When is restraint appropriate?BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4147 (Published 04 August 2010) Cite this as: BMJ 2010;341:c4147
All rapid responses
As an American surgeon recently returned from Scotland I have had a
number of discussions with colleagues about how practice patterns differ
between the two countries. The one revelation about care in the U.K. that
most reliably invokes incredulity here is that restraints are not used in
routine clinical care, and the one thing that still looks strange to me
since returning is the site of restrained patients. When I told
colleagues in the U.K. that restraints are regularly used (though this is
institution dependent and by no means universal) in U.S. intensive care
units (ICUs), they were initially surprised, but then seemed to accept it
in the same spirit as they accept that handgun ownership is commonplace in
the U.S. -- as an example of casual American brutality.
Daniel Sokol's column in the August 7th BMJ begged the question -- do
restraints work?(1) While the scenarios Sokol describes are unusual and
thus may provide intersting grist for the ethicists' mills, the vast
majority of restrained patients in my current institution are sedated in
ICUs and restrained, to quote from our restraint order template, in order
to "Limit pulling at/out equipment e.g. IVs, feeding tube, airway
management tubes, urinary drains, to prevent injury."
To me some relevant questions are: Do restraints actually result in
lower rates of equipment dislodgement than diligent nursing care alone?
Do restrained patients require less sedation, resulting in lower rates of
delirium and perhaps earlier extubation and discharge from the ICU, or do
restraints themselves agitate patients leading to more sedation and
resulting in the opposite effects on delirium and length of ICU stay?
Retrospective studies have hinted that restraints do not improve outcomes
or reduce undesirable events (such as unplanned extubation) in the ICU, a
position congruent with my own anecdotal experience in the U.K.(2,3) But
U.S. restraint practice is unlikely to change quickly unless questions of
this sort are studied prospectively in an organized fashion. While I
doubt U.K. institutional review boards (IRBs) would allow patients to be
randomized to restraint, I suspect, ironically, that some U.S. IRBs might
find randomization to no restraint to be too dangerous.
Lastly, what about the moral dimension of restraint? To me it is
disingenuous to consider the placement of soft wrist restraints (that
might allow some movement but prevent a quick grab for the endotracheal
tube) a violation of a patient's basic human rights, while physicians
might simultaneously be making judgments for the same patient about
whether a tumor is resectable, or a limb salvageable, or chemical
paralysis is warranted. We doctors do a lot of things that infringe on
people's autonomy and are much more dangerous than restraint. This is
morally acceptable because we are trying to help. Restraint should not be
treated differently. Here I must agree with Sokol, that the challenge is
not determining if restraint is ever appropriate, but defining when it
serves the end of beneficence.
1. Sokol DK. When is restraint appropriate? BMJ. 2010 Aug
4;341:c4147. doi: 10.1136/bmj.c4147.
2. Martin B, Mathisen L. Use of physical restraints in adult critical
care: a bicultural study. Am J Crit Care. 2005 Mar;14(2):133-42
3. Chang LY, Wang KW, Chao YF. Influence of physical restraint on
unplanned extubation of adult intensive care patients: a case-control
study. Am J Crit Care. 2008 Sep;17(5):408-15; quiz 416.
Competing interests: No competing interests