Individuals with Learning Difficulties and Autism: Ethical Issues of Use of Restraint - Essay Example

ETHICAL ISSUES OF USE OF RESTRAINT AND PHYSICAL INTERVENTION AS FOR INDIVIDUAKS WITH LEARNING DIFFICULTIES AND AUTISM Introduction People, sufferingfrom mental disorders, such as learning disabilities and autism, have ordinary as well as specific health care needs and experience more ill-health (including more mental ill-health) than their peers. When receiving in-patient treatment, problems of communication, diagnostic overshadowing and inconsistent personal care may act to block or delay prompt diagnosis and appropriate treatment. Physical intervention and restraint with people, who have intellectual disabilities, are sometimes necessary, even though it's known to present dangers to both patients and staff and service users. The UK, the Department of Health (2002) guideline suggests that the use of restraint in the management of imminent violence in a psychiatric setting should be geared to prevent imminent harm to the patient and/or others, if other means are not effective and appropriate, and to prevent serious disruption of the treatment program or significant damage to the environment. It also adds that the management of imminent violence within a mental health setting should be done within the legal framework, in the best interests of the patients, using the least restrictive method to minimize harm to patients and staff. The management of imminent violence should not be carried out in isolation, but should be implemented within the context of an overall care plan for the person. Moreover, violence should be used only in a very limited way, if it is absolutely necessary1. It's necessary to differ various types of restraint. In the UK, in contrast to many other countries, such restrain tends largely to be physical, That is, it involves the restriction of movement by physical holding, as opposed to mechanical, where some device is used to restrict movement. Such restraint is subject to risk assessment, and the risk involved should be considered against the risk alternatives. Such risk assumes not only risks, concerning the patient himself, and his physical and psychological health, but also medical personnel of the hospital. The purpose of this paper is to examine the ethical problems, regarding use of force and restraint towards individuals with mental disorders, such as learning disabilities and autism. In other words, the key problem is to clarify to what extent is violence acceptable in modern psychiatry, and especially in the NHS. It is clear, that certain enforcement will always remain a part of care curing such people. On the other hand, such violence should not exceed some minimal necessary amount. This study is an attempt to specify this amount, and to see, would this amount fit the demands for "ethics" or not. Literature review Available literature on the topic may provisionally divided into two groups. The first group is constituted by different guidelines, project papers, occasional papers, etc., representing a result of a so to say collective thinking of specialists, whose field of study appeared to be on touch with the problem. The studies of this sort are conducted on behalf of large medical institutions, which are part of the NHS, social organizations or initiative groups, and they in some way represent an official view of a particular institution. Among the most important studies of the first group are the guidelines, produced by The Royal College of Psychiatrists (Occasional Paper OP41, 1998) for the management of imminent violence in mental health services. Another opinion is specified in the National Association of State Mental Health Program Directors. (2001), explaining the position of the Directors on the use of seclusion and restraint. Those and other papers, as, for example "Strategies for the management of disturbed and violent patients in psychiatric units" Council Report CR 41, are similar in their general direction towards providing better treatment to a patient, but differ greatly in details, which is to some extant explained by legal uncertainty (to be explained infra). Another group of sources is formed by multiple individual and collective researches, conducted by investigators, interested in the topic. Most of the studies in this group have been conducted after 1990, when a problem of unobvious mental disorders started attracting an increasing interest of scientific community and publicity. In 1984 Richards could identify only five British studies in the previous twenty years where people with learning difficulties had been informants in research projects. In the 90-s, such a list might well run into hundreds, and it is on the increase2. Separate from the first two groups are the legal acts, regulating mental health care. The Mental Health Act 1983 is the principal Act governing the treatment of people with mental health problems in England and Wales. The Mental Health Act covers all aspects of compulsory admission and subsequent treatment. Besides these emergency procedures, there are other sections of the Act under which a person can be detained in hospital without their consent. The Government is currently taking a Mental Health Bill through Parliament to replace this Act3. The Bill, submitted to Parliament in 2004 pays special attention to the procedure of diagnosing and investigation of a mental disorder, and also concentrates on the special needs of particular groups of patients, for example the ones not aged 18. The provisions of the existing Act are broadened by 1999 Code of practice, which is a third edition of 1984 Code of practice. The Guiding Principles, published as Chapter 1 appeared for the first time in this third edition of the Code. Many of these principles were scattered throughout the previous editions, but now they are prominent. There are some innovations. For instance, at the very outset it is stated that people should receive recognition "of their basic human rights under