Fixation of a patient

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Fixation couch with straitjacket
Padded leather ankle cuffs for use in medical institutions
Belt system from medical institutions
Forced chair

The restraint of a patient describes the restraint of a patient by mechanical devices (belts, straps, etc.) for his own safety or the protection of other people. The use of medication to calm a sick person down is known as sedation .

The restraint of a person often takes place in a psychiatric emergency situation, which harbors a high risk of injury for the person concerned and is often perceived by those involved as a great burden. During restraint, the patient is restrained on his back in the bed using special belts so that there is no danger to himself or others.

history

In the past, restraint was also used for therapy and for punishing patients ( compulsory treatment , somatotherapy ). Among the devices include next straitjackets and belts also forced chairs and forced beds (including also net beds). The measures represent an interference with the patient's personal freedom.

In a study by the Institute for Forensic Medicine in Munich in 2012, 22 of the 26 deaths of patients who were fastened with a belt could be attributed to the belt fastening.

Legal requirements

This article or paragraph presents the situation in Germany . Help us to describe the situation in other countries.

Germany

Count for direct fixation

  • being held by nurses and doctors,
  • five-point fixation using fixation straps
  • attaching a bed rail or a peg table

In addition, there is spatial fixation, for example by being locked in the room, and chemical fixation through the administration of sedating medication.

In individual cases it may be that the person concerned agrees to a necessary restraint. The fixation is then easily possible. However, it must be removed immediately if the person concerned so wishes or if, in the opinion of the carers, it no longer appears necessary.

Restraint against the natural will of the person concerned regularly constitutes the criminal offense of deprivation of liberty and is only permitted if there is a justification (e.g. an acute health risk to the person to be restrained or to other people) and this can be averted by the restraint. In this case, judicial approval is required or must be submitted immediately afterwards ( placement procedure ; the requirements in the Federal Republic of Germany are regulated by Section 1906, Paragraph 4 of the German Civil Code and the federal states' mental health laws ). The fixation itself, including the reasons for it and its duration, and normally also the interruptions several times a day, must be documented in the medical history .

Legal representatives such as the legal guardian require approval from the guardianship court or family court if they agree to a restraint for the person concerned (Section 1906 (4) BGB for the guardian). This was confirmed by the Federal Court of Justice (judgment of June 26, 2012, Az. XII ZB 24/12). This also applies to the authorized representative in the context of a health care proxy . For the restraint of a child by the parents, the legislature has not provided for approval by the care or family court.

In 2018, two cases became known that were being dealt with before the Federal Constitutional Court . On July 24, 2018, the Federal Constitutional Court ruled that psychiatric patients may only be confined to bed for a long time after a court decision. If it is foreseeable that fixation will take longer than half an hour, the order of a doctor is not sufficient. If a restraint is made after 9 p.m., a judicial decision must be obtained the next morning. The restraint of a patient is an interference with his fundamental right to freedom of the person according to Art. 2 Para. 2 Clause 2 and Art. 104 of the Basic Law . The court ordered the states of Bavaria and Baden-Württemberg to create a constitutional legal basis by June 30, 2019.

Austria

Psychiatric departments

Restriction of the patient's freedom of movement in a psychiatric department requires placement . Restrictions on freedom of movement to just one room or even narrower areas - and thus also fixations - are also only permitted in terms of type, scope and duration insofar as they are

  • in individual cases to avert serious and considerable danger to the life or health of the patient himself or other persons (Section 3 subparagraph 1 Accommodation Act - UbG)
  • as well as are essential for medical treatment or care
  • and are not disproportionate to their purpose (Section 33 (1) UbG).

They must be specially ordered by the attending physician, documented in the medical history, stating the reason and immediately communicated to the patient's representative. At the request of the sick person or his representative, the district court responsible for accommodation matters must immediately decide on the admissibility of such a restriction (Section 33 (3) UbG).

Homes

With effect from July 1, 2005, the legal protection gap for old people's and nursing homes, homes for the disabled, etc. The like. Closed with the Residence Act (HeimAufG). According to this, the prerequisite for the admissibility of restrictions of freedom, i.e. also fixations as mechanical measures, is that

  • the resident is mentally ill or mentally disabled and in connection therewith seriously and seriously endangers his or her life or health or the life or health of others,
  • the measure to avert this danger is indispensable and suitable and appropriate in its duration and intensity in relation to the danger, and
  • this risk cannot be averted by other measures, in particular more gentle care or nursing measures (Section 4 HeimAufG).

The restriction of freedom may only be carried out in compliance with professional standards and with the greatest possible care; it must be lifted immediately if its requirements are no longer met (Section 5 (3) and (4) HeimAufG).

Here, too, there are detailed documentation, clarification and communication obligations (§§ 5 - 7 HeimAufG) and a judicial review must take place upon request (§§ 11 ff. HeimAufG).

