Should you restrain yourself from ordering restraints?
Federal regulations also apply to “chemical restraints” and aim to restrict their use. This doesn’t mean you can’t use drugs to treat patients, however. Regulations explicitly allow you to prescribe “standard treatment” (Table 2)3 to help your patients function or sleep better, to alleviate pain, or to reduce agitation—and such uses of medication are not “chemical restraint.” Rather, you’re using “chemical restraint” if you prescribe a drug to control bothersome behavior—for example, to “knock out” a patient with dementia whose “sundowning” bothers staff members.19 Psychiatrists should be familiar with the risks of medications used for behavioral control, particularly in elderly patients.20
Table 2
Federal criteria for ‘standard treatment‘
| Medication is used within FDA-approved pharmaceutical parameters and manufacturer indications |
| Medication use follows standards recognized by the medical community |
| Choice of medication is based on patient’s symptoms, overall clinical situation, and prescriber’s knowledge of the patient’s treatment response |
| Source: Reference 3 |
Avoiding legal risks
No study or systematic data will ever tell us whether physical or chemical restraints create a greater liability risk. Obviously, the best way to avoid legal liability for restraints is to minimize use of physical restraints and to avoid using medications as chemical restraints. Psychiatrists who work in hospitals or other institutional settings can politely but firmly decline to prescribe medications or to order physical restraints when staff members request these measures for non-therapeutic reasons—ie, for a patient who has calmed down but whom staff members believe “needs to learn a lesson” or “get some consequences” for throwing a chair. When restraints are necessary, psychiatrists (along with other staff members) should document the reasons why, including what other interventions were tried first.
Many psychiatric facilities and care systems have reduced incidence of restraint and time spent by patients in restraint through programs that broadly address institutional practices. Such programs usually involve a multi-disciplinary, multi-strategy commitment to alternatives—to helping staff members see that restraints represent a failure in treatment rather than a form of treatment, and to developing other mechanisms for averting or responding to patients’ aggression before restraint becomes the only option.10,21 Individual psychiatrists can play an important role in advocating and supporting institutional policies, practices, and training that help staff members minimize restraint use.
