Chemical Restraints And Patient Rights: An Ethical Issue

In a secure psychiatric ward a psychotic patient has abruptly become violent shortly after his last scheduled dose of Ativan. It is three in the morning and the night shift nurse has a decision to make. Should she wake up the psychiatrist and request that he come and assess the patient, or should she administer the PRN medication of

Zyprexa that the physician had previously authorized in the patient's chart? According to a strict interpretation of the published HCFA rules, chemical restraints or inappropriate use of medication is defined as "A medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychological condition." It goes on to specifically mention that this would specifically include "No PRN orders" (Federal Register, 1999). If the nurse were to administer the Zyrexa in addition to the scheduled dose of Ativan, she would be using a form of chemical restraint and thus be trampling on the patient's rights. According to protocol, this could only be done if the patient was observed by a physician within an hour of the dispensing of the drug. Yet, how is one able to control the situation otherwise? Where do the rights of the patient as defined by law end and right of the clinicians to observe safety for them and the patient begin? It is a difficult question.

The moral considerations in this situation can have two directions. On one hand, there is the right of the patient to be protected from unnecessary chemical restraint by the use of multiple anti-psychotic drugs in various combinations that would result in him being totally in the control of the clinicians responsible for this care and therapy. On the other hand, those very clinicians have their own rights to protection from violence, as well as being able to discharge their duty to prevent the patient doing harm to himself. Balancing these two seemingly opposing moral directions can be tricky. The border of where the patient's rights end and true therapy begins is difficult to define. Morally, one can justify chemical restraint when the patient is capable of harming themselves or others; yet how that is determined, and who determines it, is critical. It would also be morally murky to shoot the patient full of drugs simply because they have become a behavioral nuisance and it would make the life of the attending nurse much easier.

This complicated situation has become much more difficult since the passage of law in 1998 called "Restraint and Seclusion: HCFA Rules for Hospitals". To understand its impact, one must understand the circumstances that prompted its hurried passage. In the 1980's there were a flurry of reports associated with the death of patients in restraints throughout the United States. A major Connecticut newspaper, the Courant, undertook an investigation that documented 23 deaths within an eleven month period from 1997 to 1998 (Weiss, 1998). A major public uproar ensued that resulted in enormous pressure on politicians to immediately produce results that would alleviate the issue. The resulting hastily assembled legislation; "Restraint and Seclusion: HCFA Rules for Hospitals", caused a sensation in the national psychiatric hospital community. The new rules specified, among other things, that any patient put in restraints had to be seen within one hour of doing so by a psychiatrist (Moore, 1999). Many small rural hospitals could not comply because such a physician was not within an hour's reach. The American Hospital Association sued to halt the new rules, but lost in the courts. Before the new law, it was possible for a registered nurse to make legal decisions regarding restraints; now this was forever lost. It rapidly became obvious that if the strict application of these new regulations would result in a paralysis of the existing system. The solution around this came in the form of the PRN order which allowed chemical as opposed to physical restraint. After the initial assessment of the patient was completed, the physician would not only specify drugs fort he patient's normal routine, but would also specify powerful PRN medications that could be used as a backup if the patient shows signs of getting out of control. This adaptation allowed the physician to then not have to be called out of bed in the middle of the night and forced to "eyeball" the patient for the express purpose of authorizing physical or chemical restraint. Using the power of the PRN, the nurse on duty can then simply medicate the patient to whatever extent in necessary to achieve physical control without involving the rigid protocol attached to seclusion and physical restraint.

Yet the question must be asked, is this adaptation taking into account an accurate interpretation of the law and the rights of the patient? The concept of chemical restraint is not supposed to be part of the patient's usual treatment plan; its existence cannot be justified to simply to control the behavior of the patient. "If a medication is prescribed as a part of an assessment and a rational plan of care, whether on a schedule or an as-needed basis, it is a treatment. If prescribed simply as a reaction to the patient's behavior, it is a restraint (Allen & Currier 2000).

Often medications are formulated and prescribed to simply and effectively have no other goal than chemically restraining the patient in as short of time as possible. One approach, described as the "cocktail approach" is to use a combination of Haloperidol and Lorazepam intramuscularly to effect sedation in as little as thirty minutes. However, there can be acute neuroleptic-induced akathesia as well as acute dystonic reactions; patients must be carefully observed (Hughes,1999). In describing this aggressive approach to the out of control patient, there is not the slightest pretense that it is formulated for the purpose of a plan of care, but simply for control.

However, it must also be noted that the only alternative to chemical restraints is either physical restraints or seclusion, and the documentation of the negative effects of both of those are well known. This was especially true when poorly trained individuals were entrusted with enforcing these areas in poorly financed state institutions, which is where these abuses were uncovered back in the 1980s (Weiss, 1998). Another detriment to the seclusion solution is that once an individual is released from this environment, there is no guarantee his behavior will not regress at any moment, once again presenting an unpredictable threat to him-self and others. The only question that must