Ethical use of restraints

diversion, music, reorientation, enhanced comfort, and reduction of light and noise stimulation. At the same time, clinicians should treat potential medical sources of agitation such as hypoxemia, hypercarbia, electrolyte disorders, drug withdrawal and pain. Ventilation settings, endotracheal tube position and the fit of masks used for noninvasive ventilation should be optimized. Better methods of securing the endotracheal tube may also reduce the need to use restraint therapy.

Physicians should consider whether the benefits of restraint therapy are worth the harms. In certain situations, clinicians may consider removal of certain therapies, such as endotracheal tubes and extracorporeal membrane oxygenation lines in the very ill, to have potentially devastating consequences. Other times, however, maintenance of the therapy may be easily reinstituted, or the loss of the therapy may not be considered harmful. Between 63% and 89% of self-extubated patients do not require reintubation, suggesting that, for these patients, unplanned extubation was not harmful.¹

Potential risks of restraint therapy include regurgitation and aspiration in the supine patient, skin breakdown, dehydration and accidental death. Straining against restraints may cause muscle injury and may increase agitation. It is unclear if restraints affect the extent of posttraumatic stress disorder that occurs in ICU patients.

Chemical restraints may be seen as kinder and less invasive than physical restraints and frequently are used without the requisite oversight and continual reassessment of physical restraints. However, use of chemical restraints in lieu of using other measures has individual and societal costs. Deep sedation used for restraint may increase intensive care unit stay, perhaps decreasing access to the limited resource of intensive care unit beds. Longer intensive care unit stays expose patients to more bacterial infection, muscle wasting, and critical illness polyneuropathy, among other problems.²

Lengthy withdrawal of sedation can be minimized by either conversion to physical restraints or use of multimodal therapy at the appropriate time. A 2004 editorial stated that in the UK, while “physical restraint of patients is considered unacceptable in the [UK] … the importance of the timely withdrawal of sedation cannot be overemphasized, and the judicious use of physical restraints may legitimately be built into an overall treatment plan …”²

Case discussion

We can apply these principles to both of the example cases. In the muscular 25-year-old man with negative pressure pulmonary edema, the desire for the restraints may be misguided. The nurse may worry that he will miss the onset of agitation because other nursing responsibilities keep him from the bedside, or that inadequate in-house coverage may mean that an unplanned extubation would have a devastating effect (note that unplanned extubation might well not be harmful). Unquestioned acceptance of the nurse’s request for restraint therapy may lead to inappropriate therapy as well as a missed opportunity to highlight an institutional system-level problem. On the other hand, avoidance of restraint therapy may lead to the use of chemical restraints, which may increase the duration of mechanical ventilation and intensive care unit time. This complexity is best addressed by adopting well-considered protocols to help ensure appropriate use of restraint therapy in order to best achieve the desired goals.

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