Public Hospitals
Amendment Act (Patient Restraints), 2000, Bill 135,
Ms Lankin /
Loi de 2000 modifiant la Loi sur les hôpitaux publics
(mesures de contention),
projet de loi 135, MmeLankin
Ms Frances Lankin
Ontario PsychoGeriatric
Association
Dr Janice Lessard
Mrs Margaret Ringland
Advocacy Centre for the
Elderly
Ms Jane Meadus
Mr George Monticone
Ontario Coalition of
Senior Citizens' Organizations
Mr Don Wackley
Ontario Hospital
Association
Ms Hilary Short
Mr Michel Bilodeau
Canada's Association
for the Fifty-Plus
Mr Bill Gleberzon
Ms Judy Cutler
Geriatricians'
Alliance
Dr Marisa Zorzitto
Mr Mel
Starkman
Mental Health Legal
Committee
Ms Anita Szigeti
STANDING COMMITTEE ON
THE LEGISLATIVE ASSEMBLY
Chair /
Président
Mr R. Gary Stewart (Peterborough PC)
Vice-Chair / Vice-Président
Mr Brad Clark (Stoney Creek PC)
Ms Marilyn Churley (Toronto-Danforth ND)
Mr Brad Clark (Stoney Creek PC)
Ms Caroline Di Cocco (Sarnia-Lambton L)
Mr Jean-Marc Lalonde (Glengarry-Prescott-Russell L)
Mr Jerry J. Ouellette (Oshawa PC)
Mr R. Gary Stewart (Peterborough PC)
Mr Joseph N. Tascona (Barrie-Simcoe-Bradford PC)
Mr Wayne Wettlaufer (Kitchener Centre / -Centre PC)
Substitutions / Membres remplaçants
Mr Raminder Gill (Bramalea-Gore-Malton-Springdale PC)
Ms Frances Lankin (Beaches-East York ND)
Mrs Sandra Pupatello (Windsor West / -Ouest L)
Clerk / Greffière
Ms Donna Bryce
Staff / Personnel
Mr Andrew McNaught, research officer, Research and Information
Services
The committee met at
1005 in room 151.
SUBCOMMITTEE REPORT
The Chair (Mr R. Gary
Stewart): Ladies and gentlemen, we'll call to order the
meeting and the hearings of the committee on the Legislative
Assembly.
Can I have a motion regarding
the subcommittee report, please? Mr Tascona, will you read that,
please?
Mr Joseph N. Tascona
(Barrie-Simcoe-Bradford): Yes. I'll move the
subcommittee report and I'll read it.
Your subcommittee met on
December 18, 2000, and has agreed to recommend the following:
(1) The subcommittee request
the House to approve up to three days during the week of February
12, 2001, for the committee to consider private member's Bill
135, Public Hospitals Amendment Act (Patient Restraints).
(2) Notification of the
hearings be placed on the Ontario Parliament channel asking any
interested groups or individuals to contact the clerk of the
committee. Should there be more witnesses than time slots, the
clerk will contact the subcommittee for direction.
(3) The sponsor of the bill
will be provided with an opportunity at the outset of the
hearings to make an opening statement five to 10 minutes in
length.
(4) Witnesses will be
allocated 15-minute time slots for presentation and questions by
the members, while expert witnesses will be allocated up to 30
minutes.
(5) Amendments to the bill
will be distributed as available. Public hearings will be for two
days. If possible, clause-by-clause will commence immediately
following the hearings.
(6) The research officer will
provide the members with information on medical research and
jurisdictional comparisons.
The Chair:
Debate?
Mr Tascona:
I move approval.
The Chair:
All in favour? Carried.
PUBLIC HOSPITALS AMENDMENT ACT (PATIENT RESTRAINTS),
2000 / LOI DE 2000 MODIFIANT LA LOI SUR LES HÔPITAUX PUBLICS
(MESURES DE CONTENTION)
Consideration of Bill 135, An
Act to amend the Public Hospitals Act to regulate the use of
restraints that are not part of medical treatment / Projet de loi
135, Loi modifiant la Loi sur les hôpitaux publics pour
réglementer l'utilisation de mesures de contention qui ne
font pas partie d'un traitement médical.
The Chair:
We'll move to statements and presentations. The sponsor of the
bill, Ms Lankin, will have the opportunity for 10 minutes.
FRANCES LANKIN
Ms Frances Lankin
(Beaches-East York): Thank you very much, Mr Chair. Let
me begin by offering my heartfelt thanks to members of the
Legislative Assembly from all three parties who came together in
a majority to pass this private member's bill at second reading
and to agree to refer it to committee for public deputation. We
all know it's not often that a private member's bill makes it
even this far, so for that I am grateful, and I am hopeful that
today we're beginning a journey that will take this down a road
so that, in some form, it becomes law.
I saw "in some form" because
I think it is important to acknowledge that as private members we
lack the resources for legislative drafting and the policy advice
that one would have if they worked directly with a policy
ministry, in this case the Ministry of Health.
I am grateful that the former
Minister of Health had directed that the parliamentary assistant
and staff work with me on this, to see if we can arrive at a bill
that is acceptable to the government and the-Failure of sound
system-health sector, who you will hear from over the course
of the next two days, who have varying points of interest to draw
to your attention with respect to the bill. I have not had a
chance to speak to the new Minister of Health yet. That's
something I will follow up on. Working with Mr Tascona, hopefully
we will be able to continue on this same path.
In the next few days, you
will hear very strong research-based evidence that restraint and
a policy of use of restraint, which is so prevalent in the
treatment-and I am using that word very loosely, because it's not
really appropriate but it seems to be the way in which our system
has developed its thinking-of the elderly and particularly
elderly with dementia, is so prevalent and rampant and is so part
of the culture in Canadian institutions that people from other
jurisdictions find themselves, quite frankly, shocked. If you
look at comparisons of the use of restraints in the UK, and even
in the United States, which
has a higher use of restraints than the UK, you will find that
even there it is much lower than in Canada.
We have a policy, a mindset,
that says, "We should have institutional policies and we should
train our health care professionals in a policy of least
restraint." It's not often what you find in the front-line
practice in public acute care hospitals. But it's interesting
that we have accepted a cultural attitude of use of least
restraint as opposed to a policy of being restraint-free, which
is in fact the dominant culture in the United Kingdom. It is a
growing body of opinion, with laws to back it up, in the United
States. And in parts of Canada, like British Columbia, we are
seeing that emerge as well.
1010
You will hear that in Ontario
we do have laws with respect to the use of restraint that govern
long-term-care facilities, nursing homes and homes for the aged;
we do have laws that cover psychiatric hospitals or psychiatric
units within acute care hospitals where they come under the
Mental Health Act; and of course there are laws with respect to
the restraint of prisoners in correctional facilities. However,
in our public hospitals, in our acute care hospitals, on the
regular wards of those hospitals, there is no law other than the
common law and the criminal law which says you cannot confine
someone against their will, and yet we do it every day.
You will hear evidence that
people in the health care field truly do not like to use
restraints and do so only when they believe it is in the best
interest of the patient. That best interest is often defined as
preventing the patient from falling or preventing the patient
from pulling out intubation tubes or other medical devices that
are attached to the patient. You will hear that described as
preventing them from doing harm to themselves. Yet you will hear
evidence from experts who will come forward who will tell you
that all of the research that has been done blows a hole in those
myths, that there is no difference in the incidence of falls
between those who've been restrained and those who haven't. In
fact, you will hear that in many cases the use of restraints
leads to increased agitation, decreased cognitive ability and
decreased motor abilities, and that in some research studies the
rates of falls are shown to increase after periods of prolonged
restraint. You will hear research that shows that restraints
don't stop patients who are in periods of dementia from pulling
out intubation tubes.
You have to wonder, then, why
is it that we accept so readily that this is for the patient's
own good when all the research shows differently? It's a cultural
attitude that we have. It's not a question of ideology; it's a
question of practice that has developed in our Canadian culture
and our Canadian institutions. It is one that I find absolutely
horrific, to think that it is acceptable to forcibly confine
someone when there are alternatives. And the alternatives may
cost money, I say to my friends, and I acknowledge that. They
cost money in terms of things like beds that can be lowered to
the floor and that are not up high so that people have a lower
incidence of falling when getting out of bed. It can cost money
in terms of front-line staff who are there, who are able to be
with a person who's in a state of agitation or a state of
dementia.
There is a geriatrician, who
will present before us, who said to me in discussion about this,
"Think of an adult with dementia as someone who is mobile, can
get around and is able to get in harm's way and harm themself,
for example, but does not have the cognitive ability to be
reasoned with and to be talked into staying still or staying in
one location. Think about a two-year-old toddler who has the
ability to get up, get around, be mobile, get into harm's way or
harm themself and yet doesn't have the cognitive ability to
listen to reason and to understand to stay in one area or to stay
in bed. Would you ever consider that it is appropriate to
restrain a two-year-old child-for a parent to tie a child up? No,
we make the location what we call childproof. We make it safe, we
make it age-appropriate and we follow the child around."
In the case of elderly
patients with dementia, when they are placed on a surgical ward
in a hospital which is not an age-appropriate setting, the
front-line staff are left with a huge challenge of how to provide
appropriate care for that individual. All too often what has
happened is that in the absence of age-appropriate mechanisms, in
the absence of restraint-free policies, in the absence of
protocol for fall management or protocol for wandering patients,
you see the individual tied up. It is not acceptable I think is
the bottom line.
Now, I think everyone who
comes forward, even those who disagree with the legislation, will
tell you that they agree with the intent of the legislation. The
job for us is to understand whether or not this will ever be an
issue that is addressed unless we as legislators put at the base,
the foundation, the rights of the individual and enshrine those
in law.
There have been many, many
coroners' inquests, there have been many coroners' geriatric
committee reports, all of which talk about the elements of the
need for physician orders, for frequent monitoring, for
restraints not to be used as a method of convenience to staff or
as a method of punishment or whatever. There are very few
circumstances in which experts and the coroners and others find
that the use of restraints is in fact appropriate, and yet that's
not our experience day to day in hospitals. We have the hospital
association and others who are working on updating their
policies, working on major educational initiatives. That's
terrific but, again, we've had these policies in place for years
and yet the practice hasn't changed.
The nurses will come forward
and tell you that the RNAO is prepared to develop best-practice
standards, and we're hoping the Ministry of Health will fund that
study. That's terrific and will help a lot. But again, there have
been best practices and there have been policies in place for
years and that hasn't affected the front-line exercise of this
mechanism for patient control, because that's what it's become: a
way to control patients.
The bill in and of itself that we started off with
here is not perfect. Of course, there are many areas where I
think we can debate the actual wording, the actual provisions.
Should it be 15-minute monitoring or should it be 20-minute
monitoring? Should it be a physician's order and reorder after
two hours or after four hours? What are the connections between
substitute decision-maker and the Health Care Consent Act-very
complicated relationships. Does this bill meet that test? Do we
need to import language from the Mental Health Act that says
right up front that nothing in this bill authorizes the use of
restraints, so that it's not misunderstood that this is a bill
about how to restrain? Should we tackle the very thorny issue of
including in this bill the use of chemical restraints?
As you will remember, in my
own personal story, which led to this bill, my mother was not
only physically restrained. As a result of the position she was
restrained in and the pain, she was given Demerol; as a result of
the agitation, she was given Ativan; and as a result of those two
drugs and her cognitive impairment and her, then, onset of
hallucinations, she was given Haldol, an antipsychotic. That's
chemical restraint. It's as devastating as physical restraint.
I've chosen not to address that upfront in this bill because
there is much I don't know as a layperson about medical
prescribing versus the prescribing of drugs as a restraint,
treatment versus restraint. Perhaps this committee believes we
should look into that.
What I'm hoping will happen
over the next two days is that as a committee we are convinced
that we need to have regulation in law affecting our public acute
care hospitals, and from there that we perhaps adjourn the
deliberations for this committee so that I'm able to work with
the parliamentary assistant and the Ministry of Health on
amendments that would be appropriate based on what we've heard
and based on the ministry's policy advice, and that we are able
to come back to committee, when the Legislative Assembly
reconvenes, with appropriate amendments that reflect what you've
heard and that allow us to move to a new day in Ontario where we
collectively express that it's not just least restraint we're
looking for; it is a restraint-free, as much as possible, world
that gives respect and dignity to our elders and moves us in line
with other jurisdictions that are beginning to go in that
direction as well.
Mr Chair, thank you. I
appreciate the opportunity to provide some opening comments to
the committee.
ONTARIO PSYCHOGERIATRIC ASSOCIATION
The Chair:
We'll move, then, to the delegations. The first one is the
Ontario PsychoGeriatric Association. If you would come forward
and introduce yourselves. You have 30 minutes, either in full
presentation and/or questions. The questions will start with the
official opposition if there is time left.
Mrs Sandra Pupatello
(Windsor West): May I ask one question through the
Chair, perhaps directed to Mr Tascona, and that's the position
he's taking on behalf of the staff of the Ministry of Health and
the minister, if there are comments that might come forward
before or after, sometimes through these proceedings, about the
current position on this issue of the government.
Mr Tascona:
This is a private member's bill. The subcommittee has met in
terms of what the procedure would be in terms of an opening
statement by Ms Lankin, and we're here to listen in terms of her
bill and the basic process. She has been meeting with the
ministry, but there's not going to be any ministry staff here and
there's not going to be any ministry position taken. We're here
to listen.
1020
The Chair:
To the delegation, welcome. If you would identify yourselves,
and, as I said, you have 30 minutes.
Dr Janice
Lessard: Good morning. This is Mrs Margaret Ringland,
who is the president of the Ontario PsychoGeriatric Association.
I am Dr Janice Lessard. I will be presenting the viewpoint of the
Ontario PsychoGeriatric Association, and I thank you very much
for the opportunity to do so. At the conclusion of this, with
your permission, I would like to switch hats and then present
what I believe has been called an expert opinion.
First of all, the Ontario
PsychoGeriatric Association is a voluntary, interdisciplinary,
province-wide association which for 26 years has been dedicated
to enhancing the quality of life of the elderly. It brings
together professionals, seniors and students who are interested
in psychogeriatrics and all aspects of the well-being of the
aged.
