The Use of Physical Restraints and the Absence of Kindness

We should be grateful to the Journal for publishing the review by Dr. Levine1 of the legacy of Philippe Pinel. His astonishing act of unchaining the patients committed to the mental asylums of Bicêtre and Saltpêtrière during the Reign of Terror of the French Revolution provides a lesson from history that is relevant in 1996. The French Revolution arose from the dissatisfaction of the First and Second Estates, the aristocratic clergy and aristocratic laity, respectively. This dissatisfaction was the result of the increasing taxation levied on the nobles by Louis XVI to help fund wars, including the revolutionary army sent to the English colonies in North America, as well as the needs of France itself. To achieve their aristocratic revolution against the king, the nobles persuaded the king to reestablish, for the first time since 1614, the Estates General, subsequently the National Assembly, which had wide representation from the Third Estate, the commoners. In order to control the nobles, Louis XVI established electoral power on an equal footing for all members of the National Assembly. This effectively placed the Assembly under the control of the commoners, who outnumbered the aristocrats. This loss of Political power and authority by both kings and nobles led to the onset of the revolution in 1789 and to the execution of Louis XVI in 1793. All of this took place against a background of evolving revolutionary ideas that focused on the needs of the oppressed and culminated in the motto, “Liberty, Equality and Fraternity.” Some of these revolutionary ideas came directly from the founding principles of the Republic of the United States of America. The leaders of the successful group in the Assembly, Robespierre and Danton, though leading competing political factions, nonetheless created the Revolutionary Tribunal in September 1793. This tribunal created the Reign of Terror in which anyone could be decapitated for insignificant reasons and with no legal defense. In March 1794, within 6 months of the establishment of the Tribunal, Danton was himself guillotined on the charge that his apparent Wealth was seemingly ill-gotten. On 17 July 1794, 16 nuns were guillotined. The nuns' journey through Paris to the guillotine shamed the mob into silence, for the nuns continued to sing in ecstatic praise throughout their journey and as they walked to the guillotine. Eight days later Robespierre himself was beheaded, and the Reign of Terror collapsed. See also pp 1086 and 1130 Was it the lawless chaos of the Reign of Terror alone that allowed Pinel to unchain the insane, or was it the basic decency of the underlying philosophy of the revolution that allowed this courageous act? Dr. Levine argues from Pinel's writing and his apparent distaste of politics that Pinel's action was not mere opportunism. Rather, it was human kindness that provided his motivation.1 Nearly 200 years later, the use of physical restraints in nursing homes was addressed in the Omnibus Budget Reconciliation Act of 1987 (OBRA 87), which incorporated major legal reforms of clinical practice including medical care within nursing homes.2 OBRA uses the enforcement power of reimbursement, directly by the Federal Government through Medicare dollars and indirectly through the States' Medicaid dollars. Failure to comply with OBRA requirements can lead to loss of all reimbursement of federal monies. The codes and regulations of OBRA proscribe the use of physical restraints. This has resulted in a major reduction in their use in nursing homes, with many nursing homes becoming entirely restraint free.3 The revolutionary nature of this change is evident by the efforts of the State of California to achieve a legal exemption from this and other requirements on the grounds that they were not achievable.4,5 This unusual request by the State of California illustrates the statement of the health care economist Robert G. Evans that, “If we misread the possible, we misperceive the threat. The result can be, often is, wholly inappropriate responses.”6 Moreover, in this thoughtful article questioning the economic “good” of health care and the relevance of market forces, Evans points out that it takes many years of training to ignore the obvious. The restraint of the medically ill was an obvious unkind act, but clinicians, by their training, were taught to ignore the unkindness of this action. It also seems obvious that much of the current practice of medicine does not take simple kindness into consideration as a component in clinical decision-making. The controlled trial to improve the care of seriously ill hospitalized patients (SUPPORT) found that the intervention designed to improve that care appeared to have no effect.7 This intervention included providing physicians with probable prognoses as well as the conclusions from extensive discussions between patients and families or surrogates and specially trained nurses about the outcomes of care. A possible interpretation is that the clinical caregivers were not able to give due consideration to kindness as a guide to their clinical decisions. Further support for this interpretation may be inferred from the findings of Asch.8 He found through questionnaires mailed to critical care nurses that 141 (17%) of the responding nurses had had requests for euthanasia or assistance with suicide from patients or family members. These nurses were rarely able to provide compassionate care in keeping with their instincts, thereby creating tensions and frustrations in their clinical roles. If this is so, then the reasons for the absence of kindness should be explored. To do this, there are three possible explanatory influences that should be examined; the education and training of the physicians and other clinicians, the influence of the law on clinical practice, and the influence of financial considerations on clinical practice. Until very recently, almost all of the clinical education of physicians has taken place in an acute care hospital. Furthermore, much of the bedside care and management has been taught to medical students and first year residents in training by a second year resident. There are some exceptions to this usual training pattern where third year residents guide the clinical care and attending physicians are actively involved in clinical decision-making.9 In general, however, senior and seasoned attending physicians have had little direct influence on the provision of clinical care in academic teaching hospitals. The impact of clinical wisdom arising from more extensive professional and personal experiences on good decision making is widely underrated. Young physicians in training are grappling with the application of the science of medicine to clinical situations in their residency programs, which are designed to support this end. Equally, physicians in training should be taught to apply the art of medicine. This can be brought