1. Safe & controlled access for medical procedures when involuntary patient-interference or resistance is R!S"#!$%& !#'ICIP!'(. )or e*ample+ Postictal sei,ure patients who are not -com.ative/- yet remain confused/ can reasona.ly .e anticipated to withdraw or stri0e out when .eing stuc0 with a needle. -Prophylactic- restraint 1restraint applied before the patient .ecomes involuntarily resistive to treatment2 will protect the patient and providers/ preventing in3ury or delay in treatment. 4. !#'ICIP!'I"# of IMPR"5( P!'I#' C"#(I'I"# producing com.ativeness6resistance. )or e*ample+ o unconscious hypoglycemic patients may -improve- from unconsciousness to .ecoming com.ative7 o cardiac arrest patients who -get .etter- will #"' deflate the ' cuff prior to e*tu.ating themselves7 o C5! patients may turn out to .e -'I!- patients/ developing the a.ility to withdraw or stri0e out when .eing treated. o !nd so on ... 8. 5!%9!'I"# or 'R!'M#' of C"M$!'I5 PRS"#S when illness or trauma is suspected to .e the cause of com.ativeness. :. I#5"%9#'!R& 'R!'M#' of persons I#C"MP'#' '" R)9S 'R!'M#'. Medicolegal Aspects Of Restraint: 'he primary legal considerations in providing restraint and6or involuntary treatment for a patient can .e divided into three areas+ 1. 'he rights and needs of the patient/ 4. 'he duties of the health care providers/ 8. ! responsi.ility for the protection of involved third parties. In the 9nited States/ a citi,en;s right to refuse treatment or transportation for treatment is protected .y law 1common and statutory2 and .y his constitutional rights to privacy/ due process/ and freedom of religion. ! person has the right to come to what others would consider an -unreasona.le- decision/ as long as that person can ma0e the decision in a -reasoned- manner - meaning the person is capa.le of reasoning/ or is -competent- to ma0e a decision. COMPETENCE is defined as the capacity or a.ility to understand the nature and effects of one;s acts or decisions. !nd/ for all practical purposes/ a person is considered to .e competent until proven otherwise. 'he legal concept of competence can only .e formally determined in a court of law. %aws governing competence and the right to refuse medical treatment vary widely from state to state. $ut/ universally/ the determination of competence generally depends upon four o.serva.le a.ilities. 1. 'he a.ility to communicate a choice. 4. 'he a.ility to understand relevant information. 8. 'he a.ility to appreciate the situation and its conse<uences. :. 'he a.ility to weigh the ris0s and .enefits of options/ and rationally process this information/ .efore ma0ing a decision. 'here are situations/ however/ in which the interests of the general pu.lic 1-State Interests-2 outweigh an individual;s rights to li.erty+ 1. 'he individual is threatening self-harm or suicide. 4. 'he individual presents a threat to the community .ecause of contagious disease or other physical dangerousness. 8. 'he individual presents a specific threat to innocent third parties.. In these cases/ individuals may .e restrained and6or treated against their will. MINORS are generally considered to .e incapa.le of self-determination. In the a.sence of a parent or legal guardian/ and in the presence of a life- or health-threat/ a minor may .e treated against his will. 'he -freedom of religion- clause/ whether it .e the parent;s or the minor;s religion/ is generally not allowed to interfere with a minor;s treatment for a life- or health-threat. Some states/ however/ have statutory provisions that allow certain minors the right of self-determination. -Mature minors- or -emancipated minors- may .e defined/ and therefore would have the same rights and responsi.ilities as an adult. )or e*ample/ the state of Colorado defines a minor as any person under the age of eighteen. $ut/ Colorado also recogni,es the right of consent for minors who are fifteen years old and older/ living separate and apart from the parent1s2 or legal guardian/ with or without the parent;s or legal guardian;s consent. !ny married minor or minor parent also has the right to consent within the state of Colorado. CONSENT is defined as the voluntary agreement of a person possessing and e*ercising sufficient mental capacity to ma0e an intelligent choice to do something/ with a proposition posed .y another. Consent is generally considered to .e either e*pressed or implied. *pressed consent is defined as positive/ direct/ une<uivocal/ voluntary ver.al or physicali,ed agreement and is a more a.solute and .inding degree of consent. Implied consent is defined as signs/ actions/ facts/ or inaction which raises the presumption of voluntary agreement. 