1. Introduction

The patient's needs and rights should always be the first consideration when considering the application of restraint. Patients have died or been seriously injured by restraints. On the other hand patients and staff have been injured by lack of restraint.

The need for restraint should always be based on individual assessment of the issues. These issues span ethical, legal and medical domains. Key to this decision is finding the balance between:

• a patient's right to self determination;
• protection from harm; and
• the possibility of harm to others.

The medical practitioner providing the patient's care is ultimately responsible for the decision to restrain a patient. However, the decision to use restraints should not occur in isolation. It involves a process of request, assessment, team involvement and consent within an ethical and legal framework.

Any decision and plan of care to restrain must be documented in the patient's record.

2. Definition

A restraint is an intervention which controls or limits movement and/or behaviour.

3. Principles

The prime purpose of restraint should be the welfare and safety of the patient. In the short term the welfare and protection of others (patients, carers, residents and staff) may also be a consideration. Underlying causes of aggressive and/or challenging behaviour particularly associated with a recent change in behaviour or function should be thoroughly defined by the attending medical practitioner in partnership with the patient's family (and/or formal or informal carers) and staff. Those causes which are medical, or which may respond to medical interventions such as depression, psychosis and delirium should be considered and treated.

Restraints should only be prescribed where any potential risk or harm caused by the restraint itself is less than the risk of the patient not being restrained.

A key consideration when making such decisions is the capacity of the patient and who may provide substitute consent.

Many challenging behaviours can be prevented or minimised through appropriate social and staffing structures and creative, friendly physical environments. When such strategies have failed, and when restraint cannot be avoided, then any restraint should minimise the use of pharmacological or direct physical methods. In practice it is often necessary to manage aggressive and/or challenging behaviours in settings that are less than ideal.

Psychoactive drugs have an important role in the reduction of distressing symptoms and the specific treatment of medical conditions such as anxiety, depression and psychosis. Use of these drugs in such a context does not constitute restraint and they should not be withheld.

There are clinical situations where psychoactive drugs may be prescribed for combined purposes of both a degree of restraint and the reduction of distressing symptoms, and/or specific treatment of medical conditions.

Environmental, pharmacological and physical restraints, singly or in combination, should only be used in the community, in residential settings (including aged care) and in hospitals to facilitate patient care and to assist in the management of patients' aggressive and/or challenging behaviour.

Restraint of a patient for staff convenience or to manage patient workloads is unacceptable.

All health and residential care facilities must ensure mechanisms for review and discussion of contentious issues and decisions such as the application of restraint for both the welfare of a patient and the welfare of others.

Patients, families of patients, health care professionals and staff must have freely available provision and access to mechanisms to complain, anonymously if desired, about the usage of restraints without fear of retribution.

4. Educative Issues Related to the Use of Restraint

Education about the issues related to restraints should be a fundamental element of training for health professionals.

Any others working in health care and residential facilities and who are actively involved in the treatment and care of older persons should have undertaken formal training in issues associated with restraint.

Where restraint becomes an issue in domiciliary settings, education of formal and informal carers is essential.

All health care and residential facilities should actively address and have continuing education for staff on issues related to the use of restraint. This should be done in collaboration with the Medical Advisory Committee. Amongst these issues are included:

• The ethical, medical, and legal issues associated with the use of restraint.
• Provision of written guidelines for the application of environmental, pharmacological and physical restraint(s).
• The potential for harm arising from the use or non-use of restraints.
• Optimal prevention, minimisation, assessment and management of aggressive and/or challenging behaviour.
• Timely access to medical assessment and treatment of illnesses associated with, and potentially causing aggressive and/or challenging behaviour.
• Regular audit and clinical review of the use of restraint in the facility including individual case review, critical incidents and near miss monitoring, aggressive and/or challenging behaviours and the subsequent use of restraint(s).
• Flexible work practices.

5. Recommendations

5.1 Research

The basic rights and wrongs of restraint and what is 'best practice' are, at this time, undetermined. The AMA therefore recommends that controlled and, where possible, double blind crossover trials be held which compare matched populations in actual practice where the value of restraint and restraint free environments can be properly and scientifically evaluated.

5.2 Education

The AMA recommends that basic education courses and continuing education in restraint issues and the application of restraint be developed and become an integral part of education for health care professionals and those actively involved in the care and treatment of older persons within residential facilities. Carers should have access to such education where restraint becomes an issue in domiciliary settings.

5.3 Guidelines for Application of Restraint

The AMA recommends that guidelines for the application of restraint should be jointly developed by the AMA, relevant Medical Colleges and the nursing profession.