into focus by answering the question, “We know what to do (the science of medicine), but for this patient should we, and if so, when? (the art of medicine)” Consideration of kindness guides the answer to this difficult question. Dr. Levine points out that Pinel in his treatise on insanity posed this same question in discussing the use of medications.1 OBRA 87 raises the maintenance of resident dignity as a requirement of care. Ethicists consider beneficence in their deliberations but kindness encompasses more than dignity and beneficence. True, kindness must be tempered with common sense. It requires little imagination to think of clinical situations when apparent kindness carried to an extreme could result in harm, such as not carrying out an invasive but potentially beneficial procedure because of discomfort. In recent years the law has dominated clinical practice.10,11 Indeed, OBRA 87 itself proscribes clinical practice not just in the use of physical restraints, including bedrails, but also in the use of psychoactive medications. The law, however, has no philosophical construct for kindness and is, therefore, unable to provide for the logical incorporation of kindness into its formulations and promulgations. Nearly 400 years ago, Shakespeare found sufficient dramatic material in the tension between the law and the need to be kind to create the dramatic climax in the Merchant of Venice.12 In the court room scene, the arguments for and against tempering the law with mercy (kindness) are weighed. Two hundred years earlier, Chaucer also wrote of the absence of kindness in legal considerations. In the Friar's Tale in his Canterbury Tales, fines are extracted from the poor for assumed moral law infractions, with no regard for the harsh consequences for the fined. The Summoner extracting the fines does, however, come to an unfortunate end.13 It behooves physicians to challenge our legal colleagues and to insist that kindness be one of the values that guide the practice of medicine. The remarkable change in the organization of medicine in the last 5 years has been driven by efforts to control national health care costs by attempting to fix the level of funds available to provide that care. The Law of Medical Money, as set forth by Wildavsky, predicts that “Costs will increase to the level of available funds,” and the corollary, “That level must be limited to keep costs down,” accounts for the current emphasis on the control of funds for the provision of care.14 Much current medical energy is spent meeting the dictates of the various systems providing funds for health care. The rapid emergence of managed care as the favored mode for limiting funds and, therefore, restricting costs forces physicians and other clinicians to make clinical decisions in line with previously established budgetary requirements in order to avoid financial risk to themselves.15–19 This rapid swing from a focus on legal risks to a focus on financial risks as the overarching decision-making framework has come unexpectedly to health care. Money in itself has no inherent virtue, and for clinical care to be governed by money alone is very likely to lead to the provision of care lacking in virtue and, hence, lacking in the virtue of kindness. Kindness is a virtue that should guide the practice of medicine, especially when an outcome of a practice is not clear and the evidence of effectiveness is unknown. The decision by Pinel and his colleague, Pussin, to unchain the shackled at Bicêtre and Saltpêtrière clearly was an act of kindness and undertaken when there was no evidence that the practice of chaining was effective. The paper from Liverpool, England, in which O'Keeffe and colleagues20 were unable to find physical restraints other than bedrails in use in the Royal Liverpool Hospital one night, raises the question of why such practice differences exist between Britain and North America. I too have found such differences to exist. In 1988, I observed 353 adult medical patients in general medical wards in London, and subsequently 280 in New Zealand, in acute care teaching and nonteaching hospitals and found no physical restraints to be in use during those single observations. Moreover, the physicians and nursing staff did not know of such devices other than bedrails. Questions posed to nurses about the use of physical restraints evoked reactions of astonishment and indignation that such a practice could exist. In comparison, in the same 9 months of these observations I found that in Cleveland, Ohio, 4.6% of 575 acute medical ward patients were physically restrained. Restrained patients themselves have expressed their anger, dismay, and despair, and have withdrawn even to the point of death.21–23 It would be reasonable to interpret the Liverpool paper20 as a reflection of kindness, which still has a place in the practice of hospital medicine in Britain. Kindness in this setting may very well be an intrinsic component of care arising from the British system of hospital Firms, where clinical care by physicians in training is guided by senior physicians, allowing the art of medicine to be given a rightful place alongside the science of medicine. That approach to the organization of clinical care has been modified successfully to be adapted to this country, but it has not been studied from the point of view of preserving kindness.24,25 As geriatricians, we should be guardians of kindness in the care of frail older persons. Indeed, there is often little that can be done but to be kind. The act of being kind itself, however, can be discomforting for the physician in that it may reveal emotions around care that physicians have been taught to hide. Acts of kindness may, therefore, be avoided.26 To teach kindness poses a problem that would seem best solved by acknowledging that learning how to provide compassionate clinical care for frail older people is best accomplished through an apprenticeship, for it cannot be learned from a theoretical basis alone. The clinical components of the geriatric fellowships are well suited to achieve this end. Geriatricians, along with our colleagues in all other clinical disciplines providing care for frail older people, should have kindness as a central tenet in clinical decision making. As teachers and leaders, we must make this consideration explicit and not leave it to be inferred. Unless it is explicitly stated, the virtue of kindness cannot come to the fore, nor will it be brought back to the medical profession as a whole unless we reform the way we train physicians. As geriatricians, we should feel compelled to take up this challenge ever more forcefully because of the competing influences of legal regulations and financial considerations. Pinel was an extraordinary man. He performed courageous acts under conditions of extreme social chaos. Surely we geriatricians, who operate under much more favorable conditions, should be able to extend and elaborate on his example of kindness.