Is this restraint issue a dilemma that can go to the ethical committee?

[J-Swish]

I'll keep it brief.

Situation: Pt is A + O x 4. He is able to understand. However, he constantly pulls IV, kicks, pulls O2 off, tries to pull foley, etc. This is after acknowledging that this can hurt him...3x times in a row. IV's re-inserted again and so on. RN finally decides to assign a LVN to be a sitter. LVN is unable to keep her from pulling and calming her down. Finally, LVN decides to call in mechanical restraints. Family is also at bedside but said they disagreed with putting restraints on and said he isn't doing any harm and needs to be calmed down. Argument ensues. Mechanical restraints are finally put on. Within 30 minutes, an MD order for restraints is obtained. Pt is no longer able to pick at IV. Family is angry. Nurses are stressed.

Added to the mess was also all 4 guardrails being up, which means safety and false imprisonment.

The above was a moment in my first semester. For my part, I did not put restraints on the other side because it was against the family's wishes and at the time, i thought we can somehow calm the pt down in another way. At the same time, I realized safety was an issue and the pt can't keep picking at IV's etc.

Is this a dilemma that can potentially go to the ethical committee? This is for a research project and there must be more than 2 correct options to go about in this situation. What do you guys think?

[jadelpn, LPN, EMT-B]

Is the patient a competent adult, not a child, who is not on some sort of guradianship? Do they have periods of confusion that need to be treated? Are they able to speak?

If the patient is alert, and oriented and chooses not to have an IV, foley, etc, it is their right to refuse. Even if the outcome could be lethal, patients have the right to stop treatment at any time. For nursing to continue to re-insert IV's and such without obtaining consent is not, at the very least, correct nursing practice. If the patient is having periods of confusion, then a treatment plan for those times needs to be discussed with the doctor, and they would be considered confused and not A&Ox4 at those times. But what is the goal in 4 point restraints to have an IV and foley when perhaps there's another option as to not cause the patient further distress?

It is up to the doctor, after being made aware by the nurse of the refusal of care, to decide with the patient if the patient should just be discharged, as they are refusing care, or what the patient is comfortable with receiving for treatment, a plan of care that is acceptable to the patient, and/or a discharge plan with services at home. I am not sure what the family has to say on any of it, and it is against the rights of patient privacy to have them involved in making decisions for an alert and oriented patient. Because the patient is alert, oriented, and has their own rights, they can make their own health care decisions regardless of what their family has to say about it.

Unless the family or a family member has some sort of POA, and again, this would be on a patient who was not A&Ox4 all of the time. What the family seems to be leaning towards is a chemical restraint as opposed to 4 points, and again, I would not want to be a party to restraining an oriented adult who is declining care whether it be chemical or physical.

To restrain this patient is holding someone against their will, therefore, could be considered battery....among other legal and ethical violations. Unless the person is a minor child, on some sort of section, guradianship, that sort of thing--and even then, if the guardian wants full on treatment, then the doctor and the guardian need to come up with a plan as clearly, the patient is communicating a desire to not have these interventions. And of course there is further risk to the patient if they are pulling out foleys and discontinuing IV's. To continue medical interventions on a patient who keeps refusing them due to pulling them out and the like is something that can at the least, cost a nurse her license.

[RNperdiem, RN]

Could the family members stay at the bedside and calm him down if they don't want to use restraints?

I wonder why this guy is so agitated.

My first thought is drug or alcohol withdrawl. Many patients don't admit the truth about their drinking habits in the admission assessments.

[missladyrn]

If he is alert and oriented, why doesn't he just sign out ama? I bet then the family might have a different opinion. Why is the patient in the hospital to begin with? Is it life threatening?

[J-Swish]

I think the concern here is confusion and lack of re-demonstration of understanding. Pt says yes to all procedures but for an unknown reason, wants to get out of bed and pull out IV's, etc. I think it might have been a drug withdrawal but no drug screen was done at the time. All good questions...but do you guys see more than 1 correct option? And not 1 correct option/1 bad option.

[EponaRN]

There is not enough information here to make an informed decision on a message board. Kind of a "had to be there moment" it seems. How old is this patient is the first thing I'd ask, what is their reason for admission, why do they have a foley, IV, O2, yet they are A&Ox4? What options were tried besides a sitter? Where any pharmacological interventions tried? If not, why not? Was any attempt made to ask the patient what they would "bargain" for treatment? I.e. music, laptop, any distraction techniques at all? What is their medical history to begin with, is there dementia? Is he sundowning? Is this akithesia? In the Psych facility I work in on the Child/Adolescent unit I work on we have gone a month without Seclusions or Restraints with increased acuity and a full house so it can be done! The art of nursing has to meet the science is all...

[fakm]

I think jadelpn discussed the considerations well and gave sound suggestions/counsel. :-)

[MomRN0913]

When a patient is AAOx4 and choses to pull out own IV's and disrupt treatment with understanding the implications, that is the time you get the order from the doctor to DISCHARGE the patient. If patient is not recieving treatment for which they are inpatient for, it's time to go home, not be tied down.

[threebrats46]

Does the person have psych issues? Our protocol is to medicate first,restraint last unless person hurting himself and staff.

[EponaRN]

If it "might" have been drug withdrawal, what kind? Unless alcohol or benzo withdrawal it isn't a medical emergency and you don't really have to keep them. Then you get into competency and capacity issues for ability to accept and agree to treatment, are they really alert/oriented x4 if they are withdrawaling? Also DKA can look and smell like intoxication.

[EponaRN]

Unless they are suicidal or homicidal you don't have a legal basis to keep them under a treatment director's hold which is what you would need and in order to start that the patient has to request an AMA discharge first. Otherwise our docs would let the detoxers leave if they want the drugs that bad, if they aren't there to get clean you are wasting your time.

[reagansm]

Pt does not sound AOX4 to me. There is a lot missing in this scenario. As others have stated, if pt was really AOX4 then call the MD and get an order for different treatment that pt agrees to, or get them discharged. That seems to be the 2 options: change plan of care/mode of treatment or discharge.