18 May 2009

Chemical restraints

So I want to pose you all a question. 

A colleague from the hospital recently messaged me on facebook to ask me my opinions on chemical restraint of patients in a medical environment? My answer was a bit mixed and muddled.

So I turn the same question to you:

Do you think sedative drugs should ever be given to patients as a form of 'calming' measure outside of mental health hospitals?

Should patients be written up for lorazepam or haloperidol simply because they wander around and disturb other patients?

Should they have medicines to help them stay in bed if they are confused?

What do you think??


The Shrink said...

Usually, no.

You're probably aware, haloperidol's product licence requires that an ECG's done before initiating haloperidol. Then an ECG's repeated before any dose change (eg from 0.5mg od to bd). It's also a cause of akathisia and makes restlessness worse.

Antipsychotics aren't recommended by the MHRA for dementia related psychosis. In the USA the FDA have banned antipsychotics in dementia, even in dementia related psychosis. Evidence has shown that in Learning Difficulties, a randomised trial found that antipsychotics (including haloperidol) were no better/were worse than placebo at reducing behavioural disturbance. The DART-AD randomsied controlled trial published this Spring found that over time antipsychotics used in dementia care double your risk of death.

Generally, I can't see that sedatives have a place in routine care. Thus, by definition, their use isn't routine, so a specialist should be involved. They can then look at what the patient's presenting with, what the causes are, what the interventions can be, if there are specific target symptoms that medication can address, what's the safest Rx, then review and consider efficacy.

Usually, in my corner, antipsychotics like haloperidol aren't given for the patient's benefit, but are given so the ward staff have an easier time. When you next see folk on haloperidol, question - is the patient benefitting from this is a sufficiently substantial fashion that the risk/benefit is in favour of accepting the 2.2% risk of strokes and x2 risk of death over time? If I was asked to take meds giving such risk, I'd want to have pretty darn good outcomes/immediate benefit to me, in doing so!

Consultant Psychiatrists are well placed to consider use of antipsychotics in behavioural disturbance, evidencing and documenting rational prescribing practice is it's indicated.

Given this, I'd see use of antipsychotics as not noutine, thus needing specialist advice, thus necessitating Consultant Psychiatrist input.

The management of acute confusional state/delirium can sometimes necessitate use of medication. Although it acts on the same receptors as alcohol, so relaxes folk but can make them more disinhibited and more unsteady, benzodiazepines such as lorazepam are invariably better drugs to use than antipsychotics.

Still, they can be over used, as a quick substitute for skilled nursing care in de-escalating behavioural disturbance, since acute medical/surgical wards are so often poorly staffed, instead of as an adjunct.

The Shrink said...

As an aside, the National Dementia Strategy, to be implemented over the next 5 years, requires in Objective 8 :

Improved quality of care for people with dementia in general hospitals. Identifying leadership for dementia in general hospitals, defining the care pathway for dementia there, and the commissioning of specialist liaison older people’s mental health teams to work in general hospitals.

If folk are confused, a specific care pathway and a specialist liaison team should sort it out!

Dash said...

Hmmm difficult one. I know of people undergoing a GA who have benefited from some diazepam pre-med.

Personally I'd have liked to have some variation of this offered when I had eye surgery as I was fairly stressed, especially about the part where I was awake with someone suturing my eye!

I guess not really as chemical restraint (not in the way vets use the term anyway), but more of an anxiolytic.

kingmagic said...

Each case has its own individual merits and reasonings for prescribing meds.
If its to make the staffs shift easier then no. If its to prevent the patient from harming themselves (or others) then yes.

Before a med is actioned are all other avenues closed. ie talking to the patient and finding out what is wrong?

I was sent to a Downs Syndrome patient (female early 40s) by the local GP who wanted her admitted to the main psychy ward. She had trashed her room at the care home where she lived and been aggressive towards the carers.

When we arrived on scene there were five people pinning her to the floor...one on each limb and one supporting her head. When I asked how many staff were going to accompany us in the ambulance I was told 'None...we cant spare the staff!'

So...five people on scene are pinning her down and I'm expected to restrain her on my own in the back of an ambulance! I contacted the local GP and asked if he would reattend and administer a sedative to which he repilied he did not want the family sueing him for assault and that we should just call the police or fire brigade and 'chuck her in the back of the van and sit on her!'

Upon further questioning of the carers it seemed that the patient had kicked off because someone had rearranged her room which is a no-no for Downs patients.
I was able to talk to her and gradually calmed her down with offers of help to sort her room to which she responded to.
It seems like it was a knee jerk reaction from the GP to admit her without even considering the reason for her behaviour.

Anonymous said...

very late to this, but i had to comment.
i've been in the e.d. as a mental patient a number of times - and was 'chemically restrained'.
i do believe it was to make the nurses shift easier.
having said that, it still was to my benifit aswell because i didn't have to actually live through the horrible 'freaking-out-very-publicly-in-the-ed-what-the-hell's-going-to-happen-to-me' thing.
much better for everyone to sleep through it! (just my opinion)