The OPGA is committed to
advocating for appropriate health care delivery for individuals
with cognitive and behavioural problems. We support education for
care providers so they are able to deliver high-quality care and
services to those who are entrusted to us.
We are here today to lend our
support for Bill 135, An Act to amend the Public Hospitals Act to
regulate the use of restraints that are not part of medical
treatment. We believe this legislation is necessary to support
the initiation of and compliance with restraint use policies and
procedures in every hospital in the interest of protecting
patient rights. The legislation will supplement and reinforce
efforts to educate hospital staff and the public regarding an
individual's right to be cared for in a dignified and respectful
manner. Specifically, the legislation will ensure that new
learning through educational initiatives becomes translated into
improved and lasting practice behaviours related to restraint
use.
The focus of our remarks to
you today is the patient. We recognize that restraint use is a
complex and multifaceted clinical issue, and admittedly will
refrain from comment on the location in which care is provided
and on specific work-life issues of various health care
providers. Rather, our attention is to the individual rights to
freedom from potential abuse and respect for dignity and
autonomy.
The realities are this: the vast majority of people
being restrained in hospitals are those people exhibiting
confusion, the majority of whom are the frail elderly. Many
illustrations have been provided to you in the discussion
surrounding the first reading of the bill. Therefore, we do not
feel the need to add to these except to say they are all very
real. They do happen and they need to be addressed. We do,
however, want you to consider this legislation on the basis of
facts and information related to restraints, their impact, the
rationale for reducing their use, and the alternatives to
restraints. A few of these facts are these:
Restraint use in North
America is more prevalent than in any other developed part of the
world.
Many myths exist regarding
restraints as a means to preventing falls and wandering
behaviour.
Restraints rarely prevent
harm to patients or staff.
No studies have demonstrated
their efficacy in any setting.
Many studies have
demonstrated the negative, adverse effects of restraints.
There are many effective
alternatives to restraints.
Education of staff, patients
and family members regarding alternatives to restraints is
effective. However, education alone does not produce lasting
change-in-practice behaviours, particularly in relation to such a
value-laden and deeply entrenched practice issue like the
application of restraints.
In the copies that have been
provided to you, you will notice that there are some footnotes,
references, 20 of them. I would like to add that in Ms Lankin's
very on-target summary, none of which was opinion-they were all
facts, and the literature supports every statement that Ms Lankin
has made.
Based on these facts, it is
our perspective that there is a place for legislation to set and
reinforce parameters related to restraint use. Precedent exists
already in the legislation that applies to long-term-care
facilities. There are three of them: the Homes for the Aged and
Rest Homes Act, the Nursing Homes Act and the Charitable
Institutions Act. Where educational initiatives alone have
failed, adding the strength of legislated mandates has resulted
in practice change. Safeguards that respect human rights should
not be left solely to the discretion of individual health
professional organizations, individual hospitals nor hospital
associations. Legislation provides the anchor for hospital
policies and professional standards and helps sustain change. It
provides professionals with a reference in developing,
implementing and, more important, monitoring and complying with
least-restraint policies and procedures.
We do not wish to minimize
the complexity involved in moving to a least-restraint practice.
While we believe legislation is necessary, we also know that it
is not enough on its own. This legislation must be seen to
support initiatives related to education and research and to
provide for reasonable adherence to least-restraint policies.
Education is needed regarding
what physical restraints do not do, as well as the cascade of
harm that they precipitate. More important, hospital staff must
be educated about the many alternative solutions that have
already been studied and put into practice in many other
jurisdictions. We are encouraged by the commitment of the Ontario
Hospital Association to provide some leadership here. We
emphasize that the focus should remain on the needs of the
recipients of care and not on the needs of the providers of care.
Research into effective and less harmful interventions in Ontario
hospitals needs to be integral to the solutions.
Finally, to determine the
degree to which hospitals are restraint-free environments,
ongoing monitoring of physical restraint use is required. This
monitoring could be tied to the Canadian Council on Health
Services Accreditation program, with the use of physical
restraints applied as a quality indicator, as has been done in
the long-term-care facility sector. The Ministry of Health could,
at least for the interim, consider requiring reporting on the use
of physical restraints. Hospital report cards and patient
satisfaction surveys that are currently being introduced to
hospitals could be practical vehicles for evaluation and quality
improvements in this area.
1030
Specifically regarding the
legislation, we have the following recommendations:
(1) We urge the government to
enact this legislation.
(2) We urge the government to
support professional and public education in co-operation with
care provider associations and experts in the field of restraint
reduction and gerontology.
(3) We ask the government to
fund research on alternatives to restraints.
(4) We urge the government to
establish mechanisms to support hospitals in complying with these
new provisions of the hospital act and to require public
reporting.
Our specific recommendations
related to this bill: since our focus here today is not on the
validity of the clinical interventions or how they are to be
accomplished, we have only three specific suggestions to make
with regard to the content of Bill 135.
Our first addition relates to
embedding a basic patient right into this new provision, similar
to the resident right in the three pieces of legislation that
apply to long-term-care facilities.
(5) Specifically,
recommendation 5 is that the following statement be added to the
bill: "The patient who is being considered for restraints has the
right to be fully informed about the procedures and the
consequences of receiving or refusing restraints."
Our second amendment addition
relates to the definition of "restraint" and the term "medical
treatment." These definitions can be quite non-specific. We
believe that more comprehensive and universal definitions are
needed to prevent ambiguity and room for interpretation.
(6) To this end, we recommend that the legislative
amendment allow for definitions to be addressed in the
regulations and policies governing public hospitals.
Our final addition relates to
the need for ongoing accountability for the implementation of
this new provision.
(7) Recommendation 7,
therefore, is: we recommend that the legislation define a
framework for accountability for the implementation of this new
provision.
In conclusion, the Ontario
PsychoGeriatric Association urges all parties to support the
amendment to the Public Hospitals Act as proposed in Bill 135. It
is essential that public policy reflect the values of its society
and acts to entrench citizen human rights into our public
services and programs. The vulnerable of our province will be
well served by this legislation.
We thank you for this
opportunity to present our perspectives to you.
The Chair:
Thank you very much, Doctor. We've got about five minutes per
caucus for questions, starting with the Liberal caucus.
Mrs
Pupatello: Thanks so much for coming forward today with
your presentation. Could I just refer you to your fifth
recommendation, that is, "The patient who is being considered for
restraints has the right to be fully informed about the
procedures and the consequences of receiving or refusing
restraints." Tell us your view of the reality of the day-to-day
use of that. Are you talking about the custodian or someone who
is going to be in charge of this patient; a family member,
someone signing off? Typically, if it's perceived that the
patient requires restraint, they are likely not in a position to
give consent, to be informed, so what does that leave us with,
pragmatically?
Dr Lessard:
In this statement, we vacillated back and forth between should we
say "the patient who is being considered for restraints," or
should we add in "or the substitute decision-maker" in those
situations where the patient is not competent to consent? Does
that answer your question?
Mrs
Pupatello: And I guess if you were to go further into
the definition, because it is, I think, the crux of the matter
and you haven't been very specific in that other than
recommending that the definition needs to prevent ambiguity or
room for interpretation, if you go to your sixth recommendation,
in addressing it in regulations and policies governing public
hospitals, what would that do to change what currently exists, or
how would you define it if you could?
Mrs Margaret
Ringland: If I can add, I think what we're speaking of
here is that there is reference in other legislation or policies
and regulations to definitions, such as the long-term-care acts,
the various ones presented before, so we may want to reference
those in terms of definition.
As far as medical treatment
goes, and Dr Lessard will speak to this as well, it is our
opinion that there are rarely incidences where medical treatment
is in fact a restraint, so we would urge caution in even
considering a physical restraint to be a medical treatment.
Mrs
Pupatello: Anything to add, Doctor?
Dr Lessard:
No.
Mrs
Pupatello: I guess specifically, you realize that the
definitions are now in other acts. Are you comfortable with what
those definitions are in other acts, or would you be proposing
the definitions for "restraint" and "medical treatment"?
Dr Lessard:
It's fairly standard in the literature what "physical restraints"
refer to. It exists in other legislation, if fact, around the
world. I think they're fairly accepted, and they start at having
two bed rails up, all the way to jacketed restraints and tying
both wrists and both ankles; it's called four-point restraint. So
I think the definitions of physical restraint, if that's your
question-
Mrs
Pupatello: My question is that the second recommendation
which you're making in your submission is that you believe you
have to have a more comprehensive and universal definition, so
what is it that you propose to go further than what is
specifically in other acts currently? That is going to be the
crux of the matter.
Mrs
Ringland: I think what our recommendation is saying is
that we suggest, first of all, that the legislation itself not
necessarily embed the definitions, that you look at the
regulations. But the second part is that, yes, we believe some of
the other legislation, both long-term-care and mental health
legislation, either through regulations or policy, defines quite
clearly, and we would refer to that. We're just sort of putting a
notice that we'd like to see something more than a broad
understanding, because it isn't clearly understood. It has taken
a long while for the long-term-care legislation to review and
re-review and revise what the definitions were related to that,
so rather than reinvent the wheel, we're just suggesting perhaps
that's the way to go.
Regarding your question on
the recommendation related to the patient rights statement that's
in there, by not putting "substitute decision-maker," we're
assuming that the Health Care Consent Act and the Substitute
Decisions Act apply, so that we don't need to say "substitute
decision-maker." In essence, that is required if someone is not
capable of making the decisions.
The Chair:
Thank you. Ms Lankin.
Ms Lankin:
I appreciate both of you being here today. In the body of your
submission, you make reference to the literature search and
research search that has been done, and you have helpfully
footnoted a number of the assertions that come from that
research. I'd like to actually get it on the record, however, in
a little bit more detail.
When I look at page 2, and
you set out the realities in (a) through (g), I'm wondering if
you could tell me from the literature research a bit more
information. You say the use of restraints is more prevalent in
Canada. Can you tell me about that? Can you tell me about studies
around falls and around intubation tubes? Can you tell me about
whether there are
effective alternatives, those sorts of things, in a bit more
detail?
Dr
Lessard: Yes, and I anticipate that you are going to
hear more about the literature from other organizations and
individuals who will be presenting.
The first thing you wanted
to hear about was-
1040
Ms Lankin:
Given that you've indicated you're aware of some of the other
presentations that are coming forward and that there will be
research information in that, you've done a literature search.
You're also a practising geriatrician and have been involved in
these issues. Tell me, are seniors tied up frequently in our
hospitals? Does it help them to not fall? What's the outcome when
they are tied up? I think committee members need to hear from an
expert what the impact of restraints is.
Dr
Lessard: In that regard can we, for the purposes of
Hansard, complete the presentation from the Ontario
PsychoGeriatric Association?
Ms Lankin:
Actually, there's only this little bit of time left for questions
from the two of us. So if you want to put on your expert's hat
now, we can do that.
Dr
Lessard: OK, here we go. In Ontario we have data showing
that 33% of all adults in our acute care hospitals are physically
restrained. Dr Molloy will likely tell you later that in one of
his studies looking at people over age 75 in hospitals, 70% of
those people are physically restrained.
The reasons for the
restraints are usually these: fear of litigation-which of course
holds no water, because in Canada there has never been a
successfully litigated case against hospitals for not using
restraints; however, there have been successful ones as a result
of injuries when hospitals did use physical restraints. As you
will hear from the Registered Nurses Association of Ontario
presentation, their view is that frequently nurses need to tie
somebody up so they can have an opportunity to attend another
patient. The literature strongly shows that without exception
there is no literature to say that using physical restraints
keeps a patient safe. All of the literature says it either does
nothing or it does harm.
Ms Lankin:
A lot of people have told me that seniors are apt to fall and
that this prevents them from falling, so it keeps them safe.
Dr
Lessard: We have 20 years of scientific research that
shows that not only do physical restraints not prevent falls, but
they increase the incidence of falls. Of course, that makes
sense. If you have someone tied in bed or tied in a chair for
most of the day, they're not getting much opportunity for normal
maintenance exercise. It's a cascade of events: the wasting away
of muscle, the wasting away of bones, loss of balance mechanisms
in the brain etc, so that when they finally get the opportunity
to escape and they do stand up and take a step or two, they
fall.
Ms Lankin:
Dr Lessard, when you see a patient who has been restrained, what
are the effects that you note on that patient? What's the most
common experience you have in the hospital with a patient you
have seen restrained?
Dr
Lessard: It depends on how long they've been in the
restraints. The first few hours they are particularly angry and
thrashing. They say they feel that they are in prison. They
certainly feel that they have been assaulted. They are usually
angry. A few days later they become more tearful. Because they're
angry and noisy about it and trying to get untied, they are very
vocal, and frequently you will hear in our hospitals, walking
down a hallway, a plaintive, "Help, help, help." Of course that
is annoying to care staff, so these people are then sedated and
tied down, and this begins the cascade of terrible events that
almost always lead to either nursing home placement or death.
There is a series of things
that are happening in between. The patients become very depressed
and withdrawn and not wanting to eat. The families get very
distressed and react in a number of different ways. We start
seeing physical problems. The drugs and the immobility themselves
make these people incredibly incontinent and constipated because
their abdomens are filled with excessive amounts of stool and gas
presses on the bladder and now they are incontinent of urine.
The staff are having to put
them in-a pejorative term-diapers or, more often and even worse,
they stick plastic Foley catheter tubes into their bladders, of
which 100% become infected within six days. Now that they have
these Foley catheters in and they spike a fever, then the next
knee-jerk reaction is to give these people antibiotics. Now that
they have their antibiotics, they get antibiotic-related
diarrhea. Of course, this diarrhea is caused by bacteria that we
don't have treatment for: our famous VRE, vancomycin-resistant,
methycillin-resistant and other bacteria. So now we have to
isolate these people in their rooms.
The Chair:
I'm going to have to cut you off, Doctor, and move on to the next
caucus. Thank you. Government caucus.
Mr Jerry J.
Ouellette (Oshawa): A couple of quick points: first of
all, I'm undecided as to which way to go with the legislation. I
want to deal first of all with the realities. On your page 2, (a)
says, "Restraint use in North America is more prevalent than in
other developed parts of the world." I want to make sure we're
comparing apples to apples here. Ms Lankin mentioned the United
States and England. Are we looking at the same numbers, figures
and demographics and the same numbers of individuals in health
care, or are we seeing more because we're providing more
care?
