Restraint as a Last Resort

An emergency situation is where there is an imminent risk of harm to self, team members or others, which requires immediate action to prevent harm.

In an emergency situation, the RN or Paramedic can implement an environmental restraint, mechanical device or physical intervention, and obtain an order from an authorized prescriber immediately following the application/use of restraint. A restraint can be implemented before gaining informed consent.

In situations where refusal of a restraint creates an imminent risk of harm, the emergency situation allows for implementation of a restraint before obtaining informed consent or an authorized prescriber order.

• For example: Emergency treatment, such as a physical examination, is required for a motor vehicle accident patient who is delirious and combative. Once the emergency situation has passed, a restraint cannot be used without consent (e.g. it is no longer considered an emergency).

A post-restraint debrief should occur, as soon as practical and clinically appropriate, after an emergency situation that necessitated restraint use.

Debriefing has several benefits. It will:

• Help to re-establish the therapeutic relationship
• Facilitate a future care plan by identifying what worked and what did not work
• Identify complications or safety concerns of restraint use
• Prevent future restraint episodes

The health professional who initiated the restraint, and who is in the best position to discuss the risks, benefits and use of the restraint, is responsible for disclosing this information. The health professional will:

• Explain the circumstances leading up to the emergency
• Explain why a restraint was initiated
• List the risks and benefits that were weighed
• Answer any questions or concerns
• Validate the emotional responses of the patient and their Circle of Support/Substitute Decision Maker (SDM)

Risks of physical and environmental restraints: Refer to the user manual or product information sheets for risks that are specific to each product. Ensure a copy of same is accessible to all staff.

Risks of pharmacological restraints: Refer to the Care Notes on Micromedex, or Patient Medication Information on eCPS (RxTx) for risks, warnings, and side effects specific to each pharmacological restraint.

If the patient lacks capacity to consent to treatment, and the SDM is not physically present, the emergency disclosure may happen with the SDM over the phone.

Document the outcome of the discussion and risks discussed in the patient’s chart.