When is hospital restraint justified?

Restraint and seclusion data released by the Chief Psychiatrist of Western Australia in April has rekindled an ongoing conversation around the ethics of restrictive practices in hospitals.

The data from July 1 to December 31, 2020 showed the restraint rate for inpatients of Perth Children’s Hospital’s mental health ward was 17.4 per 1000 bed days, while seclusion events on the same ward were 9.9 per 1000 bed days. 

Chief Psychiatrist of Western Australia Dr Nathan Gibson said patients were physically restrained or confined in a locked room when there was an imminent risk they would harm themselves or endanger others.

The rate of restraint in the PCH mental health ward was the highest across all public mental health services in Western Australia.

WA Australian Medical Association mental health spokesperson Dr Helen McGowan said: “The issue of restrictive practice among all mental health consumers has been considered an important issue for more than 20 years.”

Perth Children's Hospital
Perth’s Children’s Hospital mental health ward reported higher rates of restraint compared to adult facilities.
Photo: Samuel Wiki CC0.

Honorary associate at Sydney Health Ethics Anne Preisz said children and adolescents were only restrained or secluded when it was in their best interests. 

“If restrictive practices are used so the child does not hurt themselves or others, it is a really important element of managing their care,” she said.

“But it also has to be done judiciously and with the least restrictive practice.” 

Clinicians operating under the WA Mental Health Act 2014 are legally bound to act in the best interests of the child — but there is ethical tension in gauging what these best interests are.

Dr Gibson said staff must speak to the young patient and their caregivers to ascertain what course of action was in the child’s best interest.

“Sometimes it’s better to let the child bang on the wall if it will calm them down, and other times it may be appropriate to jump in early.”

Chief Psychiatrist of Western Australia Dr Nathan Gibson

“It’s a difficult decision. It’s about what is in their best interest at that point in time, whether it’s to restrain someone or let them bang on a wall,” he said.

“Sometimes it’s better to let the child bang on the wall if it will calm them down, and other times it may be appropriate to jump in early.”

The ethical tension becomes more pronounced when a young person’s psychological history is considered. 

Dr Gibson said emotional dysregulation — a difficulty in responding to and managing emotions — was the primary reason inpatients were restrained and secluded. 

Learning to self-regulate is a critical milestone in a child’s development and occurs primarily through their environment and primary caregivers’ influence. 

Curtin School of Allied Health lecturer Dr Rebecca Waters said that while all children and adolescents can experience emotional dysregulation, those that have suffered trauma, abuse or homelessness were more likely to find it difficult to control their emotions.

“We see a little human in a hospital bed acting defiantly or violently but they have kicked straight into fight or flight — they have no cognitive shortcut process,” she said. 

Dr Gibson said restrictive practices against vulnerable young patients also risked re-traumatising them.

He said research showed most people that came into mental health inpatient services more than likely had a significant history of trauma in their lives. 

“You can imagine if a child has had physical trauma before, holding them down again might bring it all back for them,” he said. 

Dr McGowan said the MHA 2014 provided a legislative framework and reporting requirements to regulate the use of restrictive practices and the Act was currently undergoing review. 

But Dr Waters said the mental health system needed to change. 

“We know, in those cohorts of vulnerable people, the best way of supporting people is to be individualised. But we just don’t have that level of resource in our system,” she said. 

“One size fits all doesn’t work — including little humans with behaviour issues in hospitals.”