Patient Restraint Considerations & Medicolegal Issues

Reasons For Patient Restraint:

1. Safe & controlled access for medical procedures when involuntary patient-interference or
resistance is R!S"#!$%& !#'ICIP!'(. )or e*ample+ Postictal sei,ure patients who are not
-com.ative/- yet remain confused/ can reasona.ly .e anticipated to withdraw or stri0e out when
.eing stuc0 with a needle. -Prophylactic- restraint 1restraint applied before the patient .ecomes
involuntarily resistive to treatment2 will protect the patient and providers/ preventing in3ury or
delay in treatment.
4. !#'ICIP!'I"# of IMPR"5( P!'I#' C"#(I'I"# producing com.ativeness6resistance.
)or e*ample+
o unconscious hypoglycemic patients may -improve- from unconsciousness to .ecoming
com.ative7
o cardiac arrest patients who -get .etter- will #"' deflate the ' cuff prior to e*tu.ating
themselves7
o C5! patients may turn out to .e -'I!- patients/ developing the a.ility to withdraw or
stri0e out when .eing treated.
o !nd so on ...
8. 5!%9!'I"# or 'R!'M#' of C"M$!'I5 PRS"#S
when illness or trauma is suspected to .e the cause of com.ativeness.
:. I#5"%9#'!R& 'R!'M#' of persons I#C"MP'#' '" R)9S 'R!'M#'.
Medicolegal Aspects Of Restraint:
'he primary legal considerations in providing restraint and6or involuntary treatment for a patient can .e
divided into three areas+
1. 'he rights and needs of the patient/
4. 'he duties of the health care providers/
8. ! responsi.ility for the protection of involved third parties.
In the 9nited States/ a citi,en;s right to refuse treatment or transportation for treatment is protected .y law
1common and statutory2 and .y his constitutional rights to privacy/ due process/ and freedom of religion. !
person has the right to come to what others would consider an -unreasona.le- decision/ as long as that
person can ma0e the decision in a -reasoned- manner - meaning the person is capa.le of reasoning/ or is
-competent- to ma0e a decision.
COMPETENCE is defined as the capacity or a.ility to understand the nature and effects of one;s acts or
decisions. !nd/ for all practical purposes/ a person is considered to .e competent until proven otherwise.
'he legal concept of competence can only .e formally determined in a court of law. %aws governing
competence and the right to refuse medical treatment vary widely from state to state.
$ut/ universally/ the determination of competence generally depends upon four o.serva.le a.ilities.
1. 'he a.ility to communicate a choice.
4. 'he a.ility to understand relevant information.
8. 'he a.ility to appreciate the situation and its conse<uences.
:. 'he a.ility to weigh the ris0s and .enefits of options/ and rationally process this information/
.efore ma0ing a decision.
'here are situations/ however/ in which the interests of the general pu.lic 1-State Interests-2 outweigh an
individual;s rights to li.erty+
1. 'he individual is threatening self-harm or suicide.
4. 'he individual presents a threat to the community .ecause of contagious disease or other physical
dangerousness.
8. 'he individual presents a specific threat to innocent third parties..
In these cases/ individuals may .e restrained and6or treated against their will.
MINORS are generally considered to .e incapa.le of self-determination. In the a.sence of a parent or legal
guardian/ and in the presence of a life- or health-threat/ a minor may .e treated against his will. 'he
-freedom of religion- clause/ whether it .e the parent;s or the minor;s religion/ is generally not allowed to
interfere with a minor;s treatment for a life- or health-threat. Some states/ however/ have statutory
provisions that allow certain minors the right of self-determination. -Mature minors- or -emancipated
minors- may .e defined/ and therefore would have the same rights and responsi.ilities as an adult. )or
e*ample/ the state of Colorado defines a minor as any person under the age of eighteen. $ut/ Colorado also
recogni,es the right of consent for minors who are fifteen years old and older/ living separate and apart
from the parent1s2 or legal guardian/ with or without the parent;s or legal guardian;s consent. !ny married
minor or minor parent also has the right to consent within the state of Colorado.