'hus/ a patient who calls =-1-1 could generally .e considered as having implied a consent for evaluation and care. Generally, te la! i"plies patient consent d#ring an e"ergency$ 'he law has upheld that conditions which re<uire immediate treatment for the protection of a person;s life or health 3ustify the implication of consent if it is impossi.le to o.tain e*press consent either from the patient or from one who is authori,ed to consent on his .ehalf. 'hus/ the unconscious patient may .e treated under the auspices of implied consent. 'he courts assume that a competent/ lucid adult would consent to treatment necessary to maintain health or life. If the patient is clearly incompetent/ she6he may .e treated involuntarily. If circumstances are less clear/ .ut there is legitimate professional dou.t as to the competency of a patient refusing emergency care/ it is .est to err in favor of treatment. It is far .etter/ legally/ to .e accused of assault and .attery or false imprisonment secondary to involuntarily treating and transporting someone/ than to later .e accused of negligence. ASSA%&T is defined as 12 an unlawful physical attac0 upon another> 42 an attempt or offer to do violence to another/ with or without .attery/ as .y holding a stone or clu. in a threatening manner. 'hus/ threat alone/ can .e considered an -assault.- 'ATTER( is defined as an unlawful attac0 upon another person .y .eating/ wounding/ or even .y touching in an offensive manner. Chec0ing a person;s pulse without their permission may .e considered -.attery- .y some patients. !dditionally/ some religious .eliefs include considering persons of the opposite se* touching someone/ or the touching of a child;s head to .e offensive. 'ouching these types of people without prior permission may .e considered -.attery.- FA&SE IMPRISONMENT is defined as restraint without legal 3ustification. )alse imprisonment is considered a civil law and does not re<uire violent a.duction. Its e<uivalent in criminal law would .e -0idnapping.- 'he mere threat of confinement/ com.ined with an apparent a.ility to accomplish the threat/ and some limitation of movement 1i.e.> a closed door2/ is sufficient to uphold a charge of false imprisonment. ?owever/ false imprisonment cannot .e claimed if the patient consents to .eing confined. @hen faced with the apparent need to involuntarily treat and restrain a patient/ first consider the needs of the patient @ould failure to restrain and6or treat the patient result in imminent harm to the patient or other specific personsA Most patients in an emergency setting are emotionally -upset.- $eing merely -upset- does not support the use of restraints. 'here must .e an indication of lac0 of competence/ coupled with imminent health- or life-threat/ .efore a patient can .e treated involuntarily. 'here are several patient characteristics that indicate a need for involuntary treatment and6or restraint. 'he following is a -Buic0 %oo0- guide for recogni,ing patients who may not refuse treatment. ! patient may not refuse treatment if she6he is+ 9#C"#SCI"9S S9ICI(!% 1either ver.ally threatening or actively gesturing2 C"#)9S( 1to person/ place/ time/ or situation2 I#'"CIC!'(/ and appears I%% "R I#D9R( ! MI#"R C?I%(/ and appears I%% "R I#D9R( (5%"PM#'!%%& or PS&C?"%"EIC!%%& (IS!$%(/ and appears I%% "R I#D9R( 5R$!%%& or P?&SIC!%%& ?"S'I% and6or '?R!'#I#E ") "'?RS In most states/ a person who e*hi.its a danger to her6himself or others 1ver.ally or physically2 may .e ta0en into custody under an emergency mental health hold 1M??2. 'his hold is usually placed .y a police officer or psychiatric medicine official. In any event/ it is always wisest to have police present during incidents involving involuntary treatment and6or restraint. 