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ASA NEWSLETTER
 
 
March 2001
Volume 65
Number 3
   
When Should Anesthesiologists Restrain Uncooperative Patients?

Gail A. Van Norman, M.D.
Susan K. Palmer, M.D.
Committee on Ethics


Timmy is a healthy, unpremedicated 9-year-old boy scheduled to have restorative dental work under general anesthesia. Both parents have taken time off from work for the procedure. Timmy barely acknowledges the anesthesiologist when introduced. As the anesthesiologist discusses intravenous (I.V.) and mask induction with Timmy and his parents, Timmy becomes agitated, saying that he wants to go home. Timmy's father tells him that he cannot go home until his dental work is done, while his mother reassures him that nothing is going to hurt. Timmy states that, I don't want a mask. When the anesthesiologist approaches to start an I.V., Timmy becomes red-faced and begins to cry, saying loudly that he does not want a needle and that the doctor is going to hurt him. His voice becomes shaky, and he jerks away thrashing his legs as his parents attempt to physically restrain him.


How should the anesthesiologist approach the uncooperative pediatric (or adult) patient? What are the ethical and legal considerations regarding manipulation, coercion or restraint in the care of patients? Do anesthesiologists have special ethical and legal responsibilities when choosing to use their special skills on patients who have not or cannot give their consent?

Manipulation and restraint are two methods commonly used to control patients. 1-3 Manipulation of patients includes lying, omitting essential information or taking advantage of a patient's vulnerabilities to gain cooperation. Manipulation is unethical because it violates trust and exploits the inequality of power in the patient-doctor relationship.1 Ethically speaking, coercion is the control of another person by use of a credible and severe threat of harm or force, while restraint is the use of physical or chemical means of controlling a patient's unwanted behavior. 1 Withholding pain medications from a patient with a severely displaced femur fracture until a surgical consent is signed, for example, may be coercive, even if the physician's goal is to avoid claims that administering analgesics might invalidate the consent. Coercion is unethical because it destroys a patient's autonomy and thus violates a fundamental principle of Western medical ethics to promote and respect patient autonomy. 1,2

Technically, patients with impaired competence cannot be “manipulated or coerced since they are by definition not able to make autonomous decisions in the first place. 1 Such patients include minors and those with mental handicaps, psychiatric disease or organic or metabolic brain disorders. Restraint can be physical or chemical and can be voluntary or involuntary: Intramuscular (IM) injection of ketamine in an uncooperative patient is involuntary restraint, while convincing a 9-year-old who does not want surgery to agree to take oral midazolam prior to starting an I.V. is voluntary restraint.

Is it ethical for anesthesiologists to use physical or chemical restraint to manage uncooperative patients with impaired competence? Like all physicians, anesthesiologists have an ethical duty to preserve patient autonomy and dignity as much as possible. 1 If a patient is competent to refuse medical care, then proceeding against the patient’s will is unethical and probably illegal. On the other hand, it may be ethical to restrain an incompetent patient if legitimate surrogate decision-makers for the patient have determined that the care is in the patient’s best interest. Oral premedication, for example, is one humane way to restrain patients who will not be competent to consent to care on the day of surgery. For the unpremedicated, agitated patient, the ethical solution may be to choose to delay anesthesia in order to permit sedation for more humane restraint. Preventing stress and physical struggling preserves patient dignity and may be useful, provided it does not delay medical care so long that the benefits of medical therapy will be lost.

The first question to ask in any case where restraint is considered is whether the patient is competent to refuse medical therapy. Refusal of medical therapy is the moral and legal right of every competent patient, even if the therapy would be life-saving. 1-3 Examples of refusals of care that we commonly respect are the right to not be resuscitated, the right to refuse intubation and the right to refuse blood transfusions. Patients are competent to refuse care if they can understand what care is being offered, understand the risks and benefits of both receiving and refusing care, and can render and communicate a decision that is in part based on the medical information given to them. 4 Use of coercion or restraints with such a patient is unethical and might represent a criminal assault.

In the United States, unimpaired patients over the age of 18 are considered legally competent, while patients under 18 may not be. This is based on the assumption that most children and adolescents cannot fully appreciate the implications of their choices and may render decisions based on fears of short-term discomfort rather than long-term benefits. The courts have recognized, however, that some children are competent to make medical choices and that the rights of children to not undergo medical procedures to which they have not given their assent extends to very young ages. 5,6 It is against federal law, for example, to include a child over age 7 in medical research protocols without his or her assent. 5 When a child under the age of 18 refuses medical care and demonstrates all or at least some of the characteristics of medical decision-making ability, expert opinion may be necessary to resolve the issue.

The patient in the above example does not demonstrate behavior suggesting competence to refuse therapy. But that does not mean we can or should automatically proceed with physical or chemical force. The American Academy of Pediatrics Committee on Child Abuse and Neglect suggests that significant restraint should not be used in pediatric care unless it is necessary for proper diagnosis and treatment in a sick child, as in the case of a child with a high fever and potential ear infection, or in emergency situations. 7 It has been argued that chemical and physical restraints may have no place at all in a pediatric setting and only limited use with other patients who have impaired competence. 8 It is a duty of the anesthesiologist to provide safe, humane medical care while preserving as much as possible the dignity and autonomy of the patient.