Dr
Lessard: No. In fact, it's biased against us. For
example, the UK has had a population of 18% over age 65 since
World War II. We are now at 12%, so they have a much larger
senior population.
When we're referring to
physical restraints, we are today trying to find ways to stop
tying down 85-year-old, frail little women in four-point
restraints. That's what we're trying to accomplish. When we're
talking in the UK, that's not what we're talking about. We're
talking about bed side
rails. For example, the frequency of using bed side rails in the
general medical population in Ireland is 16%. In England, the
frequency of using two bed rails is 6%. We have not done a study
in North America looking at bed rails, they are so accepted in
the system here, but most of us would estimate that the use of
two bed rails approaches 100%. Ireland is very upset that they're
using it 60% of the time because there is literature showing no
benefit to the use of two bed rails and similar harm.
Mr
Ouellette: What I was trying to get there was, are we
having the same individuals in the same health care system at the
same age, or are we having people go into the system here and
providing a service that they're not providing in England?
Dr
Lessard: No. On the contrary; the opposite is true.
Their services for seniors are much more developed than ours in
Canada. First of all, they are more community-based, and ours are
acute hospital institutional-based.
Mr
Ouellette: So they would provide more care at home?
Dr
Lessard: Absolutely.
Mr
Ouellette: So they'd have more individuals in the home
care setting?
Dr
Lessard: Yes.
Mr
Ouellette: The other part is, one of the individuals I
spoke with was my sister. She works in the health care providing
service.
Dr
Lessard: How nice.
Mr
Ouellette: I need you to respond to this because, when I
first mentioned this, her response was, "Oh, great. Finally
they're going to do something about these people, and I'm sick
and tired of being beaten up all the time." Her response kind of
threw me because it was counter to what we're talking about. Then
I went on to explain it a bit more. The comment that came forward
was that part of the problem is that individuals such as she are
in there providing the service for those individuals on a daily
basis, and then doctors come in and they don't see them for very
long. So when doctors come in, they get all the gravy parts, the
nice parts, where the care providers actually in there eight
hours a day, on that ward dealing with the people on a regular
basis, are the ones who are, according to her, being beaten up on
a regular basis. Are you seeing that or can you explain that or
respond to that?
1050
Dr
Lessard: Yes, I'd love to. Certainly the non-medical
staff, particularly the nursing staff, are located on a single
floor and don't move for eight hours, whereas the physicians have
the ability to leave the scene. The nurses, however, seldom have
the same patients more than two days in a row in an acute care
hospital, so the nurses never get to know Mr Jones very well
because they're being moved around, whereas the physicians know
them because they've admitted them and they follow them through
their entire hospital stay.
The issue of physical
aggression: I suggest to you that the majority are the elderly,
and the majority of the elderly are women, and I'd like to ask
you to imagine how much defence one needs from an 85-year-old
frail woman. Not much. However, it is certainly true that nurses
are being beaten up in acute care hospitals. What many of the
hospitals have done is institute crisis intervention education,
because the principles are the same whether it's a drunk
21-year-old in the emergency department or a demented gentleman.
What I'm trying to say is that there are already effective
substitutes for tying people down. Tying people down does not
make them any more compliant; it makes them less so. Yes, they're
swinging, but often they're swinging because they are being
compelled to do something that is fitting into the routines of
the nurses for that shift, and the patient doesn't want to and is
not given alternatives. I think you are going to see a lot better
things happening in British Columbia, where they have started to
institute age-appropriate care which, as Ms Lankin was referring
to, like pediatrics-if you had children in an adult setting, you
can imagine that things wouldn't go well and a lot of nurses
would get their shins kicked frequently. If one has an
elder-friendly environment, one avoids creating these behavioural
crises in the first place.
The Chair:
I think we're going to call the end of that. Doctor and Mrs
Ringland, thank you for attending and thank you for your
presentation. We appreciate it very much.
Mrs
Ringland: May I make one summary comment?
The Chair:
Very quickly.
Mrs
Ringland: I just want to add that there's no question
that we're sympathetic to the degree to which nurses receive
education and support for implementing policies and interactions
that prevent abuse of the elderly, and therefore prevent abuse of
the nurse. I'm just raising that because I think it's clearly
important that we help people find interventions that are more
effective, that work particularly to the benefit of the patient
but also are effective for nurses to implement and prevent any
kind of injury to them as well.
The Chair:
Good. Thank you very much. I appreciate it.
Dr
Lessard: Mr Chairman, may I give these to Donna
Bryce?
The Chair:
Yes. The clerk will take them for you.
ADVOCACY CENTRE FOR THE ELDERLY
The Chair:
The next presenters are the Advocacy Centre for the Elderly, if
you would come forward and identify yourselves. Again, you have
15 minutes, either in total presentation and/or questions. We
will rotate the questions, starting with the NDP caucus.
Welcome.
Ms Jane
Meadus: Good morning, Mr Chair and honourable members.
I'd like to thank you for the opportunity to present to you this
morning.
The Chair:
Do you want to identify yourselves?
Ms Meadus:
My name is Jane Meadus, and I am a lawyer with the Advocacy
Centre for the Elderly, a legal clinic for low-income seniors
here in Toronto. I'm accompanied today by George Monticone, also a
lawyer at the Advocacy Centre for the Elderly, who prepared the
written submissions you have before you this morning.
I would also like to
acknowledge the presence of Lana Kerzner, who is seated in the
front row, a lawyer with the Advocacy Resource Centre for the
Handicapped who assisted us in the preparation of our
submissions. I understand that ARCH has provided a letter to this
committee in support of our submission.
As the institutional
advocate at ACE, it's my job to represent clients in hospitals
and long-term-care facilities who are having difficulties because
they are in one of those places. One of the frequent complaints
is that the patient is being restrained against their will. It is
from my experience representing these clients that I am appearing
before you today. I'd like to share with you a scenario which
occurs all too frequently. For reasons of solicitor-client
confidentiality, this is an amalgamation of a number of cases
which I've had; however, the details are all too true.
Picture this scenario. Mrs
Elias is an 80-year-old widow with one daughter. She resides in
Scarborough in a home she shared with her husband for over 50
years. Her daughter lives in Mississauga with her husband and
three young children. Over the years, Mrs Elias's health has
deteriorated. She suffers from arthritis and a heart condition,
which has meant that she cannot get out as much as she used to.
She uses a walker to get around her small bungalow. She relies on
home care services to assist her around the house and to get her
shopping done. Her daughter, who holds the continuing power of
attorney for property, does her banking for her. When she needs
further assistance, she calls her daughter. Unfortunately, her
daughter is not always available to assist her. Most of her
friends are now deceased, and she no longer knows her neighbours
well. She has little contact with anyone other than home care
workers, her daughter and her family doctor, as she can no longer
get out to participate in community activities. Her English is
poor.
Mrs Elias has a dizzy spell
and falls at home. She is able to call 911 and is taken to
hospital by ambulance. This is the second time this has occurred.
Once at the hospital, she is seen by the doctor, who admits her
for observation to determine what has caused the dizzy spell.
After a week she is medically cleared. However, she is advised
that she's not allowed to leave the hospital. She is left in bed
with the side rails up and cannot get them down to get out of
bed. When she asks to get out, they tell her she must stay in bed
unless accompanied by a staff member or her daughter. She asks
for her walker and is told the same thing.
Mrs Elias meets with the
social worker, who tells her she is not allowed to go home. She
insists that a taxi be called and that she be assisted in getting
out of bed, dressed and allowed to leave. She is told that she
cannot. On the one occasion that she attempts to leave, she is
returned to her room by security guards. Mrs Elias is told that
she has to move to a retirement home. She refuses. The social
worker tells her she has no choice, that the doctor has said she
cannot go home because she has been brought to hospital twice for
falls. The social worker tells her that her daughter has agreed
to this. Mrs Elias tells the social worker that she understands
that she falls and is willing to get further aids at home such as
grab bars and an alarm system to assist her. She understands that
she may fall again and could be hurt, but this is a risk she is
willing to take. She is adamant that she return to her home where
she is comfortable.
Mrs Elias speaks to her
daughter, who tells her that she's tired of all the calls from
her mother for assistance and that she has a family of her own
and cannot continue to do this. Mrs Elias states that she will
manage on her own if her daughter won't help her. But her
daughter says that doesn't matter; she's going to a retirement
home the next day. The daughter tells her that she will sell her
mother's home and pay for the retirement home out of that money
plus her mother's pension. She tells her mother that she's doing
this for her own good.
Mrs Elias becomes very
upset following this telephone conversation and demands to be
allowed to leave. When she is told no, she begins to yell at the
nurse, telling her they have no right to keep her there and that
she is an adult and can do what she likes. She begins to attempt
to get out of bed over the rails. The nurse contacts the doctor
on call, explains the situation and indicates that Mrs Elias has
become extremely agitated. The doctor orders that Haldol be
administered and indicates that Haldol should be administered
again the next morning before Mrs Elias is taken by ambulance to
the retirement home so that she won't act up on the way.
The nurse and several other
staff members enter Mrs Elias's room and restrain her while she
is injected with Haldol.
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The following day, Mrs
Elias is frightened. When the nurse comes in and tells her she
must have another injection, she complies as she is afraid of
what will happen if she does not. The ambulance attendant
arrives. She again states she wants to go home and not to a
retirement home, but they ignore her and place her on a stretcher
and she is taken to the retirement home against her will.
This is based on true
stories I have seen in my office and people I have represented.
The position of the Advocacy Centre for the Elderly is that in
Canadian society we have no authority to restrain or detain
someone except under the common law or by statute. Under the
common law, restraint can occur in emergency situations where
there is an immediate risk of harm to self or others unless the
restraint occurs. An example of authority by statute is under the
Mental Health Act, where someone can be detained and restrained
after being an involuntary patient.
It is my understanding that
some of those in opposition to this bill-for example, the Ontario
Hospital Association, as cited in Hansard on November 23-have
indicated we have no need for this type of legislation and that
it should be dealt with by way of hospital policy. With respect, I must disagree.
The ability to detain and restrain is not within the purview of
hospital policy, nor should it be. To detain or restrain a
patient is a serious restriction on their liberty, something
which requires more than a hospital board passing a policy. It is
more than simply a clinical decision that professionals can
make.
Section 7 of the Charter of
Rights and Freedoms guarantees that a person has the right to
life, liberty and security of the person, and the right not to be
deprived thereof except in accordance with the principles of
fundamental justice. Section 9 states that everyone has the right
not to be arbitrarily detained or imprisoned. And section 15
states that every individual is equal before and under the law
and has the right to the equal protection and equal benefit of
the law without discrimination and in particular without
discrimination based on race, nationality or ethnic origin,
colour, religion, sex, age or mental or physical disability. This
means you cannot simply detain someone because they are old and
ill, which is what is occurring today.
It must be made clear that
this piece of legislation before us does not provide
authorization for the use of restraints. What it does is set out
conditions as to how they can be used when they're lawful. It is
important that a section be added to the bill to state this. In
the paper you have before you, we have six recommendations we
would like to make with respect to this bill, and urge you to
carefully consider them in your deliberations as ways of
strengthening the bill to assist these vulnerable people.
Finally, we commend Ms
Lankin for bringing this important issue to the attention of the
Legislature and the public at large. We believe that in sharing
her story she has highlighted the difficulties others encounter
with respect to restraints in the health system. If Ms Lankin, a
well-known MPP, former Minister of Health and outspoken advocate,
could not prevent her mother from being restrained under the
existing system, we would like you to consider what is happening
to vulnerable people who have no advocates to assist them. We
also commend the members of this committee as well as the members
of the Legislature who support this bill and recognize its
importance to vulnerable people.
The Chair:
Thank you very much. We have about six minutes, so about one
question per caucus.
Ms Lankin:
I appreciate the recommendations you have set out. We've had an
opportunity in advance to discuss many of them, and you know I am
supportive of the recommendations you are making; I see them as
strengthening the bill.
I guess I want to ask you,
then, in your experience advocating on behalf of the clients you
have represented, have you experienced or represented clients who
have had this experience of restraint in public hospitals? As you
know, there are still problems with legislation that governs
mental hospitals, under the Mental Health Act, or long-term-care
facilities. But we have no regulations in place in the Public
Hospitals Act. Can you see a differential experience of your
clients in those sectors, and do we therefore need something that
covers public hospitals as well as these other sectors?
Ms Meadus:
I'll leave aside the mental health sector, because I think that
is a bit of a different animal, although I think the sections in
here talking about the number of minutes etc should go into the
Mental Health Act as regulations, because they are not there and
I think there is a difference between various facilities. So it
would be nice to have a set piece of regulations that say what
happens.
With respect to hospitals
and long-term-care facilities, I do have a lot of problems with
hospitals. I represent a lot of clients on a number of occasions,
and even when I go in on other things, I find my clients
restrained; I see other people being restrained. Because there is
no legislation, the hospitals often feel, "We can do whatever we
want." They're not getting consent from anyone.
There's a question of
whether some of these things are treatment. If they're treatment,
they should be getting consent under the Health Care Consent Act;
for example, for medication. That is not occurring. That's one of
the biggest complaints I get: "Dad's on Haldol and we don't want
him on it." I say, "Who's consenting?" and they say, "The
doctor." Well, the doctor can't consent. So it's a big problem.
You go in and say, "We don't want them restrained," or what have
you, and they say, "Too bad; that's what we're doing." The
families often have very good reasons not to restrain. I
certainly have clients who have been injured by restraints-legs
caught in bars of side rails, getting caught between side rails,
falling out over side rails. There have been people who have been
strangled in wheelchairs with cords. I go in all the time and see
people slipping down underneath and we have to call somebody to
get them out.
The Chair:
We'll go to the government caucus.
Mr Wayne Wettlaufer
(Kitchener Centre): Good morning and thank you for your
submission.