1$oth for purposes of legality and for sufficient assistance in the restraint of an individual.2 9nfortunately/ waiting for the police to arrive is not always an option 1such as in cases where third parties are endangered and cannot .e removed from the dangerous patient;s vicinity2. Occasionally, a patient !ill act#ally prefer to )e restrained$ Restraint often provides them with a sense of safety or control. @hen you suspect this to .e the case/ offer restraints in a supportive manner/ and solicit the patient;s assistance with their application. If the patient cooperates with restraints/ this cooperative action implies a consent to .e restrained. Any for" of restraint "#st )e *INFORME+* restraint$ ven when the patient;s lac0 of competence will interfere with their a.ility to understand your e*planation/ you must e*plain why you are restraining and treating the patient prior to doing it. 'he second consideration in providing restraint or involuntary treatment is the d#ty of te preospital ealt care ,EMS- pro.iders$ 'hrough personal commitment/ professional oaths/ and ethical medical principles/ an MS provider has a responsi.ility to provide the .est possi.le care for the patient. 'his care/ and the way in which it is provided/ is su.3ect to measurement against national and local -professional standards of care.- very MS service should have specific written guidelines for patient restraint that are approved .y the service;s administration/ medical director/ and legal counsel. Performance of such professional standards of care can then .e supported .y these service protocols/ .ut only as long as the protocols are strictly adhered to and the restraint situation is ade<uately documented. NEG&IGENCE: @hen duties or standards of care are not met/ a legal action may arise .ased on the principles of negligence. 'o succeed in a negligence action/ a plaintiff 1suing party2 must prove all of the following four elements against the defendant 1the health care provider2+ 1. 'hat the provider had a duty to provide care/ 4. 'hat there was a .reach of that duty/ 8. 'hat damages occurred/ :. 'hat the provider;s .reach of duty caused the damages. &et another consideration in providing restraint or involuntary treatment deals with te EMS pro.ider/s responsi)ilities to indi.id#als oter tan te patient 0 te *tird parties* in.ol.ed in te incident$ It is a fundamental legal principle that all persons are re<uired to use ordinary care not to in3ure others. @hen an MS provider encounters a patient who manifests a danger to others/ .y ver.al threats or threatening physical actions/ said provider may have a legal duty to control the patient/ to safely evacuate the threatened parties/ or to at least notify appropriate authorities 1police2 to effect control of the threatening party and ensure the safety of third parties. In the state of Colorado/ if a com.ative or violent patient in3ures another person/ and the MS provider is shown to have .een capa.le of preventing that in3ury - .ut did not/ the MS provider may .e held lia.le for the third party in3uries. Once Te +ecision To Restrain And In.ol#ntarily Treat A Patient Is Made, Oter &egal I"plications Co"e Into Play$ Te &EAST RESTRICTI1E MEANS OF CONTRO& "#st )e e"ployed$ 5er.al communication is/ technically/ the -least restrictive- means of control. 'herefore/ ver.al cues must .e documented as having failed to control the patient prior to the use of physical force. 5er.al de-escalation can .e successful only when the provider+ -validates- the patient;s feelings .y ver.ali,ing the .ehaviors the patient is e*hi.iting/ and attempting to help the patient recogni,e these .ehaviors as .eing threatening openly communicates/ e*plaining everything that has occurred/ everything that will occur/ and why the imminent actions are re<uired respects the patient;s personal space 1such as as0ing for permission to touch the patient/ ta0e a pulse/ e*amine the patient/ etcetera2. 