Physical restraint and near death of a psychiatric patient

Prone restraint death: Possible role of the Valsalva maneuver

There is an on-going debate about the safety of prone restraint and the exact role of the prone position in physical restraint death. Cardiac arrest in prone restraint death is essentially the end-result of a violent physical altercation wherein a combative individual suddenly loses consciousness while trying to counteract an opposing force. The direct correlations of increased static weight force with decreased inferior vena cava diameter, decreased cardiac output, and decreased stroke volume in prone restraint studies suggest that decreased venous return and decreased cardiac output could have a significant role to play in prone restraint death. Although the degree of changes observed in those studies might not be sufficient to cause cardiac arrest, they could predispose people who instinctively try to free themselves of the restraints to severe complications. The Valsalva maneuver, or forceful expiration against a closed airway, is frequently performed spontaneously in daily activities involving straining and resistance exercise, but has never been considered in restraint death. Pre-existing diminished venous return could increase the risk of major complications in individuals performing the Valsalva maneuver. A substantial decrease in venous return and cardiac output could increase the risk of cerebral hypoperfusion, loss of consciousness, hypoventilation, and sudden death. By increasing the risk of increased intra-abdominal pressure and its negative effect on venous return, high body mass index may be a significant risk factor in prone restraint death. The Valsalva maneuver may have different roles in prone restraint cardiac arrest and might be overlooked in prone restraint death.

Physical Harm and Death in the Context of Coercive Measures in Psychiatric Patients: A Systematic Review

Background: For centuries coercive measures in psychiatry have been means of averting acute danger. It has been known for almost as long that these measures can lead to harm or even death to those affected. Over the past two decades the topic has increasingly been the subject of scientific discussion and research. While the legal and ethical preconditions for coercive measures in psychiatry as well as epidemiological studies on their incidence and patients' subjective experiences have increasingly come into focus, research on possible adverse events has lagged behind. To our knowledge there is no systematic review on the harmful or even fatal physical adverse effects of coercive interventions in psychiatry. Methods: We searched the databases PubMed and CINAHL for primary literature with a search string based on the PICO framework including key words describing different psychiatric diagnoses, coercive measures, and harms. Results: In total, 67 eligible studies (mainly case reports and case series) of very heterogeneous quality were included. Two RCTs were found reporting position-dependent cardiac deterioration, but were, however, carried out with healthy people and were characterized by a small number of cases. Death was the most frequently reported harm: cardiac arrest by chest compression in 14 studies, cardiac arrest by strangulation in 9, and pulmonary embolism in 8 studies. Further harms were, among others, venous thromboembolism and injuries. Injuries during physical restraint were reported in 0.8-4% of cases. For other kinds of coercive interventions, there are no sufficient data. Venous thromboembolism occurred in a considerable percentage of cases during mechanical restraint, also under prophylaxis. The most commonly reported coercive measure was restraint, distinguishing in mechanical restraint (43 studies), physical restraint (22 studies), bedrails (eight studies), vest restraint (7 studies), and chair restraint (6 studies). Forced medication was explicitly mentioned only in two, but seems to have occurred in nine studies. Six studies included seclusion. Conclusion: Coercive measures can lead to physical harm or even death. However, there is a significant lack of data on the incidence of such adverse events related to coercive interventions. Though reported anecdotally, physical adverse events during seclusion appear to be highly underresearched.

Violence, research, and non-identity in the psychiatric clinic

Violence in psychiatric clinics has been a consistent problem since the birth of modern psychiatry. In this paper, I examine current efforts to understand and reduce both violence and coercive responses to violence in psychiatry, arguing that these efforts are destined to fall short. By and large, scholarship on psychiatric violence reduction has focused on identifying discrete factors that are statistically associated with violence, such as patient demographics and clinical qualities, in an effort to quantify risk and predict violent acts before they happen. Using the work of Horkheimer and Adorno, I characterize the theoretical orientation of such efforts as identity thinking. I then argue that these approaches lead to epistemic imperceptiveness and a subtle form of conceptual restraint on patients. I suggest a reorientation in psychiatric research, away from identity thinking and toward a more productive and just approach to the problem of violence in psychiatric clinics.

The Use of Physical Restraint in Norwegian Adult Psychiatric Hospitals

Background. The use of coercion within the psychiatric services is problematic and raises a range of ethical, legal, and clinical questions. “Physical restraint” is an emergency procedure used in psychiatric hospitals to control patients that pose an imminent physical danger. We wished to review the literature published in scientific peer-reviewed journals describing studies on the use of physical restraint in Norway, in order to identify the current state of knowledge and directions for future research. Design. The databases PubMed, PsycINFO, CINAHL, Web of Science, and Embase were searched for studies relating to physical restraint (including holding) in Norwegian psychiatric hospitals, supplemented with hand searches. Results. 28 studies were included. Most of the studies were on rates of restraint, but there were also some studies on perceptions of patients and staff, case studies, and ethnographic studies. There was only one intervention study. There are differences in use between wards and institutions, which in part may be explained by differences in patient populations. Staff appear to be less negative to the use of restraint than patients. Conclusions. The studies that were identified were primarily concerned with rates of use and with patients' and staff's perspectives. More interventional studies are needed to move the field forward.

