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18 L. Med. & Health Care 263 (1990)
The Fear of Liability and the Use of Restraints in Nursing Homes

handle is hein.journals/medeth18 and id is 263 raw text is: The Fear of Liability and the Use of Restraints in Nursing Homes Sandra H. Johnson The routine use of chemical and physical restraints in nursing homes is bad care.1 Medical and nursing lit- erature on the care of nursing home patients consis- tently criticizes the use of restraints when that use is unrelated to diagnosis and treatment considerations.2 Federal and state laws have included restrictions on the use of restraints for some time.3 The criticisms of inappropriate and indiscriminate use of chemical and physical restraints are not new. What, then, supports their continued misuse4 despite the ordinarily power- ful combination of professional and governmental approbation? The Problem with Restraints The use of restraints responds to generally quite acceptable and desirable patient-oriented goals. Restraints are used in an attempt to protect the patient with physical or mental disabilities from avoidable injury caused by falling or wandering away from the facility. in the social context of nursing homes, restraints are also used to protect residents from injury by threatening, violent patients.5 When the rationale is measured against the known effects of restraints, however, the self-evident nature of the justi- fication begins to break down. Research has yet to provide an empirical basis to support the customary uses of restraints.6 The risks of using restraints on elderly patients are serious and substantial. These risks include strangulation,7 medi- cal ailments caused by immobility,3 and increased agi- tation.9 In addition, restraints can lead to misdiag- noses due to masking of symptoms or assumptions that restraints are causing symptomatic behaviors.10 Men and women who have been restrained provide poignant testimony of the human costs of restraint: I felt like a dog and cried all night. It hurt me to have to be tied up. I felt like I was nobody, that I was dirt.'11 As with any clinical decision, less harmful but equally effective options should be chosen whenever possible. There are effective alternatives to restraints, including door alarms, staffing changes, and environ- mental alterations that lessen the risks of falls and unsupervised travel.12 Reimbursement levels13 and regulatory policies14 influence the use of these alterna- tives, although it would be incorrect to assume that they are necessarily more costly than restraints.15 Perhaps the most subtle and pervasive force sup- porting the excessive use of restraints on nursing home residents is the expectation that nursing home care should at least be custodial. Nursing homes are the keepers and guardians of their elderly resi- dents. They protect, confine, and shelter a most vulnerable group. No one would argue that safety and protection are not desirable in a nursing home. When methods used to keep residents safe from injury substantially interfere with other impor- tant goals, however, both the methods and the relative value of the goals need tobe examined. The goals of functional rehabilitation and main- tenance are diminished in the face of a therapeutic nihilism that accepts the view that decline is inevitable.'6 This view transforms the minimum expectation of custodial care to the primary goal. Risks assumed by others for the purpose of personal achievement or self realization easily become unac- ceptable if there is a less visible or less dramatic pay- off. In contrast, the expectations of nursing home res- idents balance a desire for safety and a desire for func- tion. In a survey of 455 residents in 107 nursing homes, the residents identified a safe and secure envi- ronment as a high priority; but they also ranked high on their list as much independence as possible, with

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