CONSENT is defined as the voluntary agreement of a person possessing and e*ercising sufficient mental
capacity to ma0e an intelligent choice to do something/ with a proposition posed .y another. Consent is
generally considered to .e either e*pressed or implied. *pressed consent is defined as positive/ direct/
une<uivocal/ voluntary ver.al or physicali,ed agreement and is a more a.solute and .inding degree of
consent. Implied consent is defined as signs/ actions/ facts/ or inaction which raises the presumption of
voluntary agreement. 'hus/ a patient who calls =-1-1 could generally .e considered as having implied a
consent for evaluation and care.
Generally, te la! i"plies patient consent d#ring an e"ergency$ 'he law has upheld that conditions
which re<uire immediate treatment for the protection of a person;s life or health 3ustify the implication of
consent if it is impossi.le to o.tain e*press consent either from the patient or from one who is authori,ed to
consent on his .ehalf. 'hus/ the unconscious patient may .e treated under the auspices of implied consent.
'he courts assume that a competent/ lucid adult would consent to treatment necessary to maintain health or
life. If the patient is clearly incompetent/ she6he may .e treated involuntarily. If circumstances are less
clear/ .ut there is legitimate professional dou.t as to the competency of a patient refusing emergency care/
it is .est to err in favor of treatment. It is far .etter/ legally/ to .e accused of assault and .attery or false
imprisonment secondary to involuntarily treating and transporting someone/ than to later .e accused of
negligence.
ASSA%&T is defined as 12 an unlawful physical attac0 upon another> 42 an attempt or offer to do violence
to another/ with or without .attery/ as .y holding a stone or clu. in a threatening manner. 'hus/ threat
alone/ can .e considered an -assault.-
'ATTER( is defined as an unlawful attac0 upon another person .y .eating/ wounding/ or even .y
touching in an offensive manner. Chec0ing a person;s pulse without their permission may .e considered
-.attery- .y some patients. !dditionally/ some religious .eliefs include considering persons of the opposite
se* touching someone/ or the touching of a child;s head to .e offensive. 'ouching these types of people
without prior permission may .e considered -.attery.-
FA&SE IMPRISONMENT is defined as restraint without legal 3ustification. )alse imprisonment is
considered a civil law and does not re<uire violent a.duction. Its e<uivalent in criminal law would .e
-0idnapping.- 'he mere threat of confinement/ com.ined with an apparent a.ility to accomplish the threat/
and some limitation of movement 1i.e.> a closed door2/ is sufficient to uphold a charge of false
imprisonment. ?owever/ false imprisonment cannot .e claimed if the patient consents to .eing confined.
@hen faced with the apparent need to involuntarily treat and restrain a patient/ first consider the needs of
the patient @ould failure to restrain and6or treat the patient result in imminent harm to the patient or other
specific personsA Most patients in an emergency setting are emotionally -upset.- $eing merely -upset- does
not support the use of restraints. 'here must .e an indication of lac0 of competence/ coupled with imminent
health- or life-threat/ .efore a patient can .e treated involuntarily.
'here are several patient characteristics that indicate a need for involuntary treatment and6or restraint. 'he
following is a -Buic0 %oo0- guide for recogni,ing patients who may not refuse treatment. ! patient may
not refuse treatment if she6he is+
9#C"#SCI"9S
S9ICI(!% 1either ver.ally threatening or actively gesturing2
C"#)9S( 1to person/ place/ time/ or situation2
I#'"CIC!'(/ and appears I%% "R I#D9R(
! MI#"R C?I%(/ and appears I%% "R I#D9R(
(5%"PM#'!%%& or PS&C?"%"EIC!%%& (IS!$%(/
and appears I%% "R I#D9R(
5R$!%%& or P?&SIC!%%& ?"S'I% and6or '?R!'#I#E ") "'?RS
In most states/ a person who e*hi.its a danger to her6himself or others 1ver.ally or physically2 may .e
ta0en into custody under an emergency mental health hold 1M??2. 'his hold is usually placed .y a police
officer or psychiatric medicine official. In any event/ it is always wisest to have police present during
incidents involving involuntary treatment and6or restraint. 1$oth for purposes of legality and for sufficient
assistance in the restraint of an individual.2 9nfortunately/ waiting for the police to arrive is not always an
option 1such as in cases where third parties are endangered and cannot .e removed from the dangerous
patient;s vicinity2.
