One of the most significant differences in hospital practice between the European Union and the US and its Australian counterparts is that the European tend to regard the use by nurses in intensive care of physical restraints, and doctor’s orders for the use of IV injections to sedate them, as excessive.
To be fair, on both sides of the Atlantic (and the Pacific & Indian Oceans as well) the use of restraints on the demented or otherwise aged mentally ill in chronic care has been reduced to a bare minimum, at least partly as a result of successful political agitation against its apparent cruelty, particularly in the understaffed and underfunded nursing homes and mental hospitals in which it was most commonly practiced.
The fact that these patients often died sooner of unrelated causes may be due to some peculiar unintended effects. Care that involved less use of restraints, sometimes led to fewer assessments of both the integrity of the restraints and the state of the patient, so that downturns were more slowly perceived by the healthcare team.
This is particularly the case with matters like aspiration pneumonia caused by the patient obtaining food or drink and then mis-swallowing them when unsupervised.
The American defense of their greater use of physical restraints in ICU settings is that the forceful extubation (yanking out the breathing tube) by the patient or by family members who are distraught at the sight of a loved relative on a respirator, is not uncommon, and is very dangerous for the patient.
It might be argued that adult patients who are trying to extubate themselves are expressing a wish that ought to be legally honored. (There appears to be little argument that children ought not be allowed to decide this for themselves.)
This argument against restraints tends to ignore the fact that most patients who are intubated and in an American ICU at this time of managed care in hospitals , are those who have suffered a severe illness or injury from which, in the judgment of the physicians and nurses, they are likely to recover, a fact that the patient is in no condition to assess given the combinations of pain, prior hypoxia and prescriptions, all of which have the potential to skew clear thinking.
Most hospitals, and certainly most health insurances, will no longer pay for undoubtedly terminal patients to stay in ICUs for an extended time when the situation is futile, particularly if “comfort care” can be provided in another ward or in another setting altogether.
In addition, later this year (2008), Medicare will no longer pay for the extension of hospitalization caused by patient falls, deeming this a preventable occurrence, through, among other measures, the judicious use of restraints for persons whose balance, gait, and cognitive capacity are not up to ambulating without assistance. .
Moreover, most advanced medical directives drawn up by American attorneys or made available as forms by health providers in the US specify the discontinuance of extraordinary means (including mechanically assisted ventilation) only if there is no reasonable chance for the patient to regain their health, sometimes qualified with clauses requiring that they be sustained only if it is likely that they will regain a high level of functioning, or have the chance of living without unmanageable pain.
Consequently, it would appear that decisions made by patients in their more rational moments, particularly if well-elaborated (and ideally communicated to the family well in advance) ought to be honored over those that may represent what, for the lack of a better phrase, a patient made crazy by pain or panic.
In the interim, ICU nurses must often get the patient to cooperate in their own care, sometimes when the patients are agitated and delirious, and in some cases when the patients have somehow communicated to relatives that they are being “tortured” or “being held against their will.”
Suspicious as it sounds to critics of restraints, the use of anxiety reducing drugs is often prescribed not only to minimize agitation but because its relaxant effect better enable breathing by machines ( ventilator- lung synchrony).
Critics of this chemical restraint should be somewhat assuaged by the fact that trends in the US are to wean patients off of both the ventilator and medication much sooner than was formerly done, partly because the chance for adverse outcomes from all causes seems to rise the longer one stays in the ICU, and the chances for better cognitive functioning go up when the patient is out of the ICU, breathing on their own, and ideally, in a lowered state of pain and anxiety.
There have been conflicting reports on whether the use of physical or chemical restraints has caused more or less emotional damage through vivid recall of the ICU and intubation experience.
It has generally been shown that the older the patient, the more likely it is that he or she has little or no recall, no matter what level of sedation was administered.
(At age 57, I cannot always remember what I had for lunch, so there may be some normal decline in recall of any events.)
But it has also been shown that the recalls are typically unreliable with adult ICU patients at any age, because they conflate imagined with real painful or frightful experiences.
Nonetheless, even some conflated memories of misadventures seem to have a curiously protective effect for the patient against PTSD, because they help the patient comprehend the severity of their prior illness, and cause the patient to focus on going forward to recovery.
Ultimately, it is the higher and tougher duty of the ICU nurse to get patients to that stage, because when everyone else, particularly patients and families are losing their heads, nurses have to keep theirs, even if it means tying down hands, arms, (or relatives!).
This blogger recommends all of the following e articles to you, but the two-part series by Hofso and Coyer are arguably the best overviews available if you have only limited time.
Antonelli M et al. 2007. A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-time intervention for acute respiratory distress syndrome. Critical Care Medicine 35 (1): 18-25.
Birkett KM, Southerland KA & Leslie GD. 2005. Reporting unplanned extubation. Intensive & Critical Care Nursing 21 (2): 65-75.
