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15 Aug 2019

BY ASSOCIATE PROFESSOR ANDREW C MILLER AM, CHAIR, MEDICAL PRACTICE COMMITTEE

You don’t have to look far to find examples of inappropriate use of restraints on older people living in residential aged care facilities (RACFs). The ABC’s 7.30 program ran a segment in January on the use of restraints in RACFs and featured a resident, Terence Reeves, who was allegedly restrained to a chair for 14 hours a day and was given risperidone without the consent of his family. The man deteriorated significantly in his time at the RACF. The family gave evidence to the Royal Commission into Aged Care Quality and Safety in May.

Shortly after the 7.30 segment, then Minister for Senior Australians and Aged Care (and Indigenous Health) Ken Wyatt announced that changes to regulation around the use of restraint would be released “within weeks”. The AMA participated in Chief Medical Officer Professor Brendan Murphy’s Aged Care Clinical Advisory Committee to develop the new regulations. The Quality of Care Amendment (Minimising the Use of Restraints) Principles 2014 was tabled in early April and came into effect on the 1 July 2019.

Mr Wyatt stated: “We will not tolerate the use of physical and chemical restraints. Restraint must only be used as a last resort.”

The AMA’s Position Statement on Restraint in the Care of Older People states: “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...The use of restraint must always be the last resort after exhausting all reasonable alternative management options.” Several aspects of the new regulations align with AMA’s position.

Aged care providers must now meet several conditions before a restraint can be used on a resident.

Broadly, actions required before a physical restraint can be used include a documented assessment by an approved health practitioner (i.e. a medical practitioner, nurse practitioner, or registered nurse) who has day to day knowledge of the resident, alternatives to restraint have been used and documented, and that the provider has informed consent from the resident or their representative. Restraints can still be used in an emergency, however this must be documented as soon as practicable, and the resident’s representative should be notified. The restraint must be used for the minimal amount of time necessary, and the resident must be regularly monitored.

Broadly, actions required before a chemical restraint is administered include assessment and documentation by a medical or nurse practitioner who has prescribed the chemical restraint and has concluded the restraint is required. This must be recorded in the care and services plan, as per the Aged Care Quality Standards requirement. The resident’s representative must be informed before the restraint has been administered, or as soon as practicable. The resident must be regularly monitored, and the practitioner must be provided with updates regarding the use of the restraint. The provider must also document any alternatives to restraint that have been used as well as the reason why the restraint is necessary.

Professor Murphy, in his hearing for the Royal Commission into Aged Care Quality and Safety, discussed blocking doctors from prescribing risperidone a second time, beyond the 12-week maximum as a condition under the Pharmaceutical Benefits Scheme:

“If you want to use it beyond 12 weeks you have to go to a different authority, and that will put up a lot of red letter warnings saying that this is seriously aberrant behaviour and it is only in certain circumstances you should consider this, and you should probably be consulting a geriatrician or a psychiatrist. So we can use the PBS as a tool but it’s not a regulatory mechanism to stop unsafe practice, and I think – I don’t think we should pursue it in that way.”

The Royal Australian College of General Practitioners cautiously welcomed the change.

Time will tell whether these new regulations improve the use of restraints. Beyond regulation, there are several things aged care providers and doctors can do to reduce the use of restraints.

This includes training staff to:

  • understand ethical, medical, and legal issues and responsibilities when using restraints, and consult the older person’s usual doctor before using a restraint to determine whether there are underlying causes to their distress (e.g. they are in pain);
  • ensure the aged care environment is welcoming. This includes the physical space but also through the social culture of the RACF and its staff;
  • encourage the older person and their family to develop an advanced care plan that states their preferences, values and goals of care to help guide health care decisions should they lose capacity in the future. As part of advance care planning, they should be encouraged to appoint a substitute decision maker (SDM) who will be authorised to make health care decisions on their behalf should they lose decision-making capacity in the future; and
  • ensure adequate numbers of registered nurses available to ensure medications are managed properly and the older person is monitored for any side-effects.

The Government also has a role to play by implementing a minimum aged care staff to resident ratio that reflects the level of care need of residents and ensures 24-hour on-site registered nurse availability. Inadequate staffing is a major cause of missed care in RACFs.

Our older patients deserve better care.


Published: 15 Aug 2019