Physical restraint for patients approaching their end of life may induce distress and impair dignity. Limited studies have been reported on the frequency and factors influencing restraint application during terminal phases of patients in hospital settings.
Objective:
We aimed to study the occurrence and factors that predict utilization of physical restraints in hospitalized terminally-ill adults.
Setting/Subjects:
We collected data from a single regional hospital in central Taiwan. All terminally ill patients admitted to the palliative care unit (PCU) from January 2019 to September 2023 were enrolled.
Measurements:
Physical restraint was defined as being physically restrained during hospitalization for >8 hours under medical order. We retrospectively identified potential risk factors for restraint use from a number of variables, including the type of primary diagnosis, medications used including benzodiazepine (BZD) and strong opioid, procedures involving nasogastric (NG) tube, Foley insertion, reason of discharge, and the specialty of attending physician. Multivariate logistic regression was used to analyze the risk factors predicting the use of physical restraint.
Results:
From 2019 to 2023, 688 patients with an average age of 82.1 years (standard deviation: 13.1) were included for the final analysis. Of them, 69% were male, and 9.5% received physical restraint during hospitalization. After adjusting for multiple confounding factors, the use of BZD (odds ratio [OR]: 2.34, 95% confidence interval [CI]: 1.32–4.15) and NG tube (OR: 2.53, 95% CI: 1.38–4.65) were identified as significant risk factors predicting the application of physical restraint. Subgroup analyses showed that female gender with cancer (OR: 5.43, 95% CI: 1.01–29.05) was another significant risk factor, apart from the use of BZD and NG tube.
Conclusions:
This is the first study on risk factors predicting the use of physical restraint in a palliative care setting. Palliative care professionals should carefully deliberate the use of BZD and NG tubes among terminally ill patients in PCU.
Get full access to this article
View all access options for this article.
References
1.
BleijlevensMH, WagnerLM, CapezutiE, et al.; International Physical Restraint Workgroup. Physical restraints: Consensus of a research definition using a modified delphi technique. J Am Geriatr Soc, 2016; 64(11):2307–2310.
2.
HineK. The use of physical restraint in critical care. Nurs Crit Care, 2007; 12(1):6–11.
3.
RobinsLM, LeeD-CA, BellJS, et al.Definition and measurement of physical and chemical restraint in long-term care: A systematic review. Int J Environ Res Public Health, 2021; 18(7):3639.
4.
HofmannH, HahnS. Characteristics of nursing home residents and physical restraint: A systematic literature review. J Clin Nurs, 2014; 23(21–22):3012–3024.
5.
ChouM-Y, HsuY-H, WangY-C, et al.The adverse effects of physical restraint use among older adult patients admitted to the internal medicine wards: A hospital-based retrospective cohort study. J Nutr Health Aging, 2020; 24(2):160–165.
6.
CusackP, CusackFP, McAndrewS, et al.An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings. Int J Ment Health Nurs, 2018; 27(3):1162–1176.
7.
KnowlesSF, HearneJ, SmithI. Physical restraint and the therapeutic relationship. J Forensic Psychiatry Psychol, 2015; 26(4):461–475; doi: 10.1080/14789949.2015.1034752
8.
HughesMT, SmithTJ. The growth of palliative care in the United States. Annu Rev Public Health, 2014; 35:459–475.
9.
AlexanderK, GoldbergJ, Korc-GrodzickiB. Palliative care and symptom management in older patients with cancer. Clin Geriatr Med, 2016; 32(1):45–62.
10.
GreerJA, ApplebaumAJ, JacobsenJC, et al.Understanding and addressing the role of coping in palliative care for patients with advanced cancer. J Clin Oncol, 2020; 38(9):915–925.
11.
UllrichA, AscherfeldL, MarxG, et al.Quality of life, psychological burden, needs, and satisfaction during specialized inpatient palliative care in family caregivers of advanced cancer patients. BMC Palliat Care, 2017; 16(1):1–10.
12.
ThomasJ. Optimizing opioid management in palliative care. Journal of Palliative Medicine, 2007; 10(Suppl 1):S1–S18.
13.
SuhrieEM, HanlonJT, JaffeEJ, et al.Impact of a geriatric nursing home palliative care service on unnecessary medication prescribing. Am J Geriatr Pharmacother, 2009; 7(1):20–25; doi: 10.1016/j.amjopharm.2009.02.001
14.
QuinnKL, StukelT, StallNM, et al.Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: Population based matched cohort study. Bmj, 2020; 370:m2257.
15.
ChuW-M, KuoW-Y, TungY-C. Effects of different palliative care models on decedents with kidney failure receiving maintenance dialysis: A nationwide population-based retrospective observational study in Taiwan. BMJ Open, 2023; 13(7):e069835.
16.
FrengleyJD, MionLC. Incidence of physical restraints on acute general medical wards. J Am Geriatr Soc, 1986; 34(8):565–568.
17.
GoodlinSJ, WinzelbergGS, TenoJM, et al.Death in the hospital. Arch Intern Med, 1998; 158(14):1570–1572.
18.
PivodicL, SmetsT, GambassiG, et al.; PACE. Physical restraining of nursing home residents in the last week of life: An epidemiological study in six European countries. Int J Nurs Stud, 2020; 104:103511; doi: 10.1016/j.ijnurstu.2019.103511
19.
KvaleE, Dionne-OdomJN, ReddenDT, et al.Predictors of physical restraint use in hospitalized veterans at end of life: An analysis of data from the BEACON trial. J Palliat Med, 2015; 18(6):520–526; doi: 10.1089/jpm.2014.0354
20.