Bova KA. 1996. Commentary on Decreasing unplanned extubations in the surgical intensive care unit [original article by Tominaga G et al appears in AM J SURG 1995;170(6):586-90]. AACN Nursing Scan In Critical Care 6 (3): 35-35.
Bray K, et al. 2004. British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. Nursing in Critical Care 9 (5): 9.
Byard RW, Wick R & Gilbert JD. 2008. Conditions and circumstances predisposing to death from positional asphyxia in adults. Journal of Forensic and Legal Medicine 15 (7): 415-419.
Capuzzo M, et al. 2001. Analgesia, sedation and memory of intensive care. Journal of Critical Care 16: 83-89.
Cornock M. 1998. Stress and the intensive care patient: perceptions of patients and nurses. Journal of Advanced Nursing 27 (3): 518-527.
Devlin JW et al. Survey of sedation practices during noninvasive positive-ressure ventilation to treat acute respiratory distress. Critical Care Medicine 35 (10): 2298-2302.
DeWit M & Epstein SK. 2003. Administration of sedatives and level of sedation: comparative evaluation via the Sedation-Agitation Scale and the Bispectral Index. American Journal of Critical Care 12: 343-348.
Dimond B. 2008. Dilemma: Do relatives have legal powers regarding continuation or withdrawal of treatment for patients in ICU? Nursing Times 104 (31): 13.
Egerod I, Christensen BV & Johansen L. 2006.Trends in sedation practices in Danish intensive care units in 2003: a national survey. Intensive Care Medicine 3: 260-266.
Elk S & Ferchau L. 2000.Physical restraints -- are they necessary? American Journal of Nursing 24.
Evans D & FitzGerald M. 2002. Reasons for physically restraining patients and residents: A systematic review and content analysis. International Journal of Nursing Studies 39 (7): 735-743.
Evans D, Wood J & Lambert L. 2003.Patient injury and physical restraint devices: A systematic review. Journal of Advanced Nursing 41: 274-282.
Guldbrand P, et al. 2004. Survey of routines for sedation of patients on controlled ventilation in Nordic intensive care units. Acta Anaesthesiologica Scandinavica 48 (8): 944-950.
Happ MB, et al. 2004. Communication ability, method, and content among nonspeaking nonsurviving patients treated with mechanical ventilation in the intensive care unit. American Journal of Critical Care 13 (3): 210-220.
Heffner JE. 2000.Editorial: a wake-up call in the intensive care unit. New England Journal of Medicine 342 (20): 1520-1523.
Hofso K & Coyer FM. 2007. Part 1. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: contributing factors. Intensive & Critical Care Nursing23 (5): 249-255.
Hofso K & Coyer FM. 2007. Part 2. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: a patient perspective. Intensive & Critical Care Nursing 23 (6): 316-322.
Jacobi J, et al. 2002.Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine 30 (1): 30.
Jones C, et al. 2001. Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Critical Care Medicine 29: 573-580.
Kent MA. 1996. The ethical arguments concerning the artificial ventilation of patients with motor neurone disease. Nursing Ethics 3(4): 317-328.
Kollef MH, et al. 1998. The use of continuous IV sedation is associated with prolongation of mechanical ventilation.Chest 114: 541-548.
Kress JP, et al. 2000. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine 342: 1471-1477.
Kress PK, et al. 2003.The long-term psychological effects of daily interruption on critically ill patients. American Journal of Respiratory and Critical Care Medicine 168 (12): 1457-1462.
Lavery GG. 2004. Optimum sedation and analgesia in critical illness: we need to keep trying. Critical Care 8 (6): 433-434.
Löf L et al. 2006. Severely ill ICU patients' recall of factual events and unreal experiences of hospital admission and ICU stay -- three and 12 months after discharge. Intensive and Critical Care Nursing 22: 154-166.
Maccioli GA, Dorman T& Brown BR. 2003. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies -- American College of Critical Care Medicine Task Force 2001-2002. Critical Care Medicine 31: 2665-2676.
Martin B. 2002. Restraint use in acute and critical care settings: Changing practice. AACN Clinical Issues 13 (2): 294-306.
Micek ST, et al. 2005.Delirium as detected by the CAM-ICU predicts restraint use among mechanically ventilated medical patients. Critical Care Medicine 33(6): 1260-1265.
Minnick A, Leipzig RM& Johnson ME. 2001. Elderly patients' reports of physical restraint experiences in intensive care units. American Journal of Critical Care 10: 168-171.
Minnick AD, et al. 1998.Prevalence and patterns of physical restraint use in the acute care setting. Journal of Nursing Administration 28 (11): 19-24.
Peruzzi WT&Hurt K. 2005.Approach to sedation in the ICU. Seminars in Anesthesthesia and Perioperative Medicine and Pain 2: 427-433.
Powers J. 1999. A sedation protocol for preventing patient self-extubation. Critical Care Nursing 18 (2): 30.
Prielipp RC &Young CC. 2001. Current drugs for sedation of critical ill patients. Seminars in Anesthesia and Perioperative Medicine and Pain 20 (2): 85-94.
