Nursing Homes Turn Away From Tethering the Elderly : Elder care: Restraints have been considered standard practice to protect patients who might fall or wander away. But nursing homes are finding alternatives--and finding that freeing patients has many benefits.

William Harmon used to spend every day tied to a chair in a nursing home, sometimes in a stupor, sometimes pleading to be freed.

“They’d just sit there all day long, every body tied in restraints,” said Mabel Harmon, who moved her 70-year-old husband out of the home in August. “I don’t think he would be living now if he hadn’t gotten out of there.”

Harmon’s situation was not unique. Two out of five residents of American nursing homes routinely are tied to their beds or chairs, ostensibly to protect them from injury. Concern is mounting that such restraints may do more harm than good.

Harmon now is at Stapeley in the German town section of Philadelphia. It is one of a small but growing number of homes that use no restraints.

Since he’s been over at Stapeley he’s a completely different person,” Mabel Harmon said. “He does what he wants to do. He answers your questions. He walks up and down the hall. He goes into the lounge.”

Nursing home administrators say that devices such as lap belts, wheelchairs with locking trays and vests that tie to beds or chairs are used mainly to keep residents from falling or wandering away and to control aggressive behavior.

Critics say that restraints often are used for the staff’s convenience and seldom eliminate the risk of injury. They say that tying people can cause or aggravate problems such as emotional withdrawal and depression, and that injuries are incurred in trying to get free. Strangulation, constipation, incontinence, pressure sores, loss of bone mass, weakened muscles and decreased ability to walk are the ultimate consequences for many of those who are tethered, they say.

“We have to ask ourselves: What price safety?” said Jill Blakeslee, director of health services for the Kendal Corp., a nonprofit, Quaker-run Pennsylvania corporation that has pioneered the concept of restraint-free nursing homes in the United States. “Safe and quality care can be given to our frail old people without tying them to their beds and their chairs.”

Think About Yourself

Kendal and the Senate Committee on Aging last month sponsored a symposium, “Untie the Elderly: Quality Care Without Restraints,” at which Blakeslee spoke. “Think about yourself as you grow old,” she told participants. “Is that what you would want?”

Michael Plevyak’s family chose to place his 74-year-old mother, Genevieve, who has Alzheimer’s disease, at Friends Hall in West Chester, Pa., because she would not be tied there. “The only thing she desires to do is move about and walk. That’s why we’re so thrilled that she is in a facility that allows her to engage in the one activity she gets any joy out of,” he said.

In 199, 41% of all nursing home residents were restrained; in 1977, the proportion was 25%, federal surveys show. Restraints were involved in 37 deaths in U.S. and Canadian nursing homes between 1980 and 1987. The deaths primarily were caused by strangulation or suffocation--but in two cases the victims burned to death after setting fire to their restraints in an attempt to escape.

In U.S. and Canadian nursing homes studied over the last decade, restraint rates ranged from 25% to 85%, Neville Strumpf and Lois Evans of the University of Pennsylvania School of Nursing reported in the January, 1989, issue of the Journal of the American Geriatrics Society.

Lawsuits Feared

Family members at first may be horrified to learn that their relative is restrained, but medical professionals “can talk people into a big variety of things that afterwards they must wonder about,” said Lynne Mitchell-Pederson, a nurse at St. Boniface General Hospital in Winnipeg, Canada. St. Boniface has all but eliminated the practice of tying patients since a restrained woman strangled in 1981.

On the other hand, there are attorneys and family members “wanting and willing to sue if a home doesn’t use protective devices to protect the resident,” said Fred Watson, administrator of the Christian City Convalescent Center in Atlanta. “We’ve got to get over that hurdle.”

Christian City was restraint-free when it opened 12 years ago, but began using the devices under pressure from insurance carriers, doctors and families, Watson said. It now restrains 20% to 30% of its charges, but is reducing that proportion.

The widespread use of restraints is widely attributed at least in part, to the fear of being sued, but some attorneys say that reliance on restraints as a liability protection is largely unfounded.

In fact, one study found that tying people resulted in more lawsuits than not using them, said Philadelphia attorney Alan Reeve Hunt, chairman of Kendal’s board. For example, an Alabama jury in June held a nursing home liable for $2.5 million in the strangulation of an 86-year-old woman in a restraint vest that was on backwards. The case is under appeal.

Restraints “became a standard of care without ever being tested,” said Sarah Burger, a consultant for the National Citizens’ Coalition for Nursing Home Reform. “Everybody just assumed they did good.”

