Question about the use of restraints

[LauraLou]

I am a nursing student and work PRN at a hospital as a Nurse Extern. Last Friday I was with a patient who had just had major abdominal surgery. He was on IV fluids and oxygen, as his O2 stats on room air were in the upper 70's. He suddenly decided he wanted to leave the hospital. He put his jeans on over his incision, which still had staples in and asked me to remove the IV.

I called the nurse and she can in and told the patient he wasn't well enough to leave the hospital. He said he didn't care and was going to leave right now. The nurse called the charge nurse, who also told him he couldn't leave the hospital yet. His doctor then came in and told the patient he would probably die if he went home now. He still insisted on leaving, so the doctor said to let him go but he had to sign out AMA.

The patient refused to sign any papers, so they told him he couldn't leave. The charge nurse called a code rush and the patient was put into restraints, wrist and ankle. He was also given Haldol, though he was never violent and never threatened anyone.

The situation made me very uncomfortable. It was the first time I've seen restraints used on a patient. Is it alright to use restraints to keep a patient from leaving the hospital without signing a paper saying he is leaving AMA? I thought restraints were only for violent patients. We haven't learned much about using restraints in school yet, so maybe this is a common practice. I just don't know.

I feel like I've been involved with something slightly unethical, but that could just be because of my inexperience. What are your thoughts on the use of restraints in this situation?

Thank you

[NRSKarenRN, BSN, RN]

Normal O2 sat: 95% or above

Clients require OXYGEN at 88% or less.

Anyone with sats only in high 70's are hypoxic + irrationale due to lack of oxygen to the brain which affects their decision making processes. A case can be made that since this patient was post op major abdominal surgery, hypoxic and making an irrational decision that could adversly affect his life: high risk of GYING, therefore physician judged the patient incompetent and restraints necessary to SAVE his life.

What did YOU DO /observe staff when given the information that pulse Ox in high 70's???? This is a CRITICAL reading that requires immediate attention and OXYGEN being applied to the patient--even without an order.

I've had to do this a few times in my career working on a respiratory unit. Had a patient with sats in lo 70's s/p GI surgery wanted to walk out, was restrained. We drew blood work, changed the Oxygen prongs to non rebreather mask and patient was quieting---blood sent off for analysis. He coded 1 hour later due to abd bleed, taken back to surgery, bleed cautherized and patient survived. Came back a month later for doctors visit, appoligized for his behavior and profusely thanked us for saving his life.

[begalli]

If this patient's O2 sats were in the 70s on room air, I doubt that he was in any condition to make a decision about whether he stayed in the hospital or not. His brain was not perfusing well.

I wonder what they did for his oxygenation? Did they check a blood gas?

Haldol is used in a variety of scenarios. Agitation is one and sounds like that's how this gentleman was behaving.

The restraints can be used in the case of potential injury to ones self. Sounds like he wasn't able to protect himself very well.

This doesn't sound unethical at all.

[acgemt]

I am more curious as to why they waited so long to put him on oxygen (O2 sat in the 70s on room air). Why wasn't it put on earlier, especially if he just had major abdominal surgery.

[begalli]

He was on O2:

He was on IV fluids and oxygen, as his O2 stats on room air were in the upper 70's.

I suspect though that when he was trying to leave he didn't have the O2 on thus making his decision making process in the potty.

[Tweety, BSN, RN]

It doesn't matter if the patient's oxygen sats were 20, if he was alert and oriented and capable of making his own decisions he can refuse treatment. Patients are allowed to refuse even life saving treatment. Take for instance a person with a hgb of 4, with an active bleed, who refuses a blood transfusion.

A person doesn't have to sign out AMA in order to leave the hospital freely. Obviously we want that paper. But this is America. He had the right to leave and he had the right to refuse to sign anything.

I'm sure his behavior was his hypoxia and that should have been the priority as soon as his sat were noted to be that low.

It's a whole different scenerio if he was confused.

[kitty=^..^=cat]

Right? Wrong? Not having been there, I have no idea, but...

What happens if the patient leaves with sats in the 70's and bleeds out on the way home? If he signs out AMA and, God forbid, tries to drive himself anywhere, the chances of him having an accident would be greatly increased.

Sure there are legal risks associated with restraining this patient, but what are the risks if he leaves?

[begalli]

It doesn't matter if the patient's oxygen sats were 20, if he was alert and oriented and capable of making his own decisions he can refuse treatment.

But that's just it. If a person's oxygenation is so compromised, they are NOT alert and oriented and NOT able to look after their best interests or safety.

[LauraLou]

I appreciate all your feedback. The patient did have his oxygen on when he decided to leave, but in the process of getting dressed and arguing with everyone, he did take it off. He really wasn't in any condition to leave the hospital and you are right, without his oxygen, he couldn't make sound decisions. It is just hard to see restraints used on someone, especially an elderly man who just stood there asking to go home.

I wish they spend more time at school discussing situations like this. We learn what a normal respiratory rate is and what a patient's O2 sats should be. But we don't go beyond that to say what happens to the patient's mental and physical state when he isn't getting enough oxygen and how does that affect his ability to make rational decisions, and what are your responsibilities as a nurse in a situation like this.

There is so much material to cover in class, that we really never have the chance to apply the information we are learning to real life situations.

[chad75]

With sats in the low 70's and with no other more experienced/ nursing supervisor to refere to I would probably try and stall him until I got MD clearance to either let him leave AMA or place him on a 72 hour hold. If I couldn't stall him non-physically I would restrain him using the lease invasive method possible and take my lumps if it was the wrong decision versus letting him leave and have a good chance of dying.

If his 02 sat was >90 it wouldn't have been an issue, just let him go. I think its one of those situations where you would have had to be there to make a decision...can you chart symptoms of hypoxia other then portable sat readings? There is no objective answer for such a situation, that is one of things that makes nursing dynamic. Machines can be wrong and we treat the patient not the machine.

[nursemike, ASN, RN]

If getting the AMA signed was the major issue, the patient was falsely arrested. Signing the paper doesn't determine competence. Stupidity is often fatal, but it's also an inalienable right. But you can restrain a patient for his own safety (or the safety of others) if he isn't competent to make his own decisions, and hypoxia would certainly diminish mental functions, as might lingering effects of anesthesia.

Sounds like one of them ethical ambiguities you hear about. I hope he feels better when the haldol wears off.

[Tweety, BSN, RN]

Right? Wrong? Not having been there, I have no idea, but...

What happens if the patient leaves with sats in the 70's and bleeds out on the way home? If he signs out AMA and, God forbid, tries to drive himself anywhere, the chances of him having an accident would be greatly increased.

Sure there are legal risks associated with restraining this patient, but what are the risks if he leaves?

It is up the the MD and nurses to explain these risks and document, document, document. That's why we like to get an AMA paper signed, but it's not necessary, if it's documented you explained the risks and the patient chose to leave AMA. Obviously if it's AMA there are serious risks involved to the patients wellbeing, but you can't committ assault and battery to keep them there..........if they are alert and oriented.

I had a patient recently leave with an splenic laceration from an MVA who was supposed to be on strict bedrest. Myself, my charge nurse, his wife and the MD couldn't do anything. We explained the possibility of death should he leave, he left anyway.