It is a duty of the anesthesiologist to provide safe, humane medical care while preserving as much as possible the dignity and autonomy of the patient.


Timmy is old enough to exercise some choices in his medical care. At his age, it may be possible to try to calm him enough to proceed with the case while still preserving his dignity. Timmy may not be competent to decide that he does not need dental care, but he may be capable of deciding, for example, how he wants to go to sleep. Choices, wherever possible, can allow pediatric patients or patients with otherwise impaired autonomy to retain some control over their environment. Many authors suggest that offering such choices can mitigate the fears of such patients, providing a more humane experience. 9 Many pediatric patients can be calmed enough through creative use of fantasy or hypnotic suggestion to allow some medical procedures such as a blood draw or I.V. start to be done. Protecting Timmy from current and future harm may require delaying the case and approaching him later when he is calmer. 10



What happens when, despite the parents and anesthesiologist's best efforts, Timmy cannot or will not accept the choices offered to him? Should he be restrained physically for an I.V. start or mask induction? Should he be given IM ketamine? Such a course of action may be justified if the need for medical care is urgent. Delaying an emergency appendectomy, for example, may put his life at risk, while delaying elective dental work probably does not. There are many pressures to proceed immediately, including the surgical scheduling, the potential economic loss to the physicians and the hospital, and the fact that the parents have each lost a day of work. However, it may be in Timmy's best interest to delay or reschedule his medical care in order to reduce the potential for traumatic stress, provide safer induction conditions and avoid promoting a future aversion to medical care. Timmy could be offered an oral premedication to take, for example, and then be anesthetized later in the day when he does not physically resist the anesthesiologist. When delays are not likely to provide better conditions for the patient, the anesthesiologist may have to proceed in a manner best designed to preserve patient safety and dignity.

In summary, coercion, manipulation or restraint of competent patients is generally unethical and may be illegal. An ethical and legal exception is the use of coercion or restraint to control behavior of competent or incompetent patients who pose a physical danger to themselves or to others. Premedication might be considered in incompetent patients to reduce trauma and stress to the patient and provide safer induction conditions. Patients with impaired competence should be offered as much choice in their anesthetic care as possible. Voluntary means of gaining cooperation of unpremedicated patients should be explored before resorting to involuntary restraint. When restraint is used, the anesthesiologist should choose, whenever feasible, methods that best preserve the patient's dignity and limited autonomy.

Definition of Terms

Assault: Legal term describing unconsented touching of a person's body for any purpose.

Assent: Agreement given by minor patients to medical procedures or to participate in medical research.

Coercion: Control of a person's behavior by use of credible and severe threat of harm or force.

Informed medical consent or refusal: A legally binding decision to allow or refuse medical care by a patient who understands the consequences of their decision and who meets legal criteria for competence.

Manipulation: Altering a patient’s behavior or decisions by lying or omitting essential information or taking advantage of a patient's vulnerabilities.

Medical decision-making ability: A spectrum of abilities that may be continuously or intermittently present in a patient who may or may not be competent for other purpose, e.g., a patient may never be competent for making his or her own financial decisions and yet have some ability to participate in decisions about his or her medical care.

Restraint: Physical or chemical means of restricting a person's behavior; can be voluntarily agreed to by a patient or can be involuntary.


References:

1. Beauchamp T, Childress JF. Principles of Biomedical Ethics. 4th ed. New York: Oxford University Press. 1994:7,121,471.

2. Murphy JG. Therapy and the problem of autonomous consent. Int J Law Psychiatry. 1979; 2:415-430.

3. Clarke JR, Srenson JH, Hare JE. The limits of paternalism in emergency care. Hastings Cent Rep. 1980; 10(6):20-22.

4. Lo B. Assessing decision-making capacity. Law Med Health Care. 1990; 18(3):193-201.

5. Lee L. Ethical issues related to research involving children. J Pediatr Onc Nurs. 1991; 8(1):24-29.

6. Engum ES. Expanding the minor’s right to consent to non-emergent health care. J Legal Med. 1982; 3(4):557-615.

7. Behavior Management of Pediatric Dental Patients. American Academy of Pediatrics Committee on Child Abuse and Neglect [letter]. Pediatrics. 1992; 90(4):651-652.

8. Emil S. Restraint is needed in our use of patient restraints. Can Med Assoc J. 1990; 143(11):1221-1225.

9. Selbert SM, Henretig FM. The treatment of pain in the emergency department. Pediatr Clin NA. 1989; 36(4):965-978.

10. Nathan JE. Management of the difficult child: Survey of pediatric dentists' use of restraints, sedation and general anesthesia. J Dent Child. 1989; 56(4):293-301.



    Gail A. Van Norman, M.D., is Assistant Professor, Department of Anesthesiology, and Faculty Associate, Department of Biomedical History and Ethics, University of Washington, Seattle, Washington.Center College of Medicine.


    Susan K. Palmer, M.D., is Professor, Department of Anesthesiology, University of Colorado, Denver, Colorado.


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