Under your recommendation
6, you state that only physicians and nurses who are regulated
under the Regulated Health Professions Act should be authorized
to apply restraints according to the conditions set out in
subsection (7) of Bill 135. The College of Nurses has made a
submission to this committee. The executive director, Anne
Coghlan, has said, "In contrast to the proposed legislation's
focus on the physician as the prime decision-maker relating to
the use of restraints, we firmly believe that nurses are in the
best position to determine both appropriate definitions of
`restraint' and `safe restraint application' for their specific
practice settings. It is the nurse who will implement the
application of restraints."
Also, Jackie Choiniere, the
director of policy, practice and research of the RNAO, the
Registered Nurses Association of Ontario, has said, "In our view,
the most effective way to ensure that the least-restraint
approach is systematically and effectively applied in all
settings across the province is by ensuring that the policy is
well grounded in evidence. The best-practice guidelines project,
funded by MOHLTC, the Ministry of Health and Long-Term Care, and managed by the RNAO, is
an excellent vehicle to make this happen."
Do you see that what you're
recommending is coinciding with what the college and the RNAO are
saying?
Ms Meadus:
I think so. The nurses certainly do see the day-to-day practice
of what's happening, so it may be feasible that they're the
people who should be determining whether or not restraints should
be used. I don't know that it's something we've really addressed
specifically. We were looking at it in a somewhat different way.
We don't want, for example, the janitor down the hall to take the
training and be able to do it. We were trying to limit it and
didn't want to just put in "regulated health professions,"
because that's too broad, so we had brought it down to just the
two groups. I don't think we've really addressed the issues they
were discussing.
The Chair:
To the Liberal caucus.
Mr Jean-Marc
Lalonde (Glengarry-Prescott-Russell): Thank you for your
submission. I have a few questions.
Your recommendation 6, to
me, is very vague at the present time. I do visit home care
people quite often, and we know for the home care services
availability that we have at the present time, with the reduction
in funding, we'll see more and more of those happening similar to
Mrs Elias, because at times daughters or sons don't have the time
to spend with their fathers and mothers.
Reading all the
documentation I have read over the weekend, I could see that
probably there would be some recommendations to be made besides
those in there. Do you think that if funding was made available
to those nursing homes, especially, or the senior citizens'
homes, with the home care services we could have kept Mrs Elias
longer in her own home with the additional funding?
1110
Ms Meadus:
I do believe that additional funding definitely would keep people
at home. Very often the person just isn't getting enough
assistance at home, which brings about these situations. I can
actually tell you that in the situations I've had where I get
these calls, the person does end up going home and doing quite
well and not ending up in hospital the next week. It's sometimes
a matter of trying to get in more assistance; perhaps they didn't
realize they could pay for some assistance. Although we would
prefer home care to be unlimited, sometimes they're able to get
in a friend or someone to assist them and they can do well at
home. So increased funding, certainly in the home care setting,
would go a long way to assist this.
Mr
Lalonde: At the present time, at least once a month I
visit a nursing home; I have nine in my riding. I could see more
and more people being tied either to their wheelchairs or in bed.
The rails that they have on the beds should be changed, because I
fully agree that the ones we have on the beds in nursing homes at
the present time should not be this type of rail.
Mr George
Monticone: Mr Chair, I would like to make one closing
comment, if I may.
The Chair:
Yes, go ahead; short, if you will, please.
Mr
Monticone: I would urge you to consider the question of
the definition of "restraint," and when you do that, don't define
restraints by reference to physical, chemical and environmental
restraints and leave it at that. I think "restraint" should be
defined fully. We've given you a possible definition here to
consider. Please consider it seriously.
Restraints should be
defined in terms of what they actually do to people, not in terms
of physical, chemical and environmental, because that leaves a
question as to what those things are. Give us a definition that
people understand, which is that restraints limit people's
movements and behaviour and they have no control over those
things. That's what a restraint is. We would really urge you to
consider that as a definition.
The Chair:
Thank you very much, sir, and thank you for your presentation. We
appreciate it.
ONTARIO COALITION OF SENIOR CITIZENS'
ORGANIZATIONS
The Chair:
The next group is the Ontario Coalition of Senior Citizens'
Organizations. If you would come forward and make your
presentation; identify yourself, if you would, sir. You have 15
minutes for a full presentation and/or questions, starting with
the government caucus.
Mr Don
Wackley: Good morning. I'm Don Wackley. I'm the co-chair
of the Ontario Coalition of Senior Citizens' Organizations.
You'll notice my brief is very brief, because I don't think there
are a whole lot of things to be said except, "Do it." I'll read
the brief to you.
I come with no degree
except Parkdale 101 and as someone who has had a major heart
attack and four months of shingles and almost feels like a
resident at St Joseph's Hospital. Being adopted, I have no
history, so they are searching my body to find out why I would
have shingles. So I see the hospital as a person, as a patient,
as opposed to a doctor, a lawyer, a professional. I'll put on my
glasses.
OCSCO is a provincial
organization and a registered charity. Our mission is to improve
the quality of life for Ontario's seniors. Our members include
over 130 seniors' organizations representing 500,000 seniors from
across Ontario.
Although we represent
mainly organizations, we also welcome individual members. OCSCO
is community-based and not-for-profit and represents the
following groups: seniors, disabled, trade unions, natives,
health and recreation groups, retirees and women's organizations.
We are involved in education, policy development, alliances,
information, referral and counselling, outreach, specialized
programs and research.
We support the Public
Hospitals Amendment Act on three basic counts.
We feel there is discrimination. We feel strongly
that acute care hospital patients are being discriminated
against. They do not have similar protection as residents in
Ontario's nursing homes, charitable institutions, homes for the
aged and rest homes. Why are these acute care patients not
covered by the same bill of rights? Clients needing acute care
are every bit as deserving of respect, freedom of choice and
dignity as those in other institutions. We hope the Public
Hospitals Amendment Act, 2000, will correct this injustice.
The current cuts in the
health care field should not be allowed to affect the quality of
care given acute care patients. The idea of restraining patients
because of staffing shortages is repugnant. US studies show that
restraints, when used indiscriminately, have caused patient
injury and even death. The more confused the patient, the more
vigilant we should be in the quality of care we provide. Doing
otherwise diminishes us all.
Basic human rights: I'm 70.
As a senior, and all the seniors we represent, we are all too
well aware that there, but for the grace of God, go I. Tomorrow I
could be in that hospital and I could be under restraint.
OCSCO's mission is to
improve the quality of life of seniors, and restraint is not
saying anything much about life. When patients are restrained for
long periods of every day, where is the quality? Surely
motion-limiting controls such as over-medication, belts and bed
rails cause deterioration of the patient's life. We cannot help
but believe there are more humane solutions to the problems
leading to the use of restraints. In many cases, with proper
staff training and support, these problems can be solved while
respecting the patient's dignity and basic human rights.
The Public Hospitals
Amendment Act faces the whole issue of restraints with clarity
and realism. It outlines cases where restraint can be used; that
is, only when necessary to protect the patient, only when consent
has been given and only on a physician's written order. The act
offers further protection, such as limiting the time that
restraints can be used. For these reasons, we fully support this
act.
The Chair:
Thank you, Mr Wackley. We've got about three minutes per caucus,
starting with the government.
Mr Raminder Gill
(Bramalea-Gore-Malton-Springdale): First of all, Mr
Wackley, thank you very much for being here. We wish you well.
Hopefully, you have overcome your physical-
Mr
Wackley: I'm a good 70.
Mr Gill:
Great. You look good.
A couple of things. In your
submission, you mention under point 2, "the current cuts in the
health care field." I think the reality is a little different.
I'm not trying to-you know, we need the maximum amount we are
spending now, $22 billion. I'm not going to get into the
semantics of it, but the facts are that we're spending huge
amounts of money. The pressure is now on health care in a
different way, to try to control that maybe. Secondly, I'd just
ask you what kind of restraints and under what conditions you
would see that as valid treatment?
Mr
Wackley: First of all, can I touch on the first
part?
Mr Gill:
By all means.
Mr
Wackley: One of the things I do, when I'm not with my
organization, is play piano in seven seniors' residences in
Toronto. There are people now who can no longer come down to
where the piano is. There are not enough physical bodies to bring
them down, because they need help to come down there. I don't
know how much money should be spent on health care. That's a
whole other debate. Is some of it being wasted or whatever?
Personally, in the simple things I do in health places, I see
fewer and fewer staff. Therefore they cannot bring the people
down to do a simple thing that might be more humane than being
kept in their rooms, if they could come down and listen to
someone play a piano.
What was the second
question?
1120
Mr Gill:
The second question was, do you see restraint as of any use, or
are you totally against any kind of restraints?
Mr
Wackley: No, obviously I think there must be times when
someone needs to be restrained. But I look at hospitals and
places where I am, and I'm not sure why the bars on the beds are
metal. It seems to me that you could hurt yourself hitting
against metal. I look at that as an ordinary person and not as an
engineer, and wonder if there is not some way those could be
padded so they would be less hurtful. It's been said before by
other people, as I sat here and listened, that an 85-year-old
person weighing 112 pounds cannot really be causing a whole lot
of trouble to anyone else. There could be a gentler, kinder way
to restrain that person. I'm not a legislator and I don't know
how to write law. But as a person who goes in and sees things
like that, I wonder: isn't there another way, isn't there a
better way? The most frail people in our society should be
treated with much more kindness than they sometimes are.
Mrs
Pupatello: Thanks so much for speaking to us today. I
find it of interest that our colleagues across the committee here
would discuss the overall funding of the health system, always
with the idea to get out the information that the government in
fact is spending more money than ever before on health care. They
make lots of these grand statements all the time. My biggest
question for the government members, really, is what a terrible
job they must be doing, and question that they must be asking
their own chiefs of state what a mess they've made, considering
they're spending so much more money on health care. It's amazing
to me that most people believe our health care is in a much
deteriorated state since they took over, and yet they're spending
more money. What terrible managers we've got over there. So it is
an interesting time to come to the table today to discuss a
private member's bill regarding restraints.
With what I've heard over
the course of the last almost six years, much of what is
happening in institutional care directly relates to the funding
available for help in these institutions: hospitals,
long-term-care facilities etc. The nurses I've spoken with find
there aren't enough of them on the floor. They can't come back to the room
as quickly as they'd like to. They're finding that the use of
restraints is replacing the fact that we used to have people
there to care for them on a much more regular basis. But because
of the cuts to hospitals, which cannot be denied-and they may
want to talk about overall funding in the Ministry of Health
budget, but we have to specifically address that the cuts to
these institutions have been severe and that the effect has been
where most of the money goes in these institutions and that's for
employees.
The lion's share of any
budget is salaries to fund people to be there. The result of that
funding not now being there like it was, which, I would say to
the Conservative members, is inarguable-the money simply is not
there like it was before-is that in place of that we now see the
rise of the use of restraints. We can't get away from the funding
discussion around implementation of this kind of legislation. It
is going to have to address the need for funding in its
implementation. They are so tied together that we have to have
that discussion.
Just on that, I want to
thank you for coming today-and if you have comments in the groups
you represent as seniors. We know that by the time you can be a
senior, you as a group are using the system more than younger
folks, so what you have as an opinion frankly counts.
Mr
Wackley: Can I just say that unless the money being
spent is eventually spent for the patient and the caregiver, then
in many ways it's not worth being spent at all. It's not mortar,
it's not brick and it's not nice new paint. If the patient's and
the caregiver's life is not made better, then it's got nothing to
do with health.
Ms Lankin:
There are a couple of things I'd like to put on the record in
response to the points you raise. In particular, I want to start
with the issue of discrimination, because I actually believe
there is ageism in our health care system. Ms Pupatello talks
about the lack of front-line nursing staff in acute care
hospitals, and that exacerbating the use of restraints. In fact,
it may be the reason more often given today for the use of
restraints, but the use of restraints has been an age-old
problem, and that's not intended to be a play on words. The
reasons that used to be given were the safety of the patient, the
liability of the hospital, and working conditions was another. So
we have used restraints for a long time. The reasons we say we
use them change, and now the reason we say we use them more
frequently is because there aren't enough staff.
To implement an
age-appropriate setting, you are going to require more staff, but
there are other things that can be done. In New Westminster, BC,
the Royal Columbian Hospital developed a non-restraint standard.
They came at it from the other point of view. It was the nursing
management/nursing team that was on the committee doing this.
Some of the staff members objected to removal of the use of
physical restraints, and they cited patient safety as well as
staff liability and working conditions.
The committee looked at
those and found that the research demonstrated that the
restraints did not prevent falls and that people who were put in
restraints suffered emotional, mental and physical deterioration;
on liability, they found it didn't relieve hospitals or staff of
their obligation to provide a reasonably safe environment; and on
working conditions, they found that if they looked at the issue
of acuity of patients and the physical layout of the unit and
addressed alternatives, they could deal with the working
conditions, the staffing level issues.
They developed policies of
a corporate standard, integrating patient rights into the nursing
care philosophy, and a restraint-use protocol, that it was
absolutely a last resort-in the case of threats of severe
violence or suicide, you can understand that-but specific
conditions, which is what my bill sets out to do.
They also-and I thought
this was great-brought in a falls management protocol. Staff
identified someone who was at risk of falls when they were being
admitted and they looked at alternatives to the use of restraints
to minimize falls, like beds that are lower to the floor, as we
have in our homes, for example.
They also brought in a
wandering patient protocol. Patients who are mobile and confused
or agitated are identified on admission as at risk and they wear
housecoats with a unique pattern to make it easier for staff to
identify them.
They make it
age-appropriate. Surely what we seek to do here is to understand
that our system is not age-appropriate, therefore there is ageism
within the system and there are things we can do about it other
than tying people up.
Mr
Wackley: Yes, there is. There is ageism not only from
the hospitals, but where we live and how they make us live, but
that's a whole other story and we'll come and talk about that
another day.
The Chair:
Please come back and talk to us about that another day. Thank you
very much for your presentation.
ONTARIO HOSPITAL ASSOCIATION
The Chair:
The next presenters are the Ontario Hospital Association. Would
you come forward and identify your group. You have 15 minutes for
presentation and/or questions. Welcome.
Ms Hilary
Short: I'm Hilary Short, vice-president of policy and
public affairs at the Ontario Hospital Association. With me is Mr
Michel Bilodeau, who is president of SCO Health Services in
Ottawa and the chair of OHA's newly constituted task force on the
use of restraints in hospitals. Next to Michel is Elizabeth
Carlton, who is a senior policy adviser with the Ontario Hospital
Association.
