Disagree with physician about restraining a patient

[palila]

I recently moved to the southeast from the northeast and I am unsettled about the use of restraints in this area. I worked in 4 northeast hospitals and the only time I ever saw a patient in soft restraints was when they were intubated. We used bed alarms, sitters, etc, but never restraints on someone who was simply confused. I have now worked at two southeast hospitals and I am frankly shocked at the number of patients who are in wrist restraints and waist belts (which I did not even know existed) simply because they are confused or pulled out an IV. I have even been ordered to restrain patients pulling off BiPAP masks. Oof.
Anyway, something happened yesterday that really bothered me. I responded to a rapid call on medsurg for a young adult woman who was “seizing”. Her seizures were extremely atypical and as someone who worked ED for 7 years, I suspected pseudo-seizures. This was confirmed when I transported her to the ICU and she spontaneously came out of her post-ictal period when the doctor mentioned intubation. During this whole episode, her IV’s kept becoming mysteriously dislodged and by the third, I realized she was doing it on purpose. When she pulled out the fourth, my nurse orientee actually caught her with her fingers around the tube and it was so well taped that she ripped the tubing in half. Once we were on to her she started pulling everything off, ripped out her 5th IV and got dressed. A hospitalist and a psychiatrist came to the room to see her and the psychiatrist determined and documented that she had capacity to leave AMA if she chose (she had a SO in the room who could drive her), but they convinced her to stay. She was also seen by neurology and had another “seizure” during the exam and the neurologist agreed that this was psychogenic. Another IV was placed and the intensivist ordered me to place her in soft wrist restraints so she would not pull another IV. I refused. He said that “interference with a medical device” was a valid reason for restraining a patient. So here’s my question. Am I wrong? Do I have a right to restrain an alert, oriented, adult woman who is not hurting me, not hurting herself, but simply allowing us to start multiple IV’s only to pull them out?

[NightNerd, MSN, RN]

I would feel weird restraining someone who a psychiatrist said has capacity to refuse care and leave AMA. I have restrained confused patients before to ensure that they can receive needed treatments, but I take them off once the patient is either no longer agitated or the treatment is no longer needed. I think you made the right call here; however, it is frustrating to think of having a patient keep doing this even though they've agreed to stay in the hospital. I'm curious what others will say.

[Guest219794]

The PT has capacity to make decisions.

If you do something physical to them without their consent, I am pretty confident that is an assault. 

[MunoRN, RN]

I agree that it's pretty jarring going from healthcare pretty much anywhere else in the US to the Southeast.  The cultural views on aggressive, non-beneficial care combined with an already underfunded system is what I founded the hardest to grapple with.

The restraint issue isn't necessarily regional, places with more cushy funding are more likely to utilize sitters rather than restraints regardless of the region.

The scenario you describe would seem pretty straightforward, a patient who is able to make their own decisions has refused an IV by repeatedly removing them, the solution is pretty clearly to stop putting IVs in this patient.  

Restraints are legally acceptable when the patient is currently unable to make their own medical decisions and we either know or assume based on a lack of evidence to the contrary that a patient wants to receive the treatment that the restraints are being used to facilitate.  

[JBMmom, MSN, NP]

I think I would not place another IV in a patient that keeps pulling them out if they are alert and oriented. If the goals of therapy have been explained to the patient and she refuses to comply with care, that's her decision. However, I can understand that doctor's reasoning, but I think that you're right. 

[Guest219794]

This whole situation is weird.  Soft restraints will not stop a physically healthy youg woman from doing any thing.  They are essentially designed for folks whose cognitive ability is so degraded, they can't get out of soft restraints.

[Emergent, RN]

If people don't want to cooperate, I say let them do what they want. As long as they are not hurting other people they should proceed to be able to live a self-destructive lifestyle. 

People like this should be shown the door, however. They are usually on public funds, and they should not be entitled to abuse the system like this on other people's tax dollars.

[DavidFR, BSN, MSN, RN]

I think you did right. 

I've used restraints when the patient has been a real danger to themselves or others. However this lady was deemed fit to leave if she wished by a psychiatrist, so you did right to refuse. She's an adult, deemed in charge of her own decisions by a psychiatrist. 

If a compus mentus adult not in need of life saving treatment pulls out an IV I don't site another one unless I'm sure they're going to keep it. She's clearly saying "No" and one of my favourite lines is "This isn't North Korea".  It's a bit like sexual consent: No means No.

[LovingLife123]

Pulling out medical devices is actually a reason to restrain someone.  It’s one of the choices when the order is placed.  I work in the ICU and we use a lot of restraints.  
 

I personally would have let her sign out AMA.  If she was pulling out that many IVs and stating she wants to leave, and you state she is in her right mind, I bring them the paperwork.  You don’t need a physician to OK that.  

[MunoRN, RN]

4 minutes ago, LovingLife123 said:

Pulling out medical devices is actually a reason to restrain someone.  It’s one of the choices when the order is placed.  I work in the ICU and we use a lot of restraints.  
 

I personally would have let her sign out AMA.  If she was pulling out that many IVs and stating she wants to leave, and you state she is in her right mind, I bring them the paperwork.  You don’t need a physician to OK that.  

Unintended removal of medical devices is a legitimate reason to restrain someone so long as they lack the ability to make medical decisions based on established criteria.

If they do have the ability to make medical decisions then restraining them to prevent them from exercising that right is a crime, potentially a felony.

[Sour Lemon]

How did the patient feel about it? It seems like she would be eager to play along considering her behavior up until that point. There are patients who I will restrict from movement with their consent ...like wrapping a towel around their arm to remind them not to bend their elbow (if another IV site is unwanted or unavailable).

I would have presented it as a choice for the patient to make since her IV kept coming out "accidentally". Like someone else mentioned, it wouldn't be a true restraint for a mentally and physically capable person ...just a dog and pony show.

[CalicoKitty, BSN, MSN, RN]

Sometimes I've seen "lifesaving" medical devices and at my hospitals simply pulling out an IV was not a restraint indicator (unless the IV was a lifesaving medication like cardiac meds).

If her seizures aren't real, why are they keeping her? Why did they fight so much against her AMA? Does she have other medical reasons to stay? Also, may want to figure out why she is there - what does she want?