Rose L & Bucknall T. 2004. Staff perceptions on the use of a sedation protocol in the intensive care setting. Australian Critical Care 17 (4): 151-159.
Russell S. 1999. An exploratory study of patient's perceptions, memories and experiences of an intensive care unit. Journal of Advanced Nursing 29: 783-791.
Samuelson K, Lundberg D & Fridlund B. 2006. Memory in relation to depth of sedation in adult mechanically ventilated intensive care patients. Intensive Care Medicine 32: 660-667.
Schweickert WD, et al. 2004. Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Critical Care Medicine 32: 1272-1276.
Simini B. 1998. Unexpected endotracheal extubations. Lancet 352 (129): 671-672.
Soliman HM, Melot C & Vincent JL. 2001. Sedatives and analgesic practice in the intensive care unit: the results of a European survey. British Journal of Anaesthesiology 87: 186-192.
Stein-Parbury J & McKinley S. 2000.Patients' experiences of being in an intensive care unit: a select literature review. American Journal of Critical Care 9: 20-27.
Wittbrodt ET. 2005. Daily interruption of continuous sedation. Pharmacotherapy 25 (5): 25.
Woods JC, et al. 2004. Severe agitation among ventilated medical intensive care unit patients: Frequency, characteristics and outcomes. Intensive Care Medicine 30 (6): 1066-1072.
Wunderlich R, et al. 1999. Patients perceptions of uncertainty and stress during weaning from mechanical ventilation. Dimensions of Critical Care Nursing 18 (1): 2-8.
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I {looked|checked} {on the internet|on the web|on the net} {for more info|for more information|to find out more|to learn more|for additional information} about the issue and found {most individuals|most people} will go along with your views on {this website|this site|this web site}.| {Hi|Hello|Hi there|What's up}, I {log on to|check|read} your {new stuff|blogs|blog} {regularly|like every week|daily|on a regular basis}. Your {story-telling|writing|humoristic} style is {awesome|witty}, keep {doing what you're doing|up the good work|it up}!| I {simply|just} {could not|couldn't} {leave|depart|go away} your {site|web site|website} {prior to|before} suggesting that I {really|extremely|actually} {enjoyed|loved} {the standard|the usual} {information|info} {a person|an individual} {supply|provide} {for your|on your|in your|to your} {visitors|guests}? 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Keep on posting!| I {{leave|drop|{write|create}} a {comment|leave a response}|drop a {comment|leave a response}|{comment|leave a response}} {each time|when|whenever} I {appreciate|like|especially enjoy} a {post|article} on a {site|{blog|website}|site|website} or {I have|if I have} something to {add|contribute|valuable to contribute} {to the discussion|to the conversation}. {It is|Usually it is|Usually it's|It's} {a result of|triggered by|caused by} the {passion|fire|sincerness} {communicated|displayed} in the {post|article} I {read|looked at|browsed}. And {on|after} this {post|article} SLA Biomedical & Life Sciences Division Blog: The Courage of ICU Nurses Who Must Save Patients From Themselves: The Controversy Over The Use of Physical and Chemical Restraints on Ordinarily Cognitively Competent & Nonterminal Adult Hospital Patients at Risk Of Pulling Out Their Respirator Tubes.. 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I {like|wanted} to write a little comment to support you.| I {always|constantly|every time} spent my half an hour to read this {blog|weblog|webpage|website|web site}'s {articles|posts|articles or reviews|content} {everyday|daily|every day|all the time} along with a {cup|mug} of coffee.| I {always|for all time|all the time|constantly|every time} emailed this {blog|weblog|webpage|website|web site} post page to all my {friends|associates|contacts}, {because|since|as|for the reason that} if like to read it {then|after that|next|afterward} my {friends|links|contacts} will too.| My {coder|programmer|developer} is trying to {persuade|convince} me to move to .net from PHP. I have always disliked the idea because of the {expenses|costs}. But he's tryiong none the less. I've been using {Movable-type|WordPress} on {a number of|a variety of|numerous|several|various} websites for about a year and am {nervous|anxious|worried|concerned} about switching to another platform. 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IE {still|nonetheless} is the {marketplace|market} {leader|chief} and {a large|a good|a big|a huge} {part of|section of|component to|portion of|component of|element of} {other folks|folks|other people|people} will {leave out|omit|miss|pass over} your {great|wonderful|fantastic|magnificent|excellent} writing {due to|because of} this problem.| {I'm|I am} not sure where {you are|you're} getting your {info|information}, but {good|great} topic. I needs to spend some time learning {more|much more} or understanding more. Thanks for {great|wonderful|fantastic|magnificent|excellent} {information|info} I was looking for this {information|info} for my mission.| {Hi|Hello}, i think that i saw you visited my {blog|weblog|website|web site|site} {so|thus} i came to “return the favor”.{I am|I'm} {trying to|attempting to} find things to {improve|enhance} my {website|site|web site}!I suppose its ok to use {some of|a few of} your ideas!!\
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