The OHA, as most of you
know, represents all of the hospitals in Ontario on issues such
as this and provides a number of services to hospitals.
Let me begin by saying that
the OHA certainly is very sympathetic to the motivation of the
bill as raised by Bill 135, the Public Hospitals Amendment Act.
We recognize that the
appropriate use of restraints in acute care settings is a very
important and very complex issue. Certainly in the 26 years I've
been associated with the OHA, it's one that's been front and
centre on many occasions. We know how concerned our members are
with the appropriate use of restraints in hospitals.
1130
Following discussions that
our president had with Ms Lankin late last year, we did decide to
revisit the whole issue of restraint. We had published in 1993
some guidelines which do govern the best practice of use of
restraints, but we felt it was time, following the introduction
of the bill, to take a whole new look at the issue, and so we
reconstituted the task force under the chairmanship of Michel
Bilodeau. That committee, which is still in its early stages, has
indicated to us that regulating practices that are clinical in
nature is not practical and would not achieve the goals that the
legislation has. Rather, we need to take another look at current
practices, work with patients and providers to research best
practices, such as the one that Ms Lankin just alluded to, and
launch new education initiatives in this field.
But we are going to look at
the whole issue again, look at hospital practice in the province,
get input from frontline caregivers with a view to revising our
guidelines from 1993, or indeed do anything else that our task
force of hospital experts recommends.
I'll now pass it over to
Michel Bilodeau, the chair of this committee, for his very
specific comments about the legislation.
Mr Michel
Bilodeau: Thank you and good morning. I'd like to echo
Hilary's comments, because this is indeed a very sensitive and
complex issue and we are very sympathetic to the issues raised in
Bill 135. I can say that in my own hospital, which is a chronic
care and rehab hospital, we had an internal task force that
worked for one year to develop our own internal policy of least
restraint, so this is not something that we take lightly.
But this bill attempts to
codify current policies of least restraint by strictly
legislating how health care professionals should exercise their
professional judgment. While we fully endorse the policy of least
restraint, as you can see from the OHA's 1993 guidelines, we
believe legislation would not be effective in achieving that
goal. Legislation is not an appropriate or an effective method of
addressing issues of a clinical nature. I could give as another
example where we are very much in favour of substituting generic
drugs for trademark drugs, but having a law to force physicians
to do that would not bring very efficient results.
A legislative approach
conflicts with the professional approach to clinical
decision-making based on evidence and professional standards and
the implementation of best practices. While legislation may have
some place in ensuring the necessary lines of accountability and
monitoring, it has no place in prescribing actual practices. As
drafted, we think that Bill 135 is overly prescriptive and its
spirit runs contrary to the discretion granted to health care
professionals.
This encroachment on
clinical practice will undermine the expertise and integrity of
front-line staff. It runs counter to the idea of the unique needs
of patients and conflicts with the prerequisites of
multidisciplinary patient-focused care. It eliminates the
opportunity for individual assessment and treatment by a team of
health care professionals by placing all responsibility on the
physicians. Further, in view of hospitals' concern in respect of
liability and to protect against patient injury, it is possible
that one of the unforeseen results of this legislation might be
more widespread sedation of patients-that is, chemical in lieu of
physical restraints-and the reluctance to admit patients who are
at risk of requiring restraints. We are extremely concerned about
these potential side effects of the legislation.
The OHA is also concerned
that Bill 135 does not address a number of key issues. It places
all responsibility on physicians, while assessing patients for
the risk of injury to self or others and recommending the use of
restraints is part of the nursing scope of practice.
The bill also does not
include a provision for resolution of disputes between the care
team and the patient or substitute decision-makers.
Ms Short:
One further point. We've heard reference to the fact that the use
of restraints is increasing. It's an important point, but the use
of restraint in acute care hospitals is not currently documented
or reported, so we don't really have information one way or the
other as to whether it is increasing or it is not.
In chronic care
hospitals-
Mr
Bilodeau: We have figures for chronic care hospitals
because in the last four years the government has mandated the
use of a classification system called MDS RUG, and since then, we
have to report all use of restraints for chronic care patients
throughout the province whether they are in acute care or chronic
care facilities. We know from these figures that the prevalence
has declined from 29% in 1996-97 to 25% in 1998-99, and we'll
soon get the results from 1999-2000. Then we can compare with
others. We have no such information for acute care hospitals, so
we really don't know what the prevalence is at this time.
Ms Short:
In summary, we believe that the most effective route to achieving
consumer- and patient-focused best practice is through
guidelines, education and implementation of these best practices
rather than through legislation. We have made it a priority for
our association and our members to examine current practice, and
we will be providing education based on what we learn. It is the
opinion of the OHA and our task force at this point that the
issue of appropriate use of restraints in acute care hospitals
needs to be reviewed and that the matter of legislation should be
deferred until the requisite fact-finding has been completed.
And with that, we'd be
pleased to answer any of your questions.
The Chair:
Thank you very much. We've got a couple of minutes per caucus, so
I think we'll limit it to one question per caucus.
Mrs Pupatello: Thanks so much for
your presentation.
Decades ago it used to be
widely acknowledged that the use of lids on beds for psychiatric
patients or people in sanatoriums was completely appropriate.
That's how they would put them to bed at night-put a lid on the
bed like a pot. That is wholly unacceptable today; we wouldn't
think of doing that to animals.
I guess my point in saying
that is that public opinion has certainly shifted widely toward
the patient and I respect the comments that you've made with
respect to how service is delivered within a hospital site. But
if the service is really going to be patient focused and public
opinion really has shifted significantly-you have commented on
the use of restraint and the discussion around it, but you
haven't commented on the practice that would lead up to requiring
a restraint and that is all of the alternatives that ought to be
in a discussion within a hospital site before restraint is
used.
Mr
Bilodeau: Certainly part of the work that we're trying
to do with the task force I chair is to identify best practices
throughout the various hospitals to find out why some hospitals
would have a lower rate than others, because basically everybody
endorses a policy of least restraint but some have a lower rate
of restraint than the others. So you have to look at different
types of population, but you also have to look at different types
of education for the staff and different types of other tools
that may be put at their disposal and how they actually emphasize
that issue.
There is no easy answer to
this problem. I was talking to Hilary before the presentation,
saying in my own hospital, six years ago, we had a patient who
died from falling from the bed where he was restrained, and
obviously that was an element that prompted us to reduce
drastically the use of restraint. Last week, however, we had a
patient who fell and injured himself while being washed by a
nurse. I was hearing people say, "Anybody can defend himself
against a 112-pound lady." That patient had been insulting that
black nurse with racial insults for 15 minutes and took a swing
at her. She went back, crying, and the patient, who was not
restrained, fell.
So it's not easy; it is not
simple. If it were simple, we would have resolved it a long time
ago. I think education, over time, and sharing our experience are
the best things we can do. I don't have an easy solution.
1140
The Chair:
Ms Lankin?
Ms Lankin:
I'm going to use my time to make a few comments on the record in
response to your presentation.
I appreciate the OHA's
interest in this issue, the establishment of the task force and
the work that you've invited me to be part of leading toward an
educational conference or initiative. I know we are working in
the same direction.
I must say I am not
surprised that the OHA's position is to either not support or, in
this case, defer-I am actually glad to hear the language is
"defer"-consideration of legislation. I think I know that it
actually means not to support further regulation of public
hospitals, because in my experience over the years, in the
relationship I had with the OHA as Minister of Health, that has
been a consistent position that the OHA has taken. I have told
committee members this in legislative debates.
One of the examples that
comes to my mind is the issue with respect to organ retrieval and
referral and the education of hospital staff, to have a team in
place to do the direct acts, of patients or of patients'
families, and that was resisted in terms of a regulatory answer.
The OHA said that it was sensitive, and the OHA said that they
were developing new policies, and the OHA said that they would do
further staff education, and it wasn't a simple issue, all of
which was true. A number of years later, eight years later, we
have now passed the legislation to put at the base of this and
we'll work with the OHA to implement all of the other wonderful
things.
I think the same is needed
here and, if I may, in response to your brief, point out the
reasons why I think the attitude just isn't going to get us
there: you have indicated that restraint would rarely be a
medical treatment. I agree. But you say that it's a means of
facilitating medical treatment, either to prevent tubes from
being dislodged, to prevent falls or reducing risk of additional
injury. All the research says that all three of those statements
are absolutely false, yet I know they are the attitudes that
prevail; they are the beliefs that prevail.
In your written brief as
well, in terms of getting consent to treatment, you say that's
often impractical and that it could take several days or weeks of
evaluation to determine capacity. You have to know capacity
before you can put any treatment in place. If you don't think the
person is capable, the doctor has to seek substitute decision
approval. I find it extraordinary that that would be
suggested.
You've indicated in your
oral presentation that the lack of use of restraints will often
lead to the use of chemical restraint, sedation. In fact, all the
research shows that when you physically restrain someone, the
agitation that's brought about automatically leads to a greater
use of sedation.
All of what you have put
forward I know are the commonly held beliefs on the front lines,
but all the clinical research that has been done supports
something different.
The Chair:
Ms Lankin, I think if we could just give them a chance to respond
and then move on, if that would be satisfactory.
Ms Lankin:
I wasn't intending a response. I had one more point that I wanted
to put on the record. I indicated that I wanted to make some
comments in response to what had been said.
The Chair:
Very quickly, if you would, please.
Ms Lankin:
The last thing I wanted to say is that I agree with you that we
don't have incidence rates for public hospitals, in terms of the
use of restraints, and I think the commitment to start to do that
is important.
One of the things I think we have to acknowledge is
that, although a lot of policies in hospitals say it must be
charted, it is in fact not being charted. It has become so
routine that it's not being charted. Unless we get at that, we
won't be able to do the kind of checking that the hospital report
card might propose to do to monitor the use of restraints. That's
a major piece that I hope you will look at on your task force, Mr
Bilodeau. Thank you.
The Chair:
The government caucus?
Mr
Tascona: From what I've heard this morning, the policy
you've adopted philosophically is a policy of least restraint,
and that in terms of acute care hospitals there really is no
evidence that's collected on the incidence of the use of
restraints; yet in the chronic care hospitals it would appear
that the incidence and the use of restraints are decreasing.
What I can take there is
that there really is no evidence on an increase in the incidence
and use of restraints. What I'd like to ask you is, in this area
is there any relationship between the use of restraints or the
incidence of restraints and the funding level a hospital
receives?
Mr
Bilodeau: There is certainly no relationship. Hospitals
are funded on a global basis, which means that there's not even a
relationship between the funding they get and the types of
patients they treat.
Mr
Tascona: So to bring it back one step, there really is
no evidence out there that there is an increase in the incidence
in terms of the use of restraints.
Mr
Bilodeau: Not that I'm aware of. I think there is an
increase in the awareness of what it means and certainly an
increase in the awareness means there is a practice that has been
there for a long time. Even though most people felt that it was
not the right thing to do, it has continued. Now there is an
increased awareness. Certainly, as I said earlier, in chronic
care hospitals, chronic care units and acute hospitals we now
have data as an incentive to reduce, because when you are
compared to other hospitals, if you see that your rate is higher,
you want to discover why. That brings you to look at what's going
on and to reduce the use.
Certainly, if we can do the
same thing in acute hospitals-and we do don't know what our
recommendations at the end will be, but we now have the tool of
hospital reports annually, and that's the type of thing where,
for example, we could end up trying to find indicators that would
be reported regularly that would tell hospitals how they fare
compared to others, and it would be a strong incentive to improve
what they do.
Mr
Tascona: The issue here essentially, what you oppose, is
that this is a clinical decision, an exercise of professional
judgment in terms of using restraints, and you don't want that to
be legislated.
Mr
Bilodeau: We don't want it to be legislated and we also
think it's not going to be efficient at the bedside when the
actual caregivers are faced with the situation. We think,
however, there's a major operation within the hospital world to
provide incentives and means to people to reduce the use of
restraints.
The Chair:
Thank you, folks, for your presentation. We appreciate it very
much.
CANADA'S ASSOCIATION FOR THE FIFTY-PLUS
The Chair:
The final presentation before lunch is from Canada's Association
for the Fifty-Plus, if you would come forward and make your
presentation. Again, you have 15 minutes for a presentation
and/or questions. We will be starting with the NDP caucus. If you
would identify yourselves, please.
Mr Bill
Gleberzon: My name is Bill Gleberzon. I am the associate
executive director of CARP, Canada's Association for the
Fifty-Plus. My colleague is Judy Cutler, who is the director of
public relations and communications. We've handed out our formal
brief, which I'll address, and Ms Cutler will add some comments
when I'm finished.
We obviously want to thank
you for the opportunity to present our brief on Bill 135. You can
find out about CARP, which represents 236,000 members across
Ontario. Our mandate is to express the concerns of 50-plus
Canadians. Our mandate is to provide practical recommendations
for the issues we raise. Therefore, we represent the
non-professional patients and their families and consumers and
bring that point of view to bear on the bill.
CARP recognizes that
patients can become unruly and agitated and that hospital staff
have a heavy and demanding workload. However, the use of
restraints should be regarded as a last resort to be applied only
after other alternatives have been exhausted. Although they're
not part of Bill 135 or an issue that should be legislated, CARP
represents that alternatives to the use of restraints should be
identified. In the meantime, restraints that are used should be
minimally uncomfortable, minimally humiliating, intrusive,
traumatic or life-threatening. We refer you to a study done in
1998 which identified 142 patients in the United States who died
of restraints during the previous decade.
1150
Our position on the bill is
that we support it. We would like to recommend the following
changes, however.
We think the last sentence
of the explanatory note should be revised to read, "The policies
and procedures must be provided to the patients, their families
and/or their substitute decision-makers on admission and posted
in patient rooms." Families and substitute decision-makers should
be part of any decision in treatment.
We've presented this on the
basis of the various clauses of the bill, so I'll walk you
through them very quickly.
On subsection 34.1(2), the
definition of "restraint" should include chemical restraints as
well as physical restraints.
On subsection (3), the use
of restraints should be defined in the bill as being implemented
as a last resort.
