls” in his article. Dr Yap also shared other local practices at the dementia unit (Care for the Mentally Infirm Elder or Camie) of Khoo Teck Puat Hospital which has helped the dementia unit maintained a more than four years record in being physical restraint-free.  Such practices include rostering ‘ONE extra staff to attend to patients who tried to get out of bed at night’, and ‘knowing the patient more intimately and nurturing trusting relationships in which the care provider understand the patient’s life history, preferences and habits’. Knowing the patient more intimately beyond his/her bed number, diagnosis and labels will enable the care provider to better understand that patient’s current behaviours like getting out of bed at night so as to put in place a more effective solution than physical restraint. THIS is the basis of person-centred care approach. So, if you chance upon an organisation professing to practice person-centred care yet asking you to sign a consent form to allow the use of various forms of restraints for the safety of the patient and to prevent the risk of falls, do ASK the person in-charge if they are really practising the fundamentals of person-centred care approach and DO NOT SIGN on the consent form but negotiate for an “observe-and-see” approach like Francis did for the dignity and well-being of your loved ones. Such will send a message loud and clear to these organisations that physical restraints is no longer a viable option in this century where technology and other practices can easily can adopted and/or adapted into the care practices that will eliminate the need to tie people to their beds or wheelchairs. Dr Yap, in his article, also recognised that ” restraint-free care requires a systematic and organised effort that is both ground-up and top-down to change beliefs, practices and mindsets.”

Let us unite and stand together as well-informed consumers of eldercare services and collectively reject the use of physical restraints so that organisations will admit the deficiencies of status quo and take ownership of changing towards being physical restraint-free!

Look out for upcoming articles on the increasing loose use of chemical restraints in eldercare and how to truly prevent fall when caring for seniors! Subscribe to us now so that you won’t miss any of these articles.