Occasionally, a patient !ill act#ally prefer to )e restrained$ Restraint often provides them with a sense
of safety or control. @hen you suspect this to .e the case/ offer restraints in a supportive manner/ and solicit
the patient;s assistance with their application. If the patient cooperates with restraints/ this cooperative
action implies a consent to .e restrained.
Any for" of restraint "#st )e *INFORME+* restraint$ ven when the patient;s lac0 of competence
will interfere with their a.ility to understand your e*planation/ you must e*plain why you are restraining
and treating the patient prior to doing it.
'he second consideration in providing restraint or involuntary treatment is the d#ty of te preospital
ealt care ,EMS- pro.iders$ 'hrough personal commitment/ professional oaths/ and ethical medical
principles/ an MS provider has a responsi.ility to provide the .est possi.le care for the patient. 'his care/
and the way in which it is provided/ is su.3ect to measurement against national and local -professional
standards of care.- very MS service should have specific written guidelines for patient restraint that are
approved .y the service;s administration/ medical director/ and legal counsel. Performance of such
professional standards of care can then .e supported .y these service protocols/ .ut only as long as the
protocols are strictly adhered to and the restraint situation is ade<uately documented.
NEG&IGENCE: @hen duties or standards of care are not met/ a legal action may arise .ased on the
principles of negligence. 'o succeed in a negligence action/ a plaintiff 1suing party2 must prove all of the
following four elements against the defendant 1the health care provider2+
1. 'hat the provider had a duty to provide care/
4. 'hat there was a .reach of that duty/
8. 'hat damages occurred/
:. 'hat the provider;s .reach of duty caused the damages.
&et another consideration in providing restraint or involuntary treatment deals with te EMS pro.ider/s
responsi)ilities to indi.id#als oter tan te patient 0 te *tird parties* in.ol.ed in te incident$ It is
a fundamental legal principle that all persons are re<uired to use ordinary care not to in3ure others. @hen an
MS provider encounters a patient who manifests a danger to others/ .y ver.al threats or threatening
physical actions/ said provider may have a legal duty to control the patient/ to safely evacuate the
threatened parties/ or to at least notify appropriate authorities 1police2 to effect control of the threatening
party and ensure the safety of third parties. In the state of Colorado/ if a com.ative or violent patient in3ures
another person/ and the MS provider is shown to have .een capa.le of preventing that in3ury - .ut did not/
the MS provider may .e held lia.le for the third party in3uries.
Once Te +ecision To Restrain And In.ol#ntarily Treat A Patient Is Made, Oter &egal I"plications
Co"e Into Play$
Te &EAST RESTRICTI1E MEANS OF CONTRO& "#st )e e"ployed$ 5er.al communication is/
technically/ the -least restrictive- means of control. 'herefore/ ver.al cues must .e documented as having
failed to control the patient prior to the use of physical force.
5er.al de-escalation can .e successful only when the provider+
-validates- the patient;s feelings .y ver.ali,ing the .ehaviors the patient is e*hi.iting/ and
attempting to help the patient recogni,e these .ehaviors as .eing threatening
openly communicates/ e*plaining everything that has occurred/ everything that will occur/ and
why the imminent actions are re<uired
respects the patient;s personal space 1such as as0ing for permission to touch the patient/ ta0e a
pulse/ e*amine the patient/ etcetera2.
9nfortunately/ these ver.al de-escalation techni<ues are unli0ely to .e successful with patients on PCP/
patients in ('s/ or any other significantly confused or into*icated patients.
