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March 2001
Volume 65 |
Number 3
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| 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.
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Definition
of Terms
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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.
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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.
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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. |
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Susan
K. Palmer, M.D., is Professor, Department of Anesthesiology,
University of Colorado, Denver, Colorado. |
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