The culture of nursing homes and assisted living facilities has shifted far away from the use of restraints; most places are restraint-free by law these days. The hospital is one of the only places I can imagine restraints remaining in use, and that is simply because of the acuity (how sick) our patients there are. They cannot afford to be pulling out the lines that are giving them IV antibiotics and blood transfusions, because without those things, they will die.
Even at the hospital, restraints are considered a last resort. They frequently utilize one-to-one 'sitters' to watch and maintain safety of very difficult patients. I was pulled from my regular duties to act as one last night, for a confused elderly person who would not stop climbing out of bed (and was a fall risk), pulling out lines, and removing their much-needed supplementary oxygen tubing. Even with me there, the patient was very agitated, and trying to literally climb over the furniture to get out of the bed. I was willing to let her get up, but she was so damn fast she was apt to get away before I could gather up all the things that were attached to her so I could ferry them along after her to prevent them from ripping out.
Finally the MD returned the page from the nurse, and ordered a small dose of an antipsychotic. It didn't stop the patient from trying to get up, it just calmed the patient down enough to stop physically shoving me out of the way, which was good enough.
This was one of those situations where I think that chemical restraints would be so much more effective than physical. My patient has such poor short-term memory that s/he would forget what I had said literally 20 seconds before. Putting someone like that in physical restraints is going to be a huge safety risk because they're still anxious and panicky and energetic, and will focus all of that onto getting out of the restraints one way or another.
Whereas a strong sedative seems highly appropriate and could allow this person the time to absorb their antibiotics, fluids, and oxygen in order to begin healing.
Unfortunately, I don't think we have a specific policy and protocol for chemical restraints the way we do for physical ones. I understand they're risky in terms of oversedation; you don't want to accidentally kill someone! But I wonder, if I were the physician getting paged in the middle of the night, whether I'd view the sedatives I'm prescribing as restraints or 'sleep aids' or what?
Showing posts with label Patient Rights. Show all posts
Showing posts with label Patient Rights. Show all posts
Tuesday, February 28, 2012
Sunday, January 23, 2011
Antipsychotic Drugs and Chemical Restraints
At the GreatRep, and pretty much all long term care or memory care facilities, there is a Bill of Rights list for all the residents posted prominently around the building. One of these rights is "to be free of all restraints, including chemical restraints". Logical, right?
As an aide, I have very little to do with the residents' medications. I report symptoms to the charge nurse, who then decides what to do from there. A few of the residents are on frequent doses of the same medications for certain behaviors or symptoms and so we all know what they will probably get in response to our reports of their symptoms. Lillian has severe pain and it's very obvious when it's not being controlled well, so when she hurts we all know she needs her Morphine. LuLu repetitively hits herself, which lets us know it's time for more Haldol or Ativan for her.
A lot of science news articles state that the use of antipsychotic drugs for dementia is a bad practice. It's not intuitive, because if you look at the list of symptoms of say, schizophrenia:
"They include disorganized thought processes and disorganized behavior as well as delusions and hallucinations. The disorganized thought processes are seen primarily in speech such as rambling and 'word salad'. The patient may babble about various different topics one after another, which to the normal person, do not appear to be connected in any way. The phrase 'word salad' describes a patient’s incoherent speech, which lacks correct grammar and any obvious purpose. Disorganized behavior will be discussed in a following section. Hallucinations are false perceptions; patients believe they can hear voices others can’t and sometimes see or feel things others don’t. Delusions are misinterpretations of events and their purpose such as when patients believe the CIA is plotting against them or that their psychiatrist is involved in an assignation attempt against them. Schizophrenics cannot be reasoned with over their delusions; reasoning and discussion leads to the patient’s mistrust and anger." (1)
All of that is very typical of dementia patients as well. You'd think since the symptoms are so similar that the treatments can be as well. But apparently not, since the use of antipsychotics in dementia patients increases their death risk, for reasons unknown(2).
To be clear, it seems like Doctors are warning against antipsychotics to control behavior that is merely "annoying" for caregivers such as wandering, agitation, uncooperativenesss, etc. For behavior that is truly dangerous for the patients or everyone around them (self-injury, extreme combativeness that can physically injure both caregivers and the patient, etc) I think it can still be merited.
Which is why when I read articles like this one, "Alzheimer's Therapy Focuses on Care: Giving Alzheimer's Patients their Way, Even Chocolate"(3) part of me gets really frustrated. It seems like outsiders and the media tend to think that some of the interventions we routinely do on our patients are for our own convenience, and therefore wrong. I loved that it explained about emotional states lasting longer than the patient's ability to recall or explain the reason for the emotion; however I would have liked to have seen a few more realistic examples of how this can be implemented. Things like when one of my widowed residents becomes anxious, thinking her husband is injured and missing, it's more productive to let her talk about that briefly, then steer the topic to her children, who are all alive and well. She calms down and gets happier as she tells us about what they were like when they were little, and shows us the quilt her daughter made her. That way, when the conversation ends, it ends on a happier note, which is more likely to stop her anxiety cycle about her husband. And of course there are the more conventional redirections like trying to get her involved in an activity or focused on something else.