Subsection (4): if a restraint must be used without
the consent of the patient or the patient substitute, information
about this application must be shared with the family, patient
substitute decision-maker and hospital administration or
appropriate or designated hospital official as soon after the
usage as possible. I'll leave the rationale to you in the
interests of time, but our rationale for all these
recommendations is included.
Subsection (5): the
physician's order to use restraints should be made known to and
discussed with the patient's family and substitute
decision-maker. We recognize that may not always be able to be
done before, but it must certainly be made known to the family or
substitute decision-maker if an emergency arises and it must be
applied.
Subsection (6): patients
must not be humiliated in any way through the use of
restraints.
Subsection (7): staff
training should include knowledge about acute confusion and the
sundowning effect, as well as the legal and ethical dimensions
concerning the use of restraints.
Subsection (11), referring
to subsection (10): the word "reasonable" should be defined; for
example, within two hours of restraint. Also, this information
should be shared with the hospital administration, as noted
previously.
Subsection (12): prohibited
use of restraints should include as item 5-that is, this item 5
should be added-a measure to force treatment on a competent
patient who refuses treatment. So if a competent patient refuses
treatment, they should not be forced under restraints.
Subsection (14): hospitals
should provide a copy of their policies and procedures governing
the use of restraints to a patient's family member and/or
substitute decision-maker, not only to the patient.
Finally, the name of the
bill infers that there are restraints that are part of medical
treatment. If there are, what are they?
Those are the formal
comments. I'll ask Ms Cutler to add some informal comments.
Ms Judy
Cutler: CARP feels, and I personally feel from having
had experience as an informal caregiver at home and in a
hospital, that there are some issues that have to be considered
in terms of not needing restraints.
One definitely is ageism,
as I'm sure has been brought up many times. Another is that with
increased palliative care and geriatric care, the elderly would
be in a situation that was perhaps more conducive to what their
needs were, and restraints would not be so necessary.
Because informal caregivers
are becoming integral to the health care system at home and in
institutional care, they need to be included in decision-making,
they need to be trained, and they need to be supported, because
often they are sitting around helpless and just reacting to
things instead of being able to deal with situations.
Certainly, cutbacks are an
important issue because the staff is less and the workload is
more.
I just want to close by
saying I heard a while ago a statement that we used to be
considered human beings and now we're considered consumers, and
since that, things have changed and elder abuse has become
borderline in terms of restraint.
The Chair:
Thank you very much. Again, we've probably got a couple of
minutes per caucus, so we'll hopefully limit it to a question per
caucus.
Just an explanation: you
made a comment, sir, regarding the explanation note on the bill.
That is exactly what it is. It's an explanation note and does not
form, or probably will not form, part of the bill.
We'll go to Ms Lankin.
Ms Lankin:
Thank you very much for your presentation. I think it's a good
question when you say, "When could restraints actually be part of
medical treatment?"
What was in my mind was if
you're in traction, and I've had a really hard time. People have
come forward and said, "We've got to get the right definition."
If you just view that it is a barrier to free mobility, in fact,
when you have a broken leg in traction you're in that situation.
Presumably you will have consented, but you could come in from a
trauma and not consent, and so I was trying to work through that.
But I think your point is at the crux of it: when is it in fact
medical treatment? It rarely is and yet it's frequently used.
I wanted to ask you a
specific question. In item 7 you refer to staff being trained
about acute confusion and the sundowning effect. I'm sorry, I
don't know what that terminology means. Could you explain that to
me, please?
Mr
Gleberzon: Sure. In a sense, the point of raising that
issue is that these are the kinds of issues that staff have to be
aware of before they apply restraint, and it's part of the bigger
issue of the need to properly educate staff. The reference, by
the way, is to this little pamphlet that was produced by the
Ontario government a number of years ago called Acute Confusion
in Seniors: What It Is and How You Can Help. In this little
pamphlet there are definitions of "acute confusion," which is a
medical state that many seniors fall into, and many people do as
a result of a reaction, if you will, to medications and other
forms of treatments. The "sundowning effect" is the fact that
these conditions seem to vary by time of day.
It's really to make the
point that there's a need for these kinds of conditions to be
known. I don't know if this pamphlet is still available. I was
part of the unit that produced it and they used to be in the
government. I believe they were all thrown out when the
government was formed in 1995. But if they are available, they
certainly could be very useful because they were produced by
geriatricians.
Ms Lankin:
Could we ask you to lend it to the clerk for 20 minutes so we
could photocopy it and get it back to you?
Mr
Gleberzon: Sure. I'd be happy to do that.
The Chair:
Thank you, sir. Government caucus.
Mr Gill:
First of all, thank you again for the presentation. I think your
points are very valid, but you may be wishing for quite a bit, in
the sense of on page 3, the first couple of lines, "Restraints
should be made known
to, and discussed with, the patient's family and substitute
decision-maker."
I think those are great
things but, practically, I think we heard of a case in point a
few hours earlier where the patient had fallen a couple of times.
She wanted to go home, but the idea was that she could get hurt
again. The daughter also said, "How many times am I going to be
called? You are being sort of a burden on me."
Even though this
theoretically makes sense, that you should be talking to the
family and the decision-maker, practically I don't think that's
always possible. But I think your point is valid. It should
perhaps be tried.
A little lower on the same
page, item 12 says, "A measure to force treatment on a competent
patient who is refusing treatment." I think with "competent,"
again definition-wise it could be quite challenging. How do you
determine if the patient is competent and he or she is refusing
treatment? According to the professionals, if they are refusing
treatment, they may not be felt to be competent. Do you follow
where I'm coming from?
Mr
Gleberzon: Yes.
Mr Gill:
So that may need more definition or clarification. I have just
those observations, unless you wanted to add something to
that.
Ms Cutler:
Obviously there are going to be situations where it's a fine
line, but it doesn't mean that should become the rule.
My mother was in the
hospital and I was looking after her in the hospital and at home.
She was strapped into a chair. She was very frail and she started
to feel ill. I went to get the nurse to say she was feeling ill
and I was told it's not worth going through the whole exercise
for her to sit there for less than half an hour. That's why I say
patients have to be treated as human beings and not
consumers.
1200
Mr
Gleberzon: As for the last point, I can only point out
that there's been a lot of research done on the issue that you've
raised-the last one about competent patients. There's a great
deal of literature and, as I understand it, some of the states in
the United States have actually legislated around that particular
issue. So I think that if there's going to be an exploration of
competency, there is a lot of material that you can turn to to
assist in defining it.
The Chair:
The Liberal caucus.
Mrs
Pupatello: Thank you for your presentation. I find it
interesting that the discussion revolves around what we're going
to prove in research for increased use of restraints, for
example. We are hearing now there is nothing that says there is
an increase in restraints, so maybe there isn't a problem after
all. That's what I'm starting to hear and it's worrisome to
me.
I had the unfortunate
experience of spending far too much time in a hospital and
listening quite late at night to people yelling, "Nurse, I have
to go to the bathroom," and the response was, "It's OK, you can
go." Because, you see, in my city there have been such
significant cuts to our hospitals resulting in such a lack of
staff that often the patients were diapered because they did not
have the staff to get these people to the bathroom. That's the
way it was. This is going back to 1995, 1996, 1997. Despite this
legendary funding of the health care system, that is the
practical reality on the floor for many seniors to deal with.
I've spoken with seniors who were completely humiliated to have
been diapered and they were completely cognizant that this was
happening to them, but it was because they did not have the
nursing staff to get these people to the bathroom in a timely
fashion.
So I'm suggesting that
perhaps the government should institute a count on the use of
diapers in Ontario hospitals as well. Then we'll have the proof
we need to show that diaper use is on the increase, and maybe we
can extend that to say that we don't have enough nursing staff in
our hospitals. If we're going to use this kind of rationale to do
nothing about the use of restraints, then I think we've got to
carry this mentality right through the system and start counting
these things so that we'll have a reason then to take this bill
seriously. I don't want to mock the government about it. It's
just too serious an item. But this is what we're already
seeing.
I'm also sensing from the
OHA presentation, perhaps, the battle between the will of the
people versus the will of the professionals. At some point, it's
public opinion that has to drive what we, the public, will
receive in health care. In many cases, whether it's good or bad
for us, if it's what we want, whose right is it to receive that
level of care? This is going to be the battle of the new
generation of seniors, in my view: what is it you want and
therefore what political will are you prepared to bring to bear
to ensure that is how the health service is delivered?
This is not a new
experience for CARP, because I think you are being labelled with
that advocacy role. It's becoming increasingly apparent that you
have huge numbers that you're representing and your group is
going to become larger; the demographics tell us that. I guess I
want your opinion. In this case, is it what you want as the
public that you will insist will be the care you receive or is it
going to be the will of the professionals to determine what's
best for you?
Mr
Gleberzon: Just to make a couple of comments: number
one, as I understand the bill, this is related to non-medical use
of restraints. It has nothing to do with the medical treatment.
We did raise the issue about what is, in medical treatment,
defined as restraint. Anyway, without pursuing that, the other
thing that's disturbing to hear is that in one sector of the
health care system there is no evidence being kept, there are no
records. If I understand correctly, in the chronic care part of
the system we don't know how much, if any, is being used, if it's
up or down. The issue has been raised, and the issue has got to
be explored.
The third point I can make
is that we're responding to the many calls we get from our
members who are family members, in many cases, whose parents or
family members are being restrained. They didn't know about it;
they weren't told about it. They had a sense something was going on-they didn't know
what-because they would find mysterious bruises over different
parts of the body.
So yes, we're representing
consumers on this, and the message we hear is that the people who
call us to give us guidance, to give us information, to give us
advice, say, "We do not support restraints." Therefore, we do
support a bill that will force the really very limited and
judicious use of restraints, if necessary, and the use where
everyone-the patient, the family member, the substitute
decision-maker and the public-is aware that this is going on.
The Chair:
Thank you very much for your presentation. That draws to a close
the morning session. We will reconvene at 2 o'clock. I thank
everybody for their co-operation.
The committee recessed
from 1206 to 1407.
The Chair:
Good afternoon, ladies and gentlemen. We will call the meeting to
order.
GERIATRICIANS' ALLIANCE
The Chair:
The first presenters will be the Geriatricians' Alliance, if you
would like to come forward, have a seat and introduce yourselves.
You have 15 minutes, which can either be total presentation or
part presentation and part questions. Welcome.
Dr Marisa
Zorzitto: My name is Dr Marisa Zorzitto. I am a
geriatrician and I am the past chair of the Geriatricians'
Alliance. I am presenting this submission on behalf of our
organization. I thank you for allowing us the opportunity to
present on this very important issue for the frail elderly.
The Geriatricians' Alliance
is a group of approximately 40 geriatricians and internists,
mostly in the greater Toronto area, who have organized for the
purpose of exchanging information about and advocating for the
best practices regarding the quality of care for the frail
elderly, regardless of the care setting these vulnerable
individuals may find themselves in.
The Geriatricians'
Alliance, through its information network, has gathered
considerable points of view and scientific information on the use
and the abuse of physical restraints and welcomes the opportunity
to present their collective views to this committee reviewing
Bill 135 which, as you know, is a bill to amend the Public
Hospitals Act to regulate the use of restraints that are not part
of medical treatment.
The Geriatricians' Alliance
strongly supports legislation directed toward improving the care
of the elderly and, in particular, the protection of vulnerable
elderly with cognitive and behavioural problems.
The Geriatricians' Alliance
is in favour of removing outdated practices and adopting more
progressive treatments of the frail elderly, particularly in the
acute care setting. It is with these principles in mind that the
Geriatricians' Alliance supports the proposed amendment to the
Ontario Public Hospitals Act.
Some of the background
information that leads us to make these recommendations is that
Ontario is faced with a rapidly increasing aging population, many
of whom are going to need acute hospital care because of a
medical crisis, usually pneumonia, a stroke or a diabetic crisis
of some sort. With this is associated confusion, weakness and
frailty. A review of the literature shows that in Canada,
restraint use in acute care among the confused, frail elderly is
33%, and possibly even greater than that, among this select
subgroup. This is an extraordinarily high rate compared to the
United States, where the prevalence is only 7% to 17%, and the
United Kingdom, where restraint-free is the practice.
Restraints are more
commonly used in patients who are confused. Fifty per cent of
people who die in hospitals have been physically restrained at
some point in their hospital stay. Moreover, some patients are
restrained even at the end of life. This practice is contrary to
every principle of good palliative care.
There is an extensive body
of evidence that does not support the use of restraints for the
confused, frail elderly patient. Restraints do not prevent falls
or self-harm. They do not prevent wandering. Restraints do not
prevent the pulling out of therapeutic interventions such as
intravenous lines, catheters or feeding tubes. On the contrary,
there is a great deal of information regarding the harmful and
injurious effects of physical restraint. They have been reported
to cause excess agitation, anxiety and combativeness, requiring
sedation. Sedation, in turn, causes decreased mobility, decreased
level of alertness, poor fluid and food intake, dehydration,
problems with swallowing, aspiration pneumonia, the loss of
mobility, bedsores, incontinence and regression in overall
function.
You can appreciate the
cascade of iatrogenic events when a confused older person is
restrained without knowledgeable supervision being available. The
use of restraints in this setting results in morbidity and
mortality and increased health care costs to deal with the
iatrogenic problem. Every geriatrician can cite more than one
case where physical constraints have contributed to iatrogenic
harm to the patient during their stay in hospital. Geriatricians
as a group have researched the problems of restraint and have
consistently advocated against restraints in favour of more
progressive, beneficial and, in the long run, more cost-effective
modalities.
Unfortunately, family,
nurses and other caregivers have a false sense of security in the
use of these outdated modalities of behaviour control for the
confused, disoriented elderly patient. Fortunately, reported
studies show that educational programs and ongoing monitoring
have been effective in reducing the use of restraints by over 50%
without the anticipated bad outcomes such as more falls or more
use of sedatives. Nevertheless, it has been show that without
consistent, ongoing monitoring and education, the use of
restraints tends to increase over time.