Growing concern about negative effects and recognition that restraints don’t eliminate liability are leading to a reduction in their use. So far, 13 nursing homes in the United States are known to be restraint-free, according to Kendal. Tough new federal rules will take effect in October, and Florida has untied 3,000 people since August.

“There’s a contest going on to see who’s going to be the first restraint-free facility,” Florida licensing director Connie Cheren said.

“This is not a movement in its infancy,” said Nancy Dubler, an attorney with the Department of Social Medicine at Montefiore Hospital and Medical Center in New York. “This is a discussion on the verge of bringing change.”

The Health Care Financing Administration reported last December that 8.5% of more than 15,000 nursing homes it surveyed were violating rules that allow a patient to be restrained “only when authorized by a physician in writing, for a specified period of time or in emergencies.”

The new rules ban “physical restraints imposed or psychoactive drugs administered for purposes of discipline or convenience and not required to treat ... medical symptoms.” Nursing homes for the first time will have to “show that they have tried every other conceivable means to solve the problem,” Burger said.

Removing restraints requires creative, individualized alternatives, said Beryl Goldman, Kendal associate director for health services. For example, doors that sound a buzzer when opened might be installed on a wanderer’s room. Brightly colored tape placed in front of exits can help keep confused residents from leaving. Rocking chairs can help those who need to be in motion.

One home was able to avoid restraining an 85-year-old woman who constantly paced with a doll but needed to rest so her ulcers would heal, said Joanne Rader, director of mental health at Benedictine Nursing Facility in Mount Angel, Ore.

Staff members filled the doll with seven pounds of birdseed. “Now, when she’s walking with the doll, she has a very heavy baby. So they say, ‘Oh, that baby’s so heavy. Why don’t you sit down and put your feet up?’ That’s a heck of a lot more fun than tying a person down,” Rader said.

St. Boniface’s Mitchell-Pederson cited the case of one Alzheimer’s patient who disrupted meals and stole food. “When we asked, ‘Could he be hungry?’ and doubled his calorie intake he stopped stealing food . . . In this case, it was his diet that needed attention; restraints compounded the problem.”

An 85-year-old woman restrained in a chair for fear that she would wander off and fall down the stairs was given shoes with rubber soles instead of slippers and “was thus allowed to wander at will throughout the building,” she said.

“There’s tremendous excitement out there . . . toward developing and implementing a non-restraint philosophy. It’s no fun to be the one who has to tie someone down when they don’t want to be tied down,” Rader said.

May Be No Alternative

Some nursing home officials, however, caution that there are cases where there are no clear alternatives to restraints.

“While we can agree that overuse or wholesale use of restraints is not desirable, it is equally wrong to say no restraints should ever be used,” said David Mettler of Hillhaven Corp., which runs 345 nursing homes in 38 states.

“This is not a black-and-white issue,” Mettler said. “Sometimes it may even be necessary to restrict the rights of an individual resident in order to provide for the health and safety of others.”

For dramatic reduction in restraints, residents and families must accept that “if people have a certain amount of freedom, then they also run the risk of getting hurt,” said attorney Joanne Ivancic of HFIC Management Co., which handles insurance claims for Hillhaven.

Benedictine has eliminated most restraints, but “there’s maybe 5% to 10% of the people that I can’t figure out how get restraint-free,” Rader said, citing as one example those who pull out tubes unless restrained.

Skepticism Replaced by Praise

Nursing home staffer who initially are skeptical about being able to manage residents without restraints usually find they prefer it, said Kendal’s Goldman. She quoted from a recent letter from a nurse at Friends Hall, which in 1987 adopted a no-restraint policy: “I wouldn’t work any other place now. I wouldn’t have said that or believed it two years ago.”

Nine nursing homes in a Kendal demonstration program have reduced restraint use without increasing falls, staff or costs, Goldman said.

That is possible because residents who can move around generally stay healthier and require less care. Blakeslee said. Also, it takes a lot of time to properly apply restraints and remove them for exercise and use of bathrooms.

Stapeley in 1988 set a goal of untying five residents a month and a year later removed the last restraint, said Henrietta Roberts, executive director. “I can’t tell you how the families have been pleased by this. The sense of humanitarianism, the sense that you are dealing with a person . . . has made a great deal of difference. The patients are easier to care for.”

Supporters of the change at Stapeley include Bernie Lieberman, whose 89-year-old mother, Frances, had been routinely restrained after she fell and broke a hip. Now, staffers help her walk and she wears no restraints while seated.

“She seems much more cheerful and positive as a result of having more freedom,” Lieberman said. “Even though her mind was not working well, she was just the kind of person who wanted to get up and walk.”