This week I’m in Nashville for the American Delirium Association Conference (#ADS2017). Day one was heavy on education and although I was familiar with most of the content I always find it interesting to hear how others interpret and explain things. One session on delirium in the Intensive Care got me thinking:
Now when you mention restraints to people in healthcare they will generally think about the kind that have people strapped to a chair or cot side. Thankfully these types of restraints are no longer routinely used in the NHS.
There are some kinds of restraint that can be a good thing for example, the plaster cast that stops a fracture becoming displaced.
However what about the restraints we use by proxy?
As I sat in the lecture I got to thinking about what happens to a person when they are in hospital. Last week I talked about the role of the environment in particular how it can be damaging to the person with delirium or dementia. By making simple changes there is evidence that the person will get better more quickly, so of course the environment was number one on my list.
The #endpjparalysis campaign on social media also highlights it. I recently had a patient comment she would like to get dressed but unfortunately her family had only packed her a nightdress. Most equate a hospital admission with serious illness however the aim is to get the person better as quickly as possible so we do need to see beyond that. One could argue that a person’s dignity is restrained by having them rehabilitate (walk, eat etc) only in nightwear.
Which brings me on to 7 day access to a multi disciplinary team (MDT). We know that early access to physio and occupational therapy can have huge benefits not only on the physical but also cognitive health of a person. Could limited access to the MDT be a restraint by proxy? I’m not so sure. I do think they are spread far too thin. I also think that some of the tasks could be done by others, in particular, our healthcare assistants. I just wonder if they perhaps need to be more empowered to do so instead of just doing unto the patient….?
One thing that does not help in the early mobilisation of a person is the use of sedation. It’s not just an issue for ITU, many of our older people are on medications that actively sedate them e.g. the ‘little sleeping tablet at night’, strong painkillers even some antihistamines. I would argue that Geriatricians in conjunction with our pharmacy colleagues are good at trying to rationalise medications. The community, especially care homes are not quite as good.
So coming back to the hospital setting both in acute and rehab here are a few other things that could be considered restraint by proxy;
- urinary catheters
- hearing aids that don’t work or are not fitted
- no glasses
- buzzers that are out of reach
- empty water jugs and cups
- inappropriate walking aids
- no walking aids
- no ‘getting to know me’ or ‘what matters to me’ discussions
Most would be horrified at the idea of going back to the use of physical restraints but I wonder if we realise all the other ways we achieve the same effect? Perhaps we ought to reframe the discussion so that as with straps, belts etc other restraints by proxy can become a thing of the past….