9nfortunately/ these ver.al de-escalation techni<ues are unli0ely to .e successful with patients on PCP/ patients in ('s/ or any other significantly confused or into*icated patients. After fail#re of .er)al control, te ne2t step is P3(SICA& CONTRO&: Physical control also must .e performed using the least restrictive means of restraint necessary to meet the patient;s immediate and emergent needs. !r.itrary use of -: point- restraints 1chest and lower lim. restraints/ .oth wrists and .oth an0les restrained - the most restrictive form of physical restraint2 may constitute a .reach of this re<uirement. If it can .e esta.lished that the patient;s care could have .een safely accomplished while using the lesser-restriction of only 1- or 4- point restraint/ the ar.itrary use of :-point restraint may result in successful litigation. 'hus/ restraint application should .e a gradual process/ .eginning with .asic .ody restraints and one lim. restraint/ then progressing to include restraint of additional lim.s only when the patient demonstrates a need for such increased amounts of restriction. ".viously/ there are e*ceptions to this -gradual process- suggestion. %ater we will discuss specific patients and situations that re<uire all-or- less-than :-point restraint. Only *REASONA'&E FORCE* "ay )e #sed !en applying pysical control: ! general rule for what amount of force is -reasona.le- is the use of force e<ual to/ or minimally greater than/ the amount of force .eing e*erted .y the resisting patient. !dditionally/ in order to .e -reasona.le force/- enough providers must .e present to insure patient and provider safety during the restraint process prior to applying physical force. "ptimally/ a minimum of five people should .e availa.le to physically control a patient during restraint application+ one for each lim./ and one for direction and restraint application. #ever hesitate to wait - at a safe distance - for ade<uate assistance/ if you don;t have enough people to ensure the safety of patient or providers during restraint application. In3uries resulting from e*cessive force/ insufficient provision of control during restraint/ or improperly applied restraints may present a legal lia.ility/ and the provider1s2 may .e sued .ecause of it. Remove all persons from the patient;s vicinity 1at least ensuring protection of others2/ and wait for ade<uate assistance. +OC%MENTATION OF RESTRAINTS: Improper or insufficient documentation of restraint may result in successful litigation against you. @hen what you -recall- a.out patient-care delivery and management does not fully correspond with what you documented 1often many months or years .efore2/ your credi.ility is discounted. 4en yo# a.e restrained a patient, yo# "should" doc#"ent all of te follo!ing: 1. 'hat an MRE#C& e*isted and the #( )"R 'R!'M#' was CP%!I#( to the patient. 4. 'hat the P!'I#' R)9S( 'R!'M#' or was 9#!$% '" C"#S#' '" 'R!'M#' 1such as an unconscious patient2. 8. 5I(#C of the patient;s I#C"MP'#C 1or ina.ility to refuse treatment2. :. )!I%9R of %SS RS'RIC'I5 M'?"(S of RS'R!I#' 1if conscious/ failure of 5R$!% !''M'S to convince the incompetent patient to consent to treatment2. F. !SSIS'!#C of %!@ #)"RCM#' "))ICI!%S with restraint/ or "R(RS from M(IC!% C"#'R"% to restrain the patient/ or !(?R#C '" S&S'M RS'R!I#' PR"'"C"%S. G. 'hat the 'R!'M#' and6or RS'R!I#' was for the P!'I#';S $#I)I' and S!)'&. H. 'hat the R!S"#S for RS'R!I#' were CP%!I#( '" '? P!'I#'. I. 'he '&P of RS'R!I#' MP%"&( 1soft/ leather/ mechanical2. =. 'he %IM$S RS'R!I#( 1.ilateral wrists/ wrist and an0les - -four points-2. 1J. !ny I#D9RIS '?!' "CC9RR( (9RI#E or !)'R RS'R!I#'. 11. CIRC9%!'I"# C?CKS every 1F 1or fewer2 MI#9'S. 14. 'he $?!5I"R and6or M#'!% S'!'9S of P!'I#' !)'R RS'R!I#'. Certainly/ not every restraint situation re<uires such e*tensive documentation. I routinely document only those points num.ered 4/ 8/ F/ H/ I/ =/ 1J/ and 11. 'hey represent the .asic minimum of restraint documentation needs. ?owever/ we are all familiar with the litigious nature of today;s society. @henever you have restrained someone who stri0es you as having a litigious nature/ or when the .ystanders or family mem.ers stri0e you as having a litigious nature/ the more of these points that you document/ the more protected you will .e .y your documentation.