Institutions cite the
funding cutbacks and the shortage of nursing staff as causes for
the high use of restraints, particularly in acute care. The
Geriatricians' Alliance does not accept this argument and does not
accept restraints as a substitute for properly educated staff,
nor for an enabling environment. There is evidence-legislation
such as the restraints bill in the USA and the Long-Term Care Act
in Ontario-that restraint-free policies are effective in reducing
the use of restraints in these settings. In Ontario there is
monitoring of the use of restraints by Ontario Ministry of Health
compliance officers and the Canadian Council on Health Services
Accreditation. It is with these results in mind that the
Geriatricians' Alliance recommends such legislation, regulation
and monitoring in the acute care setting.
To be more specific, we
would make the following recommendations.
The Geriatricians' Alliance
certainly supports the passage of Bill 135 to regulate the
non-medical use of physical restraints in our Ontario hospitals.
Geriatricians, however, also recognize that laws themselves do
not stop undesirable care practices, and for this reason we
recommend several strategies to rid our hospitals of this
physical abuse of frail, confused elderly.
Some of the methods that we
would include are the inclusion of standards in the Canadian
Council on Health Services Accreditation of hospitals, as is done
with accreditation of long-term-care facilities, to ensure
compliance with standards; ensuring mechanisms are in place that
enhance education of health care providers in issues around
physical restraints, including alternative strategies; supporting
the Ontario Hospital Association in reporting restraints use as a
quality-of-care indicator in the hospital report card; funding
research into the medical reasons why restraints may be
justified; and lastly, funding research into the cost-benefit of
restraint-free practices.
In conclusion, the
Geriatricians' Alliance recommends that the amendment to the
Public Hospitals Act be enacted in order to promote humane,
quality care for the most vulnerable citizens in the province
who, through unfortunate circumstances, find themselves in the
acute care setting. Moreover, the use of restraints is not a
substitute for adequate staffing, nor is it a substitute for
progressive care practices, nor a substitute for age-appropriate
physical environments.
Thank you for giving me
your attention in addressing this issue.
The Chair:
Thank you very much. We've got a couple of minutes for each
caucus, so we'll limit it to one question, if we could. The first
one would be the PC caucus.
Mr
Tascona: I want to thank you for your presentation.
Earlier this morning we heard from the Ontario Hospital
Association. I note in your presentation, at the second page,
that the Geriatricians' Alliance does not accept any relationship
between funding and shortage of nursing staff as causes for the
use of restraints. The OHA accepted that there was no
relationship between funding and the incidence of restraints. In
fact, their policy is the least restraint, and that's what the
focus of their task force is going to be.
In their conclusions, they
don't support the legislation as drafted. They're embarking on a
task force to look into this matter a little bit more in terms of
there needing to be an impact analysis of what's going on out
there in their own sector, which is the public hospitals. Would
you support the OHA task force, which was established in December
2000, as something that should be done before any legislation
would be implemented in this area?
Dr
Zorzitto: I'll speak for the alliance.
Mr
Tascona: That's who I'm asking to speak.
1420
Dr
Zorzitto: OK. The alliance is in favour of legislation.
I should say that in 1993 or 1994 the Ontario Hospital
Association already had guidelines, but if these guidelines for
the participating hospitals have been implemented, they certainly
haven't been monitored or been effective. Reviving this whole
issue of the use of restraints has come much more to the
foreground and has seen a lot greater activity in this area just
by virtue of the fact that we are contemplating legislation,
because it has more clout and gives the public and the vulnerable
more protection. I think if the legislation is in place, there
will be a greater incentive for organizations to be serious about
this.
Mr
Tascona: I think the OHA is serious about it. They
started a task force in December 2000, and I think their position
was to complete that task force and then look at dealing with
legislation, if any is necessary. Do you think that's a fair
position?
Dr
Zorzitto: I think it would bring unnecessary delay.
Mrs
Pupatello: Good afternoon. I believe you have some roots
in my city.
Dr
Zorzitto: Yes.
Mrs
Pupatello: On behalf of all the members of the Fogolar
club who watch your career proudly, even though you're in Toronto
now, I'm going to go back there and tell them we had a chance to
hear from you at committee today. It's very nice to see you.
I want to correct the
record in terms of what the OHA did say and what they were
supporting in terms of use. What the OHA said when they were here
this morning was that they don't have data to prove that the cuts
in funding are resulting in increased use of restraints. They
don't know for certain that there's an increased use of
restraints because no one is monitoring it. That's what the OHA
said. They did not in fact deny that was the case; they simply
don't know for certain. We need to be clear about that.
Mr
Tascona: I think that's on the record, member.
Mrs
Pupatello: That certainly will correct the record.
I really found your
language quite strong when you said, on page 2 of your
submission, "For this reason we recommend several strategies to
rid our hospitals of this physical abuse." That's very strong
language. If the language is so strong-there is no doubt in your
mind that this is considered abuse-what other methods are there
for professionals in this field, such as yourself, to go forward?
Recognizing why it's sometimes required, I'm surprised that as an
alliance you would come forward with that strong language and not have an
impact in the hospital setting currently.
Dr
Zorzitto: There may be a number of reasons. Education is
certainly a part of it, and also the physical environment. The
physical environments of most of our hospitals today are really
not geared to dealing with a fairly large number of elderly and
confused people who wind up in an acute care hospital. So it's
the number of confused elderly who are in the hospital. There is
a certain body of knowledge that is not being transmitted to
general staff, and the actual hospital environment doesn't allow
for people wandering around, doesn't allow for maybe a safe
private room where a person could stay, maybe doesn't allow for
other means of having some supervision there.
Mrs
Pupatello: As a for instance in this case, the doctor is
the one who is going to say, "This is what you are to do with
this patient and this is what you are not to do with this
patient." If you are a patient who is confused in Windsor, the
staff will beg family members to stay all night, because the
patient is not in control. If that same patient were then sent to
a London hospital, like university hospital, that hospital
administration will call a private company and bring in a person
to stay overnight with the patient. That's because the London
hospitals have funding to pay for that staff person, whereas the
Windsor hospitals do not have the funding to pay for that
additional staff person. This is a very concrete example, within
the last two days, where this has happened and it is a function
of the budget. But if the doctor who is in charge of the patient
were to say, "I order this patient not be left alone," which may
then preclude the use of restraint, that in fact is the role that
the doctor would play. Is that how it would pan out in real
life?
Dr
Zorzitto: Yes. That additional person could also be
requested by, let's say, the nursing profession who say this
person requires more one-on-one supervision or attention. It
doesn't necessarily require a doctor's order. But restraint
does.
The Chair:
Ms Lankin.
Ms Lankin:
Just picking up on Mrs Pupatello's point about the difference in
hospitals, I've seen, for example, within the Toronto area, very
different treatment of confused elderly. I can cite one hospital,
for example, the Orthopaedic and Arthritic, which has a different
atmosphere in it, because they're not treating diseases. They're
treating bones, right? It's hips and knees, and there's just a
whole different mentality.
Many of their patients are
elderly and many of those patients coming through a major
operation, spinal or hip operation, have post-anaesthetic
confusion for a period of three or four days, and it is regular
practice for them in the evenings to bring in a bed-sitter as
part of the service that they provide, and yet other acute care
hospitals don't have that. It's a question of staffing
allocation, not necessarily funding of the hospitals but the
decisions within the hospitals. Are you aware of different
hospitals' approaches to this issue?
Dr
Zorzitto: Personally, most of the acute care hospitals
that I have been involved with seem to be pretty much the
same.
Ms Lankin:
And that is?
Dr
Zorzitto: That is that mostly they use restraints.
Ms Lankin:
We heard this morning the Ontario Hospital Association indicate
that there's just no data to say whether or not restraint is
being used frequently, more frequently, less frequently, and I
think that's true. There isn't hard evidence at this point in
time. There are studies that have been done at moments in
time-
Dr
Zorzitto: Yes.
Ms Lankin:
-that give us some indication of the higher frequency of use of
restraints in Canada versus other jurisdictions, but the members
of the alliance are people who serve that age population in our
hospitals in the GTA in particular. From your experience, do you
think there is a high frequency of restraint being used? Could
you describe for us what your experience is?
Dr
Zorzitto: My experience in the acute care facilities 0I
have worked in is that physical restraint use is quite common. I
can't say whether it's 50%, but it is common.
Ms Lankin:
Maybe just one last question. Compared to long-term-care
facilities where we actually have regulation in place that says,
"Use least restraint," there's a law, have you had experience
there? Is there a difference in the-
Dr
Zorzitto: I have episodically gone to attend at nursing
homes or homes for the aged. It seems to me that it's a much more
home-like environment-maybe many more individuals who deal with
attendant kind of care, less formal but still supervisory
care-and they may not be quite as agitated in that environment as
well and not requiring the various restraints.
Ms Lankin:
More age-appropriate care.
Dr
Zorzitto: Right.
The Chair:
On that, we will finish. Thank you very much for your
presentation, Doctor. It's a pleasure.
1430
MEL STARKMAN
The Chair:
The next presenter is Mr Mel Starkman, please. You have 15
minutes, sir, either for presentation and/or questions or both.
Welcome.
Mr Mel
Starkman: I'll just take some water, if you don't mind.
I take medication, and my mouth is very dry.
You have in front of you a
deputation that was sent to you by Don Weitz, a close friend of
mine. I'm Mel Starkman, the Mel who is mentioned in that
particular deputation.
I basically agree with this
bill, in what it's trying to do. The only thing I would have to
say is that the bill should cast its net a bit wider. I know the
Mental Health Act does have provisions for restraints and that's
the problem we're concerned about, that those regulations are
being used and abused. People go into mental hospitals, they have
problems and they're supposed to be cared for by the caregivers.
This bill doesn't designate, other than public hospitals, but a wider net should
be cast, as no one is speaking for the consumer-survivors
therein. We have people suffering from various illnesses and
injuries who are prone to be put under restraint, which this bill
speaks to, but inadequately in an age of fuller restraints.
In my situation, I was in
mental turmoil, not physical turmoil, as I will describe below.
How much worse off are those who are ill, old or injured? I would
argue, after my initial psychiatrization, everything that
occurred to me after that event was iatrogenic, medically
induced.
For the purpose of this
submission I am calling myself a survivor of the mental health
services. For three to five years I was under physical
restraints, off and on. Since 1966 I have been in and out of the
system, first in Branson hospital, then the Clarke and then Queen
Street, or satellite facilities such as a home for special care,
a men's boarding home and now a retirement residence, still as an
outpatient of Queen Street. I have been under physical,
mechanical, chemical and what I call menial restraints. I have
also had 38 shock treatments over a period of two years from 1966
to 1968, and that is part of the problem that I carry with me to
this day. Whether or not something else could have been done, I
don't know; I'm not a professional. I was a professional
archivist, and I was working at my job off and on for close to 20
years and I was going into hospital every few months getting
shock treatments. The long and short of it is they didn't do me
any good, despite what I was told.
We need to pierce the veil
behind excessive restraints for "mental patients" who are treated
on a sliding scale from neglect to abuse.
My memories of being in
restraints aren't very distinct, just fleeting flashbacks. The
memories have left emotional and some physical scars. In various
numbers of leather straps I was very uncomfortable and agitated,
at times incontinent and delusional. My nurses' and medical care
notes that I do have from my review board hearing make for very
interesting reading from 1991 to 1993. I reviewed them last year
and noticed that it was written in when I was in restraints, what
time I went into restraints, but it was never written in when I
left restraints.
I could have been in
restraints for two hours, four hours or six hours. I have no
recollection, and the notes don't make any particular note of
that. I know I was on Q15 observation, and the nurses looked in
on me every now and then and they didn't do very much. I know
that I was struggling in these restraints and finally I drifted
off into some kind of delusional stupor. If I was doing badly in
the restraints, their answer was chemical restraints. They would
give me something in the arm or the buttocks or something of that
nature, and I would drift off into sleep. As I said, it was a
very delusional sleep.
They did say what was
happening before I went into restraints and then they debriefed
me when I came out of restraints. Debriefing was, "Well, how did
you feel when you were in restraints? Can you talk to us now? Can
you behave now?" What was I supposed to say to them? As you
notice, I am very nervous now, even though I'm six years out of
hospital. I'm still under a lot of medication, which is making me
shaky or what you want.
As I said, in each case I
had no idea how long I was in restraints. No mention was made in
the notes of possible lesser, least-restrictive restraints.
While under restraint, you
become agitated, fearful and insecure, to say the least.
Restraints can lead to muscle deconditioning or lack of
co-ordination, putting one at risk of a fall. I've seen a number
of studies which have shown a marked decrease in falls from less
intrusive restraints. The greater the restraints, the higher the
injury factor.
In countries like Great
Britain and New Zealand, the use of restraints is a rare
option.
I couldn't find it in my
case notes, but I distinctly remember being tied up in rough
rope, not straps or anything of that nature but rough rope. I was
tied up from the top of my head through my arms and down to the
bottom of my feet. Who ordered that, I don't know. I can't
believe it was the doctor who ordered that. I think it was
just-I'm looking for the word-some malicious orderly who thought
they were having some fun or something like that by putting me in
that kind of restraint. Every time I figured out why I was in
restraints, that something was wrong, they said, "You're OK now.
You're out of the restraints." I've read the Mental Health Act
with the various kinds of restraints you put in it. I have never
seen rough rope being included.
Nobody else on the floor
was having this done to them. This was in the rehabilitation ward
and, as I remember correctly, I don't think in the rehabilitation
ward there was anybody else who was on restraints. There were
people who were in seclusion rooms, that I admit, but on the
rehabilitation ward there was nobody else who was on physical
restraints. I was the only one. Why I was in rehabilitation, I
don't know. I was much better off on the other floors, where I
wasn't in restraints, where I wasn't as agitated and as nervous
as I was when I got on the rehabilitation floor.
Chemical restraints are
another story altogether. The effects and the side effects are
very dangerous. I recommend that all survivors and "mental health
professionals" read Peter Breggin and David Cohen's book on
drugs, Your Drug May Be Your Problem. My problem is that I live
in a city where there are no doctors who can wean me off the
pills. Never again will I try-I tried to get myself off the
pills. I did a very foolish thing. I went off the pills cold
turkey and I lasted for two years, but then I got horrendously
sick. So I can tell you that chemicals do hinder
rehabilitation.
