What are the ethical considerations for using child restraints in pediatric care?

Ethical Issues with Child Restraints in Pediatric Care

The use of restraints in pediatric care presents significant ethical concerns related to patient safety, dignity, and autonomy, and should only be implemented as a last resort when less restrictive measures have failed and there is immediate risk of harm to the child or others. 1

Primary Ethical Considerations

Safety vs. Autonomy Balance

• Physical and mechanical restraints carry significant mortality risk: 45 deaths were attributed to restraint use in child and adolescent psychiatric facilities between 1993 and 2003 1
• Potential medical complications include:
  • Airway obstruction and asphyxia
  • Skin breakdown and neurovascular damage
  • Rhabdomyolysis leading to kidney failure
  • Accidental strangulation (particularly with vest restraints)
  • Brachial plexus injuries
  • Electrolyte abnormalities and hyperthermia
  • Deep vein thrombosis and pulmonary injuries 1

Psychological Impact

• Restraints may provoke fear in children, especially those with history of trauma or abuse 1
• May contribute to an aggression-coercion cycle that worsens behavioral issues 1
• Can traumatize not only the restrained child but also other children who witness the restraint 1

Dignity and Rights Considerations

• Restraint use conflicts with principles of patient dignity, privacy, and autonomy 2
• The National Association of State Mental Health Program Directors emphasizes that "Seclusion and restraint should be considered a security measure, not a form of medical treatment that should only be used as 'last resort measure'" 1

Ethical Decision-Making Framework

Step 1: Determine if restraint is truly necessary

• Only use restraints when:
  • Patient presents acute danger to self or others
  • Significant disruption to treatment plan has occurred
  • Less restrictive measures have failed or are not possible 1

Step 2: Select least restrictive appropriate option

• Hierarchy of interventions (from least to most restrictive):
  • De-escalation techniques
  • Environmental modifications
  • Brief physical holding (under 15 minutes)
  • Chemical restraint (when appropriate)
  • Mechanical restraint (as last resort) 1

Step 3: Implement with proper safeguards

• Required safety measures:
  • Minimum of two trained staff per child during physical restraint 1
  • Continuous monitoring of vital signs 3
  • Proper positioning to prevent airway obstruction 1
  • Regular reassessment by qualified clinical staff 1

Special Ethical Considerations

Prone vs. Supine Positioning

• Prone positioning has been associated with deaths due to respiratory compromise 1
• If prone positioning must be used:
  • Ensure airway is unobstructed
  • Minimize pressure on neck and back
  • Discontinue as soon as possible 1
• Supine positioning with head elevation is generally preferred to reduce aspiration risk 1

Duration of Restraint

• Physical restraints exceeding 15 minutes require reassessment by nursing staff and attending psychiatrist 1, 3
• All physical holding episodes of 1 hour or longer must be reviewed by medical director and facility committee 1

Contraindicated Practices

• Never use:
  • Restraints that cause airway obstruction (e.g., choke-holds)
  • Covering patient's face during therapeutic holding
  • "Prone wrap-up" (immobilizing face-down)
  • Restraint by untrained staff 1

Balancing Ethical Principles

Beneficence vs. Non-maleficence

• While restraints may be necessary to prevent immediate harm (beneficence), they carry significant risk of physical and psychological harm (non-maleficence) 1
• The lack of empirical data supporting necessity and efficacy of restraints raises questions about whether their use can be justified 1

Autonomy vs. Protection

• Children have developing autonomy that should be respected whenever possible
• Restraint use should be balanced against the duty to protect vulnerable patients from harm 2

Best Practices to Minimize Ethical Concerns

• Implement trauma-informed and strength-based care approaches 4
• Involve youth and family in treatment planning to build trust and improve communication 4
• Provide comprehensive staff training in restraint reduction and prevention 4
• Conduct thorough debriefing after restraint incidents 4
• Review all restraint protocols at least yearly by medical staff and appropriate committees 1

The evidence demonstrates that restraint reduction initiatives can be highly successful - one pediatric psychiatric hospital achieved a 100% reduction in mechanical restraints and 88% reduction in physical restraints over a 10-year period through implementation of trauma-informed care principles 4.