Table 1 Examples of tabular form of a recommendation

Example 1

 Presupposition

For all cases of the use of physical restraints, it is true that certain elderly people have a higher risk of being subjected to restraints than other elderly people if they exhibit the following traits: functional disabilities, higher dependencies for day-to-day-activities, mobility problems, cognitive disturbances, behavioral problems, or a history of multiple falls

 Recommendation

The use of restraints has to be especially justified and reviewed in all cases that apply to the presuppositions

 Justification

None given

 Elucidations/comments

Authors: the stated traits can be interpreted as risk factors for being subjected to physical restraints, irrespective of whether or not they are justified. As elderly people with these risk factors have a higher probability of being subjected to physical restraints that may also be unjustified, special care is judicious as soon as a patient exhibits such traits

 References

“Older people with functional disabilities, increased activities of daily living dependence, mobility problems, cognitive disturbances, behavioral problems, or a history of multiple falls run a much higher risk of being physically restrained.”

(Gastmans C, Milisen K. Use of physical restraint in nursing homes: clinical-ethical considerations. J Med Ethics. 2006 Mar;32(3):148–52,148).

Example 2

 Presupposition

For all cases of the use of (physical) restraints, it is true that the reasons for applying them may change as situations change

 Recommendation

The use and the rationale of (physical) restraints have to be re-evaluated on a regular basis

 Justification

This takes place on patient’s behalf:

(Physical) restraints must not be longer used as necessary for reaching the goals that were initially defined for applying them

(Principle of Nonmaleficence, Principle of Respect for Autonomy)

 Elucidations/comments

For this, the use of physical restraints should be stopped periodically, and the patient should be put under continuous monitoring regarding her/his physical condition (e.g., skin color, extremity movement, sensation) and her/his personal needs (e.g., toileting, food, fluids).

 References

“The proposed ethical guidelines devised by the Ethics and Humanities Subcommittee of the American Academy of Neurology include the following:

1.) restraints should be ordered when they contribute to the safety of the patient or others and are not simply a convenience for the staff

2.) restraints should not be ordered as a substitute for careful evaluation and surveillance of the patient, as appropriate for good medical practice

3.) the perceived need for restraints should trigger medical assessment and investigation of the precise reason for them, intended to correct the underlying medical or psychological problem

4.) if a proxy decision maker is known, restraints should be ordered after full discussion of the risks and benefits. However, in an acute situation doctors should act in the best interest of the patient

5.) when they are indicated, pharmacological agents should be used at the lowest dose possible

6.) all restraints should be reassessed frequently so that they may be in effect for the shortest duration necessary to achieve their goals”

(Rai, Guchuran S/Eccles, Jim, Ethical issues in dementia, in: Rai, Gurchuran S., Medical Ethics and the Elderly, Oxford 2009, 125–137, 133).

“[…] For example, Moss and La Puma (1991) and Evans and Strumpf (1989) proposed the following ethical guidelines: (1) mechanical restraints should never be ordered routinely or as a substitute for careful patient surveillance; (2) orders for restraints should trigger a medical investigation aimed at identifying and correcting the medical or psychological problem responsible for the order; (3) the patient’s surrogate decision-maker should consent to the restraints and be given full disclosure of the risks and benefits; (4) when indicated, mechanical restraints should be applied carefully, temporarily, and with the least-restrictive device possible; and (5) when indicated, pharmacological restraints should be prescribed with the proper agent in the lowest effective dose and with frequent reassessments.”

(Bernat, Jamels L, Ethical Issues in the care of the patient with dementia, in: Duyckaerts C, Litvan I (eds) Handbook of Clinical Neurology, Vol. 89 (3rd series) Dementias, 115–130, 121–122).

[There are three further references that, for readability reasons, are not included in this example]