I just hate the idea that we're somehow failing LuLu because sometimes medication is the only way to get her to stop hitting herself. You can redirect her, feed her, hold her hands gently, all sorts of things, but if she's in that mood she will not be deterred and it's not safe for her.
Patients have the right to refuse care, for example. But an incontinent person who refuses to be changed for 8+ hours isn't making a reasonable choice and is endangering themselves by hugely increasing their risk for a pressure ulcer. So sometimes we just have to force someone to let us perform very basic hygeine on them. And it sucks. And sometimes the only way to do that without anyone ending up seriously hurt is to premedicate them, and sometimes even that doesn't work. I wish there were a magic wand to make combative people cooperate when you're trying to help them.
But for all the caregivers and family members who read that article, I want to tell them that baby dolls and chocolate are a part of the answer, and can be good tools, but we need more solutions. And that even as a profession, caregiving is rarely "convenient"; that's not why we do this work. So please give your facility the benefit of the doubt and ask first before assuming they're chemically restraining people for no good reason. It's a last resort, but sometimes it's the only way.
And I don't know if it really belongs on any patient's Bill of Rights. Because the truth is, they do have the right not to be restrained unless they're hurting themselves or others and nothing else will stop them.
1. About schizophrenia http://healthpsych.psy.vanderbilt.edu/AntiPsychoticMeds.htm
2. Antipsychotics and death risk increase http://www.webmd.com/alzheimers/news/20080616/antipsychotics-for-dementia-up-death-risk
3. Giving Alzheimer's Patients Their Way http://www.nytimes.com/2011/01/01/health/01care.html?_r=2&pagewanted=1
As an aide, I have very little to do with the residents' medications. I report symptoms to the charge nurse, who then decides what to do from there. A few of the residents are on frequent doses of the same medications for certain behaviors or symptoms and so we all know what they will probably get in response to our reports of their symptoms. Lillian has severe pain and it's very obvious when it's not being controlled well, so when she hurts we all know she needs her Morphine. LuLu repetitively hits herself, which lets us know it's time for more Haldol or Ativan for her.
A lot of science news articles state that the use of antipsychotic drugs for dementia is a bad practice. It's not intuitive, because if you look at the list of symptoms of say, schizophrenia:
All of that is very typical of dementia patients as well. You'd think since the symptoms are so similar that the treatments can be as well. But apparently not, since the use of antipsychotics in dementia patients increases their death risk, for reasons unknown(2).
To be clear, it seems like Doctors are warning against antipsychotics to control behavior that is merely "annoying" for caregivers such as wandering, agitation, uncooperativenesss, etc. For behavior that is truly dangerous for the patients or everyone around them (self-injury, extreme combativeness that can physically injure both caregivers and the patient, etc) I think it can still be merited.
Which is why when I read articles like this one, "Alzheimer's Therapy Focuses on Care: Giving Alzheimer's Patients their Way, Even Chocolate"(3) part of me gets really frustrated. It seems like outsiders and the media tend to think that some of the interventions we routinely do on our patients are for our own convenience, and therefore wrong. I loved that it explained about emotional states lasting longer than the patient's ability to recall or explain the reason for the emotion; however I would have liked to have seen a few more realistic examples of how this can be implemented. Things like when one of my widowed residents becomes anxious, thinking her husband is injured and missing, it's more productive to let her talk about that briefly, then steer the topic to her children, who are all alive and well. She calms down and gets happier as she tells us about what they were like when they were little, and shows us the quilt her daughter made her. That way, when the conversation ends, it ends on a happier note, which is more likely to stop her anxiety cycle about her husband. And of course there are the more conventional redirections like trying to get her involved in an activity or focused on something else.
I just hate the idea that we're somehow failing LuLu because sometimes medication is the only way to get her to stop hitting herself. You can redirect her, feed her, hold her hands gently, all sorts of things, but if she's in that mood she will not be deterred and it's not safe for her.
Patients have the right to refuse care, for example. But an incontinent person who refuses to be changed for 8+ hours isn't making a reasonable choice and is endangering themselves by hugely increasing their risk for a pressure ulcer. So sometimes we just have to force someone to let us perform very basic hygeine on them. And it sucks. And sometimes the only way to do that without anyone ending up seriously hurt is to premedicate them, and sometimes even that doesn't work. I wish there were a magic wand to make combative people cooperate when you're trying to help them.
But for all the caregivers and family members who read that article, I want to tell them that baby dolls and chocolate are a part of the answer, and can be good tools, but we need more solutions. And that even as a profession, caregiving is rarely "convenient"; that's not why we do this work. So please give your facility the benefit of the doubt and ask first before assuming they're chemically restraining people for no good reason. It's a last resort, but sometimes it's the only way.
And I don't know if it really belongs on any patient's Bill of Rights. Because the truth is, they do have the right not to be restrained unless they're hurting themselves or others and nothing else will stop them.
1. About schizophrenia http://healthpsych.psy.vanderbilt.edu/AntiPsychoticMeds.htm
2. Antipsychotics and death risk increase http://www.webmd.com/alzheimers/news/20080616/antipsychotics-for-dementia-up-death-risk
3. Giving Alzheimer's Patients Their Way http://www.nytimes.com/2011/01/01/health/01care.html?_r=2&pagewanted=1
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