the European Convention on Human Rights". The Guiding Principles, stipulated in the code emphasize communication, confidentiality and the provision of information. Precise rights and obligation of medical staff are formed on the basis of the Act and the Code of Practice and are used for every single category of staff, example Royal College of Nursing Guidance for Nursing Staff4. nursing staff Design and Method As the violence remains inevitable, it is necessary to specify it exact forms, available for medical staff to be used. It's necessary to establish exact aims, which are to be achieved and means, which are to be used for such achievement. Those aims and methods chosen are to correspond to some specified ethical criteria, and in case they do - they will remain ethical. Physical intervention and restraint should never be used alone, separately from the entire period of treatment. Both autism and learning difficulties do not belong to severe mental disorders, terminating patient's mind, so the people, suffering from such inborn disorders are still unique individuals. Their mental capacity allows them to pass the course of treatment and integrate into society5. So, the primary aim of physical restrain in the case is to contribute to patients cure. On the other hand, restraint is also a form of public protection from possible assaultive actions of the patient himself, so legal regulation on the subject must steer between the Scylla of individual liberties and Charybdis of public safety. Current legislation certainly heads toward Scylla. Commentary to 1999 Code, by Frank Dobson and Alun Michael (which reminds us that the Act only covers England and Wales) stresses, that the experience of patients and carers and mention "a new emphasis on the patient as an individual". Professionals must work together to provide effective care and treatment. Into the Code comes an acceptance of the notion of advance refusal of treatment made validly in the past. This is another manifestation of respect for the individual's autonomy. Furthermore, the new Code incorporates the Law Lords' decision on Bournewood thus: "If at the time of admission, the patient is mentally incapable of consent, but does not object to entering hospital and receiving care or treatment, admission should be informal"6. Perhaps the strongest tack towards Charybdis is taken in discussion of after-care. While intended to protect patients, it is also a means of controlling them. In the absence of more resources, some regard "supervised discharge" as otiose and bureaucratic. Some psychiatrists would prefer a form of community treatment order. Controlling individuals in the community - the challenge for any new Mental Health Act - makes the passage between Scylla and Charybdis even tighter to navigate. In the case of the dangerous patient with severe personality disorder, the Government's proposals clearly aim at better protection for the public. And, despite recognition of human rights law, to some the proposals seem routed only via Charybdis7. In the medical institution themselves ideally "violence remains a last resort, only being used in the emergency, where there appears to be a real possibility of serious harm, if withheld. Also, it must be of minimum decree necessary to prevent harm and be reasonable at the circumstances"8. The purpose of physical restraint is firstly to take control of a dangerous situation and secondly to limit the service user's freedom for no longer than is necessary in order to end or significantly reduce the risk to self or others. According to the Royal College of Psychiatrists (1998) and the Department of Health and Welsh Office (1999), the most common reasons for the use of restraint are: Serious degree of urgency and danger Significant physical attacks Significant threats or attempts at self injury Serious destruction of property Prolonged and serious verbal abuse, threats, disruption of ward Prolonged over activity, risk of exhaustion Risk of serious accident to self and others Attempts to abscond, (if detained under the 1983 Mental Health Act) Non compliance with treatment Physical interventions should not rely on the infliction of pain in order to restrain the patient, as techniques are available which are intended to isolate and immobilize limbs without pain. Presently, the NHS approach recognizes the use of painful methods of physical restraint as being barbaric and an infringement of the service user's human rights9. Wherever possible, it is expected that staff who have received training would take the lead in situations of physical restraint. Where an incident is being dealt with in a safe and professional manner by people who are 'untrained' in restraint skills, it may not be desirable or prudent for 'trained' staff to take over unless requested to do so. Wherever possible the planned use of restraint should only be undertaken by appropriately trained staff. However, in extreme or emergency situations there is an expectation that all staff will assist. Applied violence is to be reasonable in the circumstances and utilize minimum force for the shortest duration possible. The precise aim of restraint is to immobilize arms and legs swiftly and safely, and, if necessary, to protect head from harm and maintain airway. The reason for action should be continually explained to the service user and encourage their co-operation and voluntary control as soon as possible. The use of any form of physical restraint must be in the context of care as a measure to reduce the degree of risk presented. It can never be used as a form of punishment or as humiliating action. Use of restrain or physical intervention must be a well coordinated action, in which one person should be nominated by the nurse-in-charge, to take control of the whole situation and utilize resources to meet all of the needs of the incident. A full detailed account of the incident must be recorded in the service user's casenotes and an incident form completed. If physical restraint methods are employed