Some restraints are very
radical, meant to subdue you, like shock treatment and
psychosurgery. The former is still being used even though we
don't have very many statistics about that, but we know it is
still being used, while the latter is used only with informed
consent, or so-called informed consent. Bill 135 unfortunately
does not address these problems.
In an effort to be more positive, I'd like to
make some recommendations.
Stop demeaning
restrictions, like putting you in pyjamas and taking away your
street clothes and restricting visits from friends and relatives;
facilitate a prompt visit from a patient advocate and lawyer;
make a telephone available; and no seclusion rooms. And this is
one idea which could be very well used in a time of declining
budgets or cutbacks: peer support workers who could be trained
and could monitor consumers or survivors in restraints. When the
staff can't be with them, you could have a peer support worker.
They work in other venues even as we speak today, in places like
Sound Times, where they are very helpful to people who come in
there, and in other patient-oriented drop-ins where the peer
support workers do help out their fellow "patients."
1440
What I did want to say is
that I developed neuroleptic malignant syndrome from the drugs
and came close to death. I wouldn't want to repeat that
experience.
In conclusion, I want to
thank you very much for listening to me. I could say a few more
things. I am very active in the survivor community. I'm on the
board of Sound Times, a member-driven social, recreational and
educational program. Further, I'm on the Edmond Yu Safe House
committee, with various subcommittees, and the No Force
committee, which takes its time to try to educate both survivors
and "mental health workers." Thanks to my survivor friends, I've
developed strengths that Queen Street never really thought I had,
but I'm still under chemical restraints, as I've said, and as so
many of my friends are. That's why we have to go beyond Bill
135.
Thank you very much. Do you
have any questions?
The Chair:
We have about a minute per caucus, so it will have to be a very
quick question, and I believe it's the Liberal caucus first.
Mr
Lalonde: Thank you very much for taking the time to come
down and explain to us the experience you have gone through.
You're the type of person we should have at any time we discuss
amending especially the health act.
You have gone through the
physical restraint and you've gone through medication restraint.
Given the fact that on a daily basis you have to deal with a
nurse who is taking care of you and the fact that she's the one
who probably tied you up to a chair, how do you feel about that
person if you had a good rapport with her in the past prior to
her tying you up in the chair?
Mr
Starkman: The truth of the matter is that I didn't
particularly hate or despise the person whatsoever. In my own
way, I felt sorry for her because she was in a situation where
she had very little choice. If she hadn't put me in
restraints-there was so much going on around the place, and from
the medications I was going haywire-what was she supposed to do?
She had no choice. But I keep saying they could have used lesser
restraints than what they used. I was treated well, but some
parts of it I don't understand. I'm just at a loss to
understand.
Ms Lankin:
Mr Starkman, thank you so much for coming forward. I'm sure it's
difficult to retell those days that you've lived through.
As the sponsor of the bill,
let me tell you that my goal was to try and bring in some kind of
law for a section of the health system where there's no law at
all, and that's the acute care hospital.
I've had a number of people
say to me that there are elements in this bill that they wish
were in place for patients under the Mental Health Act, whether
they are in an Ontario psychiatric hospital or in a psychiatric
ward of a general hospital that's covered under the Mental Health
Act, and that would apply to the situation you've spoken to, or
in fact under the Long-Term Care Act. I think that perhaps down
the road one of the things we need to do in Ontario is look
overall at restraint policy that governs all of our health care
facilities, but in the meantime not to lose the opportunity to
proceed.
I'm hopeful that people
like yourself would appreciate why I'm trying to proceed to cover
the area that's not covered yet and maybe engage the government
in a longer-term process to look at harmonization of the
provisions across all the sectors.
Mr
Starkman: Just to make one comment, I know that Cam is
already doing something toward this, because I'm involved in a
video that they are making. They're asking patients who have had
various experiences in restraints what they think of restraints,
and very much of what I covered today I covered in that video. I
hope it gets further exposure than just to the mental health
professionals. The Working Like Crazy video that was made about
the Ontario Council of Alternative Businesses I hope gets further
distribution throughout the population.
Mr
Wettlaufer: Mr Starkman, I just want to thank you for
having the courage to come down here and relay your personal
experiences. That will be invaluable to each of us as we review
the amendments to the bill, or clause-by-clause, whichever Ms
Lankin wants. Thank you very much.
The Chair:
Thank you, Mr Starkman, for your presentation. We appreciate
it.
MENTAL HEALTH LEGAL COMMITTEE
The Chair:
The final presenter today will be the Mental Health Legal
Committee. Welcome. You have 15 minutes, either by questions or
presentation. Would you identify yourself, and thank you very
much for coming.
Ms Anita
Szigeti: Good afternoon, Mr Chair. I was hoping you'd be
happy to see me because I appear to be the last presenter
today.
My name is Anita Szigeti.
I'm chair of the Mental Health Legal Committee. We are an
organization of lawyers who advocate on behalf of the civil and
legal rights of persons with serious mental health issues. In
some sense, I'm here to buttress and support the arguments and
eloquent submission that Mr Starkman has just made to you, as
well as to support the submissions you heard earlier from the
Advocacy Centre for the Elderly.
I want to bring to you our experience as lawyers
who represent hundreds of clients in mental health facilities
regarding their experience with restraints.
I want to tell you that the
use and application of various types of restraints in psychiatric
facilities varies widely from institution to institution, and
within each facility from ward to ward. Sadly, we see many
instances where locked seclusion, which health care practitioners
often refer to as therapeutic quiet, consisting of a mattress or
a pad on the floor, often without any bathroom facilities,
becomes someone's home without reprieve for days, weeks or months
at a time. Many of our clients never get out of some type of
physical restraint, for instance, a waist-wrist restraint. For
years, they will eat, sleep and go to the washroom wearing those
types of restraints.
Many of our clients are
routinely given major tranquilizers or injectable anti-psychotic
medications as so-called "as needed PRNs," also known as chemical
restraint. Alarmingly, sometimes these measures are obviously
implemented for staff convenience and, on occasion, as a form of
punishment of the patient. It is very disturbing indeed that the
same patient, manifesting the same set of behaviours, will be
secluded and restrained often in one unit of a facility while
allowed to roam free in another unit.
To illustrate our clients'
experiences with restraints, I would like to highlight for you
three examples. These are actual stories of my clients. For
purposes of solicitor-client confidence they've been shuffled
around a bit but, I tell you, it's close enough.
One of my clients is a lady
who was born in 1924. At the age of 23 she gave birth to a son.
Shortly thereafter, she suffered an episode of what is now
believed to have been post-partum psychosis, a condition which
apparently has never responded to treatment. Mrs X, let's call
her, is now 77 years old. Since 1947 she has been an involuntary
psychiatric in-patient in a provincial psychiatric facility, for
over 53 years. Most of her life she has been the subject of one
type of restraint or another. Always residing on locked
psychiatric units, often in physical or mechanical restraints,
constantly administered chemical restraints, these days she is
most often found secured to her geri-chair.
Another client is only 26
years old. He suffers from a genetic disorder which resulted in
developmental delays such that his intellectual or emotional age
appears to have been capped at about the age of four.
Approximately six years ago
he became angry at a convenience store owner for not giving him a
quarter that he was asking for and strong words were exchanged.
The individual was found not criminally responsible of the
offence of mischief or some other minor criminal offence and,
then, under the auspices of the ORB, was remanded to detention in
a psychiatric facility.
For the first four years or
so, he was very often secluded, regularly spending extended
periods of time in physical restraints, receiving PRN injections
of chemical restraint, due to aggressive behaviour vis-à-vis
other clients, patients or staff. He had a diagnosis of something
called intermittent explosive disorder, which in 1999 was removed
from the DSM, because I think it became apparent that it meant he
got angry sometimes. His speech was also difficult to understand
because the Hurler's syndrome he had affected the structure of
his mouth.
1450
Then one day a behavioural
therapist started to work with him. This therapist discovered
that my client was fluent in sign language, something he'd
learned as he was raised with children who were hearing-impaired.
The therapist began his work with the client. This, slowly over
time, allowed my client to live almost entirely without the need
for any type of restraint, including any locked seclusion. So
today you have an individual who is essentially a happy, smiling
young man who goes out on excursions every day, who has learned
with the appropriate help to just walk away when he gets angry
and frustrated.
My last story is about a
young native woman who was 17 years old when she was raped,
became pregnant as a result of the sexual assault and had an
abortion. Subsequently, she turned to street drugs and suffered a
drug-induced psychosis. Upon admission to a psychiatric facility,
she was promptly restrained and injected with a chemical
restraint. This experience for her rendered her essentially mute
for a long period after the admission to the psychiatric
facility. She subsequently told us of the treatment she received
in the psychiatric ward. It became for her a direct
retraumatization of the sexual assault, something which then
drove her away from voluntarily accessing psychiatric care at a
time when she most needed it.
Those were the anecdotes.
Unfortunately, as you've heard from Mr Starkman, there are
hundreds, if not thousands, of similar stories around the
province.
I just want to make two
comments about the debates we heard earlier in the morning. One
is that my reading of this bill is that it's not meant to be
politically motivated, that it's not meant to be about health
care funding. We're all in favour of health care funding, but
this bill, as I see it, is not meant to be about health care at
all. It's about, what I read from it and what I support,
prohibiting the illegal use of restraint. It's about a legal
point, and that is, when does our law permit restraint and when
is a restraint that's applied illegal? So it's a purely legal
question.
The other thing I heard
being debated is whether or not there are statistics to support
the notion that the incidence of restraint is on the rise. It's
my feeling that those statistics are entirely beside the point.
If there has been one situation where restraint has been applied
to an individual that may have been illegal-and it sounds as if
the justifications perhaps for the restraint of Ms Lankin's
mother may or may not have been there. But you've got at least
one incident where someone was bound and restrained, to which
someone objected. If you've got one situation where that type of
restraint has been used, it's my submission that that's one too
many and we need this type of legislation to make sure that doesn't
happen again.
These are the reasons we
support any effort to regulate or control the administration of
restraints to anyone under any circumstances. We support the
intent of Bill 135. We would, however, as Mr Starkman has said,
like to see its protections extended to involuntary psychiatric
patients and all patients under the forensic mental health stream
who are now detained in psychiatric facilities.
What I'm saying is actually
more immediately relevant than just asking for the dream world of
applying this to the MHA, the reason being that, as you well
understand, while some psychiatric facilities are not public
hospitals and some public hospitals are not psychiatric
facilities, certainly there are a great number of public
hospitals that are also psychiatric facilities. What I'm
concerned about is that by enacting this bill with the best
intentions, you're actually going to have the impact of eroding
some existing rights of some psychiatric patients when they are
psychiatric patients in psych facilities that are also public
hospitals. We've given you some written submissions that I think
take you through very clearly what some of those inadvertent
dilutions of existing rights might be. I'm not going to go
through all that. I want to leave a bit of time for people to ask
questions.
I want to tell you that we
support ACE's recommendations. The recommendations we want to
focus on are included on the second page of the executive
summary. Essentially, they are to agitate for the definition of
"restraint" to be more comprehensive, to include environmental
and chemical restraint as well as physical restraint; to make
sure that you include something in Bill 135 that makes it very
clear that this bill does not give authority to physicians to
detain either voluntary patients who happen to be psychiatric
patients, whether within a psychiatric facility that is a public
hospital or not; that this bill does not authorize the restraint
or detention of medical patients in public hospitals who would
otherwise fit the criteria for an involuntary psychiatric
admission.
What I'm worried about is
that physicians will say, "I don't need to certify this patient
even though they meet the involuntary admission criteria under
the Mental Health Act. I can just go by Bill 135 and apply
restraint to them, because that's all I really want to do
anyway." That will deprive the individual of a right of review
before a tribunal and an opportunity to get out not only of those
restraints but of the institution.
Those are some of the
points I wanted to make.
In a perfect world I'd like
to see the importation of some of the due process protections and
the higher level of protection that Bill 135 affords into the
Mental Health Act, so that you don't have a discrepancy-in ACE's
paper they point this out to you-between two individuals lying in
the acute care unit of a public hospital, one of whom happens to
also be an involuntary psychiatric patient at that public
hospital, which is a psych facility, and the other one is not an
involuntary psychiatric patient. For the person who is not an
involuntary psychiatric admission, the Bills 135 rules around
restraint would apply: there is consent that's required, there is
documentation that is more excessive, there is two-hour
monitoring, there's the requirement to disclose when a restraint
has been administered. Meanwhile, the individual who is an
involuntary psychiatric patient is governed by the Mental Health
Act and doesn't have any of those types of protection, just has
the minimal protections attaching to the Mental Health Act. This
could be very problematic for my clientele.
In general terms, the
thrust of the bill is appreciated and I think it's in the right
direction.
I'll stop there. If I have
left any time, I'll be happy to answer questions.
The Chair:
Thank you very much. I think we probably do have a couple of
minutes each.
Ms Lankin:
Thank you, Ms Szigeti. As always, it was clear, concise and
powerful, and a bit overwhelming in a sense. As we know, there
are complexities in the Mental Health Act and all of the
issues-rights issues and rights advice and those sorts of
things-which we don't want to see anyone lose, but which are very
difficult to import into the Bill 135 acute care setting, yet
some of the monitoring and accountability provisions in Bill 135
would be nice to have in the Mental Health Act. You heard what I
said to Mr Starkman. I could repeat my comments, how I feel like
I don't want to lose the opportunity to move in terms of the
acute care system.
From a legal perspective,
one of the things I find most fascinating is that in fact there
is no law, other than common law duty to care in an emergency
situation, that allows, as I understand it, for the restraint of
patients in an acute care hospital, outside of what is in the
Mental Health Act in that circumstance. So at this point in time,
an alternative for someone who was in my family situation, who
had a family member restrained against their will, would have
been to potentially pursue what, criminal charges? What options
are there if we don't move to have something that clarifies
this?
Ms
Szigeti: I think that's correct, first of all. My paper
sets out very clearly the only source of law on this issue is the
common law, which strictly says that in an emergency you may
prevent immediate serious bodily harm to the person or others, or
the Mental Health Act, which applies only to involuntary
psychiatric patients in psychiatric facilities.
The remedy is two-fold. One