AN ETHICAL REVIEW CONCERNING THE USE OF PHYSICAL RESTRAINTS ON INTUBATED PATIENTS IN THE ICU
INTRODUCTION: Physical restraints are common devices used to reduce a patient’s mobility. Often applied in intensive care units with patients experiencing agitation and insufficient sedation, physical restraint techniques are advised for prevention of self-harm and unplanned extubations. In practice, however, there is significant variability in use and many patients across the US and other countries worldwide are restrained while awake, calm, and co-operative. While most clinicians believe that restraining a patient will limit risk for self-extubation and subsequent poorer health outcomes, the evidence that this is the case appears to be contrary. Moreover, physical restraint is associated with many significant negative physiological and psychological health impacts, including increased agitation and ICU delirium, prolonged intubation and ICU times, and even increased risk for self-extubation when used without focused education or specific intervention.
When reviewing the use of physical restraint, it is important to consider the ethical justification for or against such use. As a basic moral principle of medical ethics, patient autonomy is upheld only when adequate informed consent is obtained from the patient or from appropriate proxy.
In cases of patient self-endangerment, autonomy may be viewed as secondary to safety; however, it is our intention to demonstrate that such instances requiring physical restraint interventions can sometimes be avoided through a number of other practices. Equally important to autonomy is the principle of non-maleficence, that it is a clinician’s duty to do no harm to a patient, and thus the negative impacts of restraint are also investigated.
METHODS: Two authors conducted separate literature reviews in the following databases: PubMed, Scopus, Google Scholar. 38 journal articles were collected with evidence included in this review pertaining to physical restraint, self-extubation, and medical ethics.
DISCUSSION: While the current use of physical restraint varies widely, the effectiveness of physical restraints in preventing self-extubation is limited. There is, in fact, sufficient evidence that up to one third of self-extubations occur even with wrist restraints. In some studies, restraints actually increase the risk for self-extubation and can lead to less favorable health outcomes. Inappropriate use can be detrimental to a patient’s health, causing serious concerns including nerve damage, asphyxiation, and death. Because of this, general guidelines recommend minimizing the use of physical restraints, however, these consistently remain outdated and non-specific for strategies to do so. Several studies demonstrate alternative strategies, although their effectiveness as individual interventions to reduce physical restraint use has yet to be fully elucidated. Such alternatives include better education for the clinical care team and staff regarding restraint, increased number and familiarity of staff on duty, occupational and recreational therapies, pain management, sleep promotion, additional and more frequent supervision, observation, and companionship of staff, family, friends, and volunteers, as well as many more. Restraint is not always removed rapidly following resolution of patient agitation, which can lead to further negative impacts including PTSD for ICU survivors. This is consistent with a 2010 review of physical restraint examining patient perspectives from 1966 to 2009 which found four major themes: negative psychological impact, retraumatization, perceptions of unethical practices, and the broken spirit. This focus on negative consequences is addressed in our analysis of physical restraint practices and examined in an ethical light. In delivering optimal care to ICU patients, both patient comfort and safety must be evaluated. It is therefore recommended to always minimize use of restraints and to specifically avoid their use during end of life care.
CONCLUSION: There is lacking evidence to support the use of restraints on ICU patients and many studies have shown that restraints increase the risk of self-extubation and patient harm. Ethical concerns for patient autonomy and non-maleficence in combination with ineffectiveness of physical restraint to reduce self-harm lead to the conclusion that restraints ought not be used in intubated patients. Many of the risks associated with physical restraint can be mitigated through improved care and there is a need for further research into strategies that minimize the use of physical restraint as well as a better understanding of how widespread its negative consequences are. Although there exist inconsistencies in policy and adherence, general guidelines are still to minimize use of physical restraint and we recommend that if even considering physical restraint, care teams should first fully understand self-extubation and have educated themselves and staff on other prevention strategies. We further advocate for research that seeks better management of agitation and prevention of factors leading to unplanned device removal.