After fail#re of .er)al control, te ne2t step is P3(SICA& CONTRO&: Physical control also must .e
performed using the least restrictive means of restraint necessary to meet the patient;s immediate and
emergent needs. !r.itrary use of -: point- restraints 1chest and lower lim. restraints/ .oth wrists and .oth
an0les restrained - the most restrictive form of physical restraint2 may constitute a .reach of this
re<uirement. If it can .e esta.lished that the patient;s care could have .een safely accomplished while using
the lesser-restriction of only 1- or 4- point restraint/ the ar.itrary use of :-point restraint may result in
successful litigation. 'hus/ restraint application should .e a gradual process/ .eginning with .asic .ody
restraints and one lim. restraint/ then progressing to include restraint of additional lim.s only when the
patient demonstrates a need for such increased amounts of restriction. ".viously/ there are e*ceptions to
this -gradual process- suggestion. %ater we will discuss specific patients and situations that re<uire all-or-
less-than :-point restraint.
Only *REASONA'&E FORCE* "ay )e #sed !en applying pysical control: ! general rule for what
amount of force is -reasona.le- is the use of force e<ual to/ or minimally greater than/ the amount of force
.eing e*erted .y the resisting patient.
!dditionally/ in order to .e -reasona.le force/- enough providers must .e present to insure patient and
provider safety during the restraint process prior to applying physical force. "ptimally/ a minimum of five
people should .e availa.le to physically control a patient during restraint application+ one for each lim./
and one for direction and restraint application.
#ever hesitate to wait - at a safe distance - for ade<uate assistance/ if you don;t have enough people to
ensure the safety of patient or providers during restraint application. In3uries resulting from e*cessive force/
insufficient provision of control during restraint/ or improperly applied restraints may present a legal
lia.ility/ and the provider1s2 may .e sued .ecause of it. Remove all persons from the patient;s vicinity 1at
least ensuring protection of others2/ and wait for ade<uate assistance.
+OC%MENTATION OF RESTRAINTS:
Improper or insufficient documentation of restraint may result in successful litigation against you. @hen
what you -recall- a.out patient-care delivery and management does not fully correspond with what you
documented 1often many months or years .efore2/ your credi.ility is discounted.
4en yo# a.e restrained a patient, yo# "should" doc#"ent all of te follo!ing:
1. 'hat an MRE#C& e*isted and the #( )"R 'R!'M#' was CP%!I#( to the
patient.
4. 'hat the P!'I#' R)9S( 'R!'M#' or was 9#!$% '" C"#S#' '"
'R!'M#' 1such as an unconscious patient2.
8. 5I(#C of the patient;s I#C"MP'#C 1or ina.ility to refuse treatment2.
:. )!I%9R of %SS RS'RIC'I5 M'?"(S of RS'R!I#' 1if conscious/ failure of
5R$!% !''M'S to convince the incompetent patient to consent to treatment2.
F. !SSIS'!#C of %!@ #)"RCM#' "))ICI!%S with restraint/ or "R(RS from
M(IC!% C"#'R"% to restrain the patient/ or !(?R#C '" S&S'M RS'R!I#'
PR"'"C"%S.
G. 'hat the 'R!'M#' and6or RS'R!I#' was for the P!'I#';S $#I)I' and S!)'&.
H. 'hat the R!S"#S for RS'R!I#' were CP%!I#( '" '? P!'I#'.
I. 'he '&P of RS'R!I#' MP%"&( 1soft/ leather/ mechanical2.
=. 'he %IM$S RS'R!I#( 1.ilateral wrists/ wrist and an0les - -four points-2.
1J. !ny I#D9RIS '?!' "CC9RR( (9RI#E or !)'R RS'R!I#'.
11. CIRC9%!'I"# C?CKS every 1F 1or fewer2 MI#9'S.
14. 'he $?!5I"R and6or M#'!% S'!'9S of P!'I#' !)'R RS'R!I#'.
Certainly/ not every restraint situation re<uires such e*tensive documentation. I routinely document only
those points num.ered 4/ 8/ F/ H/ I/ =/ 1J/ and 11. 'hey represent the .asic minimum of restraint
documentation needs. ?owever/ we are all familiar with the litigious nature of today;s society. @henever
you have restrained someone who stri0es you as having a litigious nature/ or when the .ystanders or family
mem.ers stri0e you as having a litigious nature/ the more of these points that you document/ the more
protected you will .e .y your documentation.