MedicareC, ServicesM. Freedom from Unnecessary Physical Restraints: Two Decades of National Progress in Nursing Home Care. US Department of Health and Human Services: Washington, DC; 2008.
21.
HuangHC, HuangYT, LinKC, et al.Risk factors associated with physical restraints in residential aged care facilities: A community‐based epidemiological survey in Taiwan. J Adv Nurs, 2014; 70(1):130–143.
22.
HamersJP, GulpersMJ, StrikW. Use of physical restraints with cognitively impaired nursing home residents. J Adv Nurs, 2004; 45(3):246–251.
23.
AndresEB, ChaudhryI, BalasubramanianI, et al.; PISCES study group. Caregiver‐reported use of physical restraints among community‐dwelling older adults with severe dementia in Singapore. J Am Geriatr Soc, 2024; 72(6):1817–1823.
24.
LinL-S, HuangL-H, ChangY-C, et al.Trend analysis of palliative care consultation service for terminally ill non-cancer patients in Taiwan: A 9-year observational study. BMC Palliat Care, 2021; 20(1):181; doi: 10.1186/s12904-021-00879-z
25.
FinkelsteinEA, BhadeliaA, GohC, et al.Cross country comparison of expert assessments of the quality of death and dying 2021. J Pain Symptom Manage, 2022; 63(4):e419–e429.
26.
ChengS-Y, ChenC-Y, ChiuT-Y. Advances of hospice palliative care in Taiwan. Korean J Hosp Palliat Care, 2016; 19(4):292–295.
27.
DavisMP, VanenkevortEA, ElderA, et al.When does early palliative care influence aggressive care at the end of life? Support Care Cancer, 2022; 30(6):5371–5379; doi: 10.1007/s00520-022-06954-2
28.
CuiN, ZhangH, GanS, et al.Prevalence and influencing factors of physical restraints in intensive care units: A retrospective cohort study. Risk Manag Healthc Policy, 2023; 16:945–956; doi: 10.2147/rmhp.S408919
29.
SandsdalenT, HovR, HøyeS, et al.Patients’ preferences in palliative care: A systematic mixed studies review. Palliat Med, 2015; 29(5):399–419; doi: 10.1177/0269216314557882
30.
ChoiE, SongM. Physical restraint use in a Korean ICU. J Clin Nurs, 2003; 12(5):651–659.
31.
RaguanB, WolfovitzE, GilE. Use of physical restraints in a general hospital: A cross-sectional observational study. The Israel Medical Association Journal: IMAJ, 2015; 17(10):633–638.
32.
BenturN, SternbergS, ShuldinerJ, et al.Feeding tubes for older people with advanced dementia living in the community in Israel. Am J Alzheimers Dis Other Demen® 2015; 30(2):165–172.
33.
ShinozakiT, EbiharaM, IwaseS, et al.Quality of life and functional status of terminally ill head and neck cancer patients: A nation-wide, prospective observational study at tertiary cancer centers in Japan. Jpn J Clin Oncol, 2017; 47(1):47–53.
34.
OrrevallY, TishelmanC, PermertJ, et al.A national observational study of the prevalence and use of enteral tube feeding, parenteral nutrition and intravenous glucose in cancer patients enrolled in specialized palliative care. Nutrients, 2013; 5(1):267–282.
35.
ChauhanD, VarmaS, DaniM, et al.Nasogastric tube feeding in older patients: A review of current practice and challenges faced. Curr Gerontol Geriatr Res, 2021; 2021(1):6650675.
36.
HsuCY, LaiJ-N, KungW-M, et al.Nationwide prevalence and outcomes of long-term nasogastric tube placement in adults. Nutrients, 2022; 14(9):1748.
37.
YehL, LoLH, FetzerS, et al.Limited PEG tube use: The experience of long‐term care directions. J Clin Nurs, 2010; 19(19–20):2897–2906.
38.
HendersonM, MacGregorE, SykesN, et al.The use of benzodiazepines in palliative care. Palliat Med, 2006; 20(4):407–412.
39.
ZaalIJ, DevlinJW, HazelbagM, et al.Benzodiazepine-associated delirium in critically ill adults. Intensive Care Med, 2015; 41(12):2130–2137.
40.
AiragnesG, PelissoloA, LavalléeM, et al.Benzodiazepine misuse in the elderly: Risk factors, consequences, and management. Curr Psychiatry Rep, 2016; 18(10):89–89.
41.
HuiD. Benzodiazepines for agitation in patients with delirium: Selecting the right patient, right time, and right indication. Curr Opin Support Palliat Care, 2018; 12(4):489–494; doi: 10.1097/spc.0000000000000395
42.
LivingstonG, KellyL, Lewis-HolmesE, et al.Non-pharmacological interventions for agitation in dementia: Systematic review of randomised controlled trials. Br J Psychiatry, 2014; 205(6):436–442.
43.
GouldRL, CoulsonMC, PatelN, et al.Interventions for reducing benzodiazepine use in older people: Meta-analysis of randomised controlled trials. Br J Psychiatry, 2014; 204(2):98–107.
44.
GoftonTE, GraberJ, CarverA. Identifying the palliative care needs of patients living with cerebral tumors and metastases: A retrospective analysis. J Neurooncol, 2012; 108(3):527–534.
45.
LandrumLM, BlankS, ChenL-M, et al.Comprehensive care in gynecologic oncology: The importance of palliative care. Gynecol Oncol, 2015; 137(2):193–202.
46.
SandhuSK, MionLC, KhanRH, et al.Likelihood of ordering physical restraints: Influence of physician characteristics. J Am Geriatr Soc, 2010; 58(7):1272–1278.