Exposures to conducted electrical weapons (including TASER® devices): how many and for how long are acceptable?

TASER(®) conducted electrical weapons (CEWs) are an important law-enforcement tool. The purposes of this study are a) to review recent literature regarding potential pathophysiological responses to applications of CEWs, and other related issues and b) to evaluate whether enough data exist to determine the acceptability of longer-duration (or repeated) exposures. This is a narrative review, using a multidisciplinary approach of analyzing reports from physiological, legal-medical, and police-strategy literature sources. In general, short-duration exposures to CEWs result in limited effects. Longer-duration or repeated exposures may be utilized with caution, although there are currently not enough data to determine the acceptability of all types of exposures. Data examined in the literature have inherent limitations. Appropriateness of specific types of CEW usage may be determined by individual police agencies, applying risk/benefit analyses unique to each organization. While more research is recommended, initial concepts of potential future long-duration or repeated CEW applications are presented.

Frequency of physical restraint and its associations with demographic and clinical characteristics in a Chinese psychiatric institution

PURPOSE

Physical restraint (PR) is a highly controversal topic in psychiatry. Little is known about PR among psychiatric inpatients in China. This study examined the frequency of PR and its relationships with demographic and clinical characteristics among a large psychiatric institution in the Hunan Province, China.

DESIGN AND METHODS

The study included a consecutively assessed sample of 160 psychiatric inpatients. Sociodemographic and clinical data including use of PR were collected from the medical records using a form designed for this study and confirmed via interview.

FINDINGS

The frequency of PR was 51.3% in the whole sample; 63.2% among female and 39.2% among male patients. In multiple logistic regression analysis PR was independently associated with male gender (p = 0.001, odds ratio [OR] = 0.2, 95% confidence interval [CI] 0.1-0.6), less outpatient treatment prior to admission (p = 0.03, OR = 0.3, 95% CI 0.1-0.9), more frequent use of mood stabilizers (p = 0.002, OR = 5.6, 95% CI 1.9-16.7), more aggressive behavior prior to admission (p = 0.002, OR = 1.1, 95% CI 1.04-1.2), and younger age (p = 0.04, OR = 0.97, 95% CI 0.93-0.99).

PRACTICE IMPLICATIONS

PR is very common in clinical practice in China. Its demographic and clinical correlates are similar to findings in Western settings.

Investigation of Deaths of Chronically Disabled Persons and Institutionalized Persons

The investigation of deaths involving chronically disabled and/or institutionalized persons represents an important challenge to the medicolegal death investigation community. For the purposes of this review, the chronically disabled and/or institutionalized are considered to include three non-mutually exclusive subcategories: the disabled elderly, the severely disabled, and psychiatric patients. Because deaths within certain of these populations tend to be common and expected, a very important goal when such deaths occur is the appropriate referral of cases to the medical examiner/coroner. Although each subcategory has distinct issues of importance regarding death investigation, there is also a reasonable amount of overlap between the three groups. This review provides an overview of the three subcategories, the reasons such persons may be at risk for premature, unexpected, or unnatural death, the many important issues of concern when investigating deaths within these vulnerable populations, and important preventative strategies within each group.

The clinical case report: a review of its merits and limitations

Background

The clinical case report has a long-standing tradition in the medical literature. While its scientific significance has become smaller as more advanced research methods have gained ground, case reports are still presented in many medical journals. Some scholars point to its limited value for medical progress, while others assert that the genre is undervalued. We aimed to present the various points of view regarding the merits and limitations of the case report genre. We searched Google Scholar, PubMed and select textbooks on epidemiology and medical research for articles and book-chapters discussing the merits and limitations of clinical case reports and case series.

Results

The major merits of case reporting were these: Detecting novelties, generating hypotheses, pharmacovigilance, high applicability when other research designs are not possible to carry out, allowing emphasis on the narrative aspect (in-depth understanding), and educational value. The major limitations were: Lack of ability to generalize, no possibility to establish cause-effect relationship, danger of over-interpretation, publication bias, retrospective design, and distraction of reader when focusing on the unusual.

Conclusions

Despite having lost its central role in medical literature in the 20th century, the genre still appears popular. It is a valuable part of the various research methods, especially since it complements other approaches. Furthermore, it also contributes in areas of medicine that are not specifically research-related, e.g. as an educational tool. Revision of the case report genre has been attempted in order to integrate the biomedical model with the narrative approach, but without significant success. The future prospects of the case report could possibly be in new applications of the genre, i.e. exclusive case report databases available online, and open access for clinicians and researchers.

The recent history of the clinical case report: a narrative review

Clinical case reporting in the form of case reports and case series reports has always been an integral part of medical literature. From the late 1970s the genre appeared to fall from grace and was marginalized in many medical journals. There was controversy as to its value as a research method. From the late 1990s and onwards, there has been an increased demand for and publication of case reports and case series. The various causes for its decline and subsequent return are discussed with an emphasis on the recent historical context.