Switzerland

On January 1, 2013, the revised Articles 360–456 ZGB came into force and replaced the previous guardianship law of the ZGB.

execution

The reason for the fixation is explained to the patient. It serves to protect himself or others and does not constitute a punishment . Sufficiently trained staff must be available, which usually excludes restraint in home care . If strong resistance is to be expected when carrying out the fixation, the actors must be strong enough to avoid a fight and precisely the damage that is to be averted by the fixation. The patient is strapped to the nursing or hospital bed or in a wheelchair or nursing chair so that there is safety against escape or accidents. There are specially developed belt systems for this. Once you know how the patient will behave in the restraint, you can subsequently increase the degree of freedom of the belts gradually or remove individual belts completely. The use of net beds is more widespread in Austria than in Germany. On September 1, 2014, their use in the psychiatric departments of Vienna's hospitals was abolished.

When fixing in bed, the procedure is staggered as necessary in order to be able to achieve the aim of fixing with the least possible restriction of movement.

The patient is fixed at one point with a single abdominal belt. The method guarantees a high degree of freedom of movement, but in itself is not escape-proof and can lead to fatal accidents with strangulation if the patient slips out of bed. Therefore, appropriate measures are taken to prevent this. The risk of accidents is also countered by constant, close monitoring.

With the diagonal fixation, the body is fixed at three points: stomach, right arm and left leg or left arm and right leg. The method still offers a certain freedom of movement. With a five-point fixation, the body is also fixed on the two extremities that have remained free. With shoulder, thigh and head fixation, freedom of movement can be further minimized if necessary.

Alternatives

Fixation is an ultima ratio when a situation cannot be controlled in any other way and alternative courses of action are no longer available. The protection provided by the coercive measure can be used to treat the underlying disease and to find a solution without the use of force. A sick person can also be calmed down through “ talk down ” or through anxiolytics . As a measure that massively restricts basic rights, fixation is at the center of criticism of the usual practice in care and nursing (violence in care, nursing scandal ). The Werdenfelser Weg is a newer procedural law approach to reduce custodial measures in care facilities.

Especially old people with dementia are fixed to falls to avoid. However, the fixation through the associated immobilization leads in the long term to a decrease in muscle mass and a further deterioration in the person's ability to move. It is therefore not a long-term solution. Restraint for people with dementia continues to be problematic because it increases patient insecurity. The dementia patient perceives the fixation, but cannot understand the context. Alternatively, other methods can be used that serve to prevent accidents and make the environment safer. With a suitable construction, beds can be lowered almost to the floor, which reduces the possible fall height. The floor can be padded, and technical reporting systems indicate when the dementia patient wants to get up. Providing activity, good lighting, and removing tripping hazards will help prevent falls. The use of hip protectors mitigates their consequences. The case law in an individual case exemplifies the diverse aspects that have to be weighed against each other in the prevention of accidents.

criticism

Restraint is classified as torture by several United Nations agencies . In addition to the UN Special Rapporteur on torture , Juan Méndez , also has UN Committee on the Rights of Persons with Disabilities evaluated according to this practice and other medical coercive measures and the Parties to the United Nations Convention against Torture and the UN CRPD asked to ban these.

In addition, various organizations of former psychiatric patients and human rights organizations in particular complain that restraint and the associated violence are cruel and inhuman violations of human rights. Those affected report that, in contrast to the psychiatric presentation, many people are not fixed as a last resort , but, for example, for punishment, for observation, to prevent socially undesirable behavior or to render the patient defenseless against further violent interventions, such as forced medication . In addition, it is said again and again that sadistic and arbitrarily motivated fixations are commonplace in psychiatry.

Even within psychiatry there are sometimes strong reservations about restraint. Studies that examine the effects of restraints on those affected show that they lead to extreme agony and psychological damage in an overwhelming majority of those affected. Direct physical dangers are also to be feared, even if the restraints are correctly applied and, in addition to circulatory disorders or shortness of breath, can even result in the death of the restraint. In the UK, psychiatry rejects fixations as inhuman and unethical, but (as of 2017) it is carried out ten thousand times a year.

See also

literature

  • Friedhelm Henke: Restraint in care - legal aspects and practical handling of restraint belts . Kohlhammer, Stuttgart 2006, ISBN 3-17-018771-6 .

