In May 26, 2006, 7-year-old Angellika Arndt became a casualty of physical restraint. Angellika was in a Wisconsin day treatment program and had been restrained nine times in four weeks, for up to two hours during each episode. The face-down, prone restraint was initiated because she was gargling her milk during a meal and did not stop when told to do so by staff. The cause of her death was listed as complications from chest compression asphyxiation. In other words, she was suffocated. The convention in forensic pathology is to rule such deaths as homicides.
The above scenario is a terrible situation: Angellika lost her life, her parents lost a child, and the staff members must live with the knowledge of the death and be haunted by the word homicide.
The same events happen with depressing regularity in facilities that exist to provide therapeutics and mental health services. Although in the U.S. there are no official data on such deaths, one study found that between 1993 and 2003, 45 child deaths had been reported in newspaper articles or were the subject of lawsuits (Child Abuse and Neglect. 2006: 30). In recent times, these deaths must be reported (www.access.gpo.gov/su_docs/aces/aces140.html); however, it is not known how often they have occurred in the past.
The dangers of restraint use have been known for some time, and the geriatric literature has been full of articles on the issue for many years. However, they did not receive the same attention from the mental health community until 1998. Following a series of articles in a Connecticut newspaper, Congress investigated the issue of restraint death in mental health facilities, and the psychiatric community began to examine coercive practices with greater scrutiny (www.courant.com/news/specia/restraint/day2.stm). In 2000, specific regulations on restraint use in psychiatric facilities were enacted by federal authorities and adopted by the JCAHO as well.
Despite this professional and federal attention, many people working in the field of mental health services remain unaware of the dangers of physical restraints. Some facilities still use the euphemism therapeutic hold when they mean restraint, despite the fact that there have been no therapeutic benefits established for these procedures. Some aggression management vendors may say that their restraint techniques are safe, but those companies that base their teaching programs on theory and research will stress that there is no safe restraint and that skillful de-escalation (and prevention of a restraint) are the safest alternatives available to staff members.
There are a number of ways in which people can die from a restraint (http://ww1.cpaapc.org:8080/publications/archives/CJP/2003/june/june2003.asp). These causes include the following
Death by aspiration
Blunt trauma to the chest
Malignant catecholamine-induced cardiac dysrrhythmias
Rhabdomyolosis with subsequent renal failure
Overwhelming metabolic acidosis from intense struggle
Although any prone restraint has the potential to be deadly, children and adults receiving psychotropic medications are at great risk for asphyxiation in prone positions secondary to the abdominal adiposity, a result of second-generation antipsychotics. When a child who is forced into a prone position has a protuberant abdomen, he or she experiences significant reduction in the size of the respiratory cavity.
Inaccurate assumptions and information
Close examination of the episodes that led to a restraint death shows that staff members operated with some false assumptions and knowledge deficits about the process of physical restraint (J Child Adolesc Psych Nurs. 2001: 14).
One of the most dangerous false assumptions is If an individual can talk, then he or she can breathe adequately. In many of the restraint-death scenarios, the medical record indicates that the restrained individual said, I cant breathe, and staff members believed that he or she was manipulating them.
Another dangerous assumption concerns the intensity of the struggle. Staff members, while using restraints, may believe that the forceful battling by a patient against those who are restraining him or her is an indication of opposition. Although it may be opposition, too often it is a struggle to breathe; the more the patient struggles, the more oxygen the patient uses, creating increasing hypoxia. In many death cases, patients had actually suffered respiratory arrest, but the staff thought that they had become compliant, holding them down for a few more minutes to make certain that they were calm.
Certainly, there could be times when there is no other alternative but to restrain; however, these situations are rare. Across the country, psychiatric centers of excellence have committed to eliminating the use of restraint and have succeeded in this goal. Pennsylvania and Massachusetts are two states that have reduced their restraint use dramatically; however, little discussion currently exists in the New Jersey psychiatric community about efforts to follow their examples.
Websites of the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Association of State Hospital Program Directors (NASHPD) have information that contains best practice models, curricula, and information about training. New Jersey nurses can learn much from others efforts to stop these dangerous practices.