for more than 2 hours continuously, the Senior Nurse must be notified. In this case a Senior Officer should be appointed and see the service user as soon as possible to talk to the service user about the incident and ascertain if he/she has any concerns or complaints10. One can easily notice, that the use of a special kind of treatment method, including physical intervention and restraint depends largely on the discretion of the medical staff. Unfortunately, poor training of the staff and possible negligence may lead to serious consequences, such as injury and even death of the patient and personnel. Such methods as physical pressure on the neck, hobble tying or prone restraint may cause asphyxia or heart attack with the patients, suffering from health problems, other than mental disorders. For example, Stratton et al.'s (2001) case series reports a total of 214 episodes of hobble tying in agitated delirium, in which death occurred in approximately 12%11. In order to avoid such accidents in future and summarize the practice of physical intervention and to trace the cases of unnecessary violence or abuse, all cases of restraint or intervention, especially causing undesirable consequences, need to be duly reported and recorded. The National Patient Safety Agency recommends to report about all the serious incidents immediately, so, that the information could be "fast-tracked". The reported incidents are to be graded according to their actual impact on the patient's, and the, potential future risk to patients and to the organization, and reviewed to establish stakeholder reporting requirements. Adverse patient incidents should be a subject to an appropriate level of local investigation and causal analysis and, where relevant, an improvement strategy is prepared12. Implications Physical intervention and restraint remains one of the methods of modern psychiatry, frequently used within the NHS. Some violence and enforcement are always a part of curing process, necessary to provide the safety of the patient himself and the publicity. However, first and foremost such use of force is to correspond to patient's needs. The approach, accepted by the NHS makes physical impact a "last resource", applicable, when nothing else can be done to prevent inevitable and serious harm to a patient himself, the surroundings or property. Use of force is recognized to be an undesirable method, every single case of which is to be justified by the situation, and which should never be used for purposes, other than withholding an individual from destructive behavior. If possible, physical intervention should be conducted only as a part of treatment process, and in accordance with the existing guidelines, assuming, that it is conducted only by an organized a group of professional staff, the aims of impact are clearly indicated, and are constantly explained to a patient, in order to achieve cooperation. Only under the named circumstances can intervention be justified and lawful. Conclusions Presently, it is impossible to avoid using measures of physical impact in treating patients with mental disorders. However, more and more attention is paid to individual's rights and benefits. It is recognized, that physical impact should contribute the entire course of treatment, and is to be used only in the most critical circumstances. The desirable practice for physical impact towards mentally disabled persons should include: Individual approach to every single case and to every single patient. Revision of methods of restraint and intervention in order to choose and apply only the most humanist and expedient ones. Good training of staff, applying those methods. Dual report and record of every incident, making it possible to trace and analyze it in future. Being combined, those elements will hopefully make physical intervention more controlled and traced, and also make it's use as expedient, as possible. The approaching changes in legal regulation of treatment of mentally disabled individuals will likely touch physical intervention too, so the methods are going to be revised not only in the respect of expediency, but also in respect of legal justness. This should ideally make the use of physical intervention and restraint towards people with mental disorders more fit to the ideas of human rights and freedoms, and more corresponding to individual and social needs, in other words more "ethic". REFERENCES 1. Dereka M. July 2004 "Life Skills for Young Adults with Learning Disabilities", Tizard Learning Disability Review. 2. Hughes J. C., Lawson T. 2000 "Code of Practice 1999: navigating before reform of the Mental Health Act 1983", Advances in Psychiatric Treatment, vol. 6, p. 3-4 3. Paterson B., Bradley P., Saddler D. Leadbetter D. 2003 "Deaths associated with restraint use in health and social care in the UK. The results of a preliminary survey" Journal of Psychiatric and Mental Health Nursing, vol.: 10, at p. 3-15 4. Walmsley J. 1997 "Disability Studies: Past Present and Future". Leeds: The Disability Press 5. "South Birmingham Health NHS Trust. Physical Interventions: Restraint" SBMHT/VPS/PIR/March 2002. 6. "Strategies for the management of disturbed and violent patients in psychiatric units" Council Report CR 41 March 1995 7. "Safeguarding people with learning disabilities within the NHS: an agenda for the National Patient Safety Agency" www.npsa.nhs.uk/site/media/documents/ 1087_npsa_learningdisabilities_review.pdf viewed: August 20, 2005 8. "Violent Restraint: End of Inhuman Practice " http://www.crisisprevention.co.uk/media/pdf/UK_EOY_2002.pdf Viewed: August 20.2005 9. Mental Health Legislation in the United Kingdom http://www.mentalhealth.org.uk/page.cfmpagecode=TILG viewed: August 19. 2005 10. "Mental Health Policy Implementation Guide: Developing Positive Practice to Support the Safe and Therapeutic Management of Aggression and Violence in Mental Health In-patient Settings" National Institute or Mental Health in England. www.nimhe.org.uk viewed: August 18, 2005 Read More