Web links

Individual evidence

  1. ^ Deutscher Ärzteverlag GmbH, editorial office of the Deutsches Ärzteblatt: Deaths from belt fixations .
  2. ↑ Anna Stenger: The restraint of patients in the hospital - not only an issue in psychiatry and nursing . In: IWW Institute for Knowledge in Business (Ed.): Chefärztebrief , No. 6/2013, p. 7. Retrieved on June 17, 2018.
  3. ^ So also expressly the Federal Court of Justice , judgment of June 26, 2012, Az. XII ZB 24/12 [1]
  4. ^ BGH: Fixation of residents only with judge's approval . ( Memento from July 28, 2012 in the Internet Archive ) DPA report on Stern.de , July 26, 2012.
  5. ↑ LTO: BVerfG negotiates on restraint for the mentally ill .
  6. ↑ "A fixation is always the failure of a treatment". In: sueddeutsche.de. January 31, 2018, accessed June 30, 2018 .
  7. ↑ Federal Constitutional Court: Restraint of psychiatric patients in future only with judge's approval . Frankfurter Allgemeine Zeitung, July 24, 2018.
  8. ↑ ADVOKAT Management Consulting: Residence Act (HeimAufG) - JUSLINE Austria .
  9. ↑ Urs P. Gasche: Fixation has to be added to the protocol - St.Galler Tagblatt .
  10. ↑ turmoil in the U Committee against expert net beds . Die Presse, Vienna, April 18, 2008.
  11. ↑ end of net beds in Viennese hospitals wien.orf.at from September 1, 2014
  12. ↑ “Of the 22 victims in need of care who died due to restraint measures alone, 13 were female and nine were male. The mean age was 75.8 years (range: 39–94 years), with six of those affected having reached an age of more than 90 years. The majority of the casualties were demented (n = 15), two suffered from Huntington's disease with severe restlessness of movement and slight impairment of intellectual, but without loss of cognitive abilities. 109 (3): 27-32; doi : 10.3238 / arztebl.2012.0027
  13. ↑ Circular of the Düsseldorf home supervisory authority of July 1, 2010. (PDF; 122 kB) Archived from the original on May 16, 2011 ; Retrieved October 1, 2010 .
  14. ↑ BfArM - Recommendations of the BfArM - BfArM recommendation regarding abdominal belt fixation systems .
  15. ^ Hans-Ludwig Kröber: Handbook of forensic psychiatry 5: Forensic psychiatry in private law and public law. Springer Verlag Heidelberg, 2009, p. 172, ISBN 978-3-7985-1449-2
  16. ↑ Heidrun Holzbach-Linsenmaier: Tying is part of everyday life . In: The time . October 16, 1987
  17. ↑ Katrin Hummel: Psychiatry: She was already tied up . In: Frankfurter Allgemeine Zeitung . October 11, 2009
  18. ↑ Susanne Rytina: Compulsion in psychiatry: The last resort . In: Spiegel Online . January 15, 2012
  19. ↑ Susanne Andreae , Dominik von Hayek & Jutta Less: Elderly care professional: Disease theory. Thieme, Stuttgart / New York 2006, pp. 183ff., ISBN 978-3-13-127012-2
  20. ↑ Federal Court of Justice : Judgment of April 28, 2005 - III ZR 399/04 ( Memento of the original of June 14, 2010 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.rws-verlag.de
  21. ^ Juan E. Méndez: Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment. February 1, 2013, accessed June 3, 2016 .
  22. ^ Committee on the Rights of Persons with Disabilities: General Comment No. 1 - Article 12: Equal recognition before the law. United Nations, May 19, 2014, accessed June 3, 2016 .
  23. ↑ Federal Association of Psychiatry Experienced (ed.): Behind closed doors. Coercion and violence in German psychiatric hospitals . Self-published, Bochum 2014.
  24. ^ Nancy K. Ray, Karen J. Meyers & Mark E. Rappaport: Patient perspectives on restraint and seclusion experiences: a survey of New York State psychiatric facilities . In: Psychiatric Rehabilitation Journal . No. 20 (1) , 1996, pp. 11-18 .
  25. ^ Mary E. Johnson: Being restrained: a study of power and powerlessness . In: Issues in Mental Health Nursing . No. 19 (3) , 1998, pp. 191-206 .
  26. ↑ Ruth Gallop, Elizabeth McCay, Maya Guha & Pamela Khan: The experience of hospitalization and restraint of women who have a history of childhood sexual abuse . In: Health Care for Women International . No. 20 (4) , 1999, pp. 401-416 .
  27. ↑ Britta Olofsson & L. Jacobsson: The demand for respect - psychiatric patients forcibly admitted to report about coercive measures . In: Psychiatric Care . No. 9 (6) , 2003, pp. 302-310 .
  28. ↑ Raija Kontio, Grigori Joffe, Hanna Putkonen, Lauri Kuosmanen, Kimmo Hane, Matti Holi & Maritta Välimäki: Seclusion and restraint in psychiatry: patients' experiences and practical suggestions on how to improve practices and use alternatives . In: Perspectives in Psychiatric Care . No. 48 (1) , 2012, p. 16-24 .
  29. ↑ Andrea M. Berzlanovich, Jutta Schöpfer & Wolfgang Keil: Deaths from belt fixations . In: Deutsches Ärzteblatt . No. 109 (3) , 2012, p. 27-32 .
  30. ^ André Nienaber: "Same procedure as ...?" Compulsory measures restricting freedom in comparison . In: Psychiatric Care Today . No. 18 (4) , 2014, pp. 188-192 .
  31. ↑ George Greenwood: Rise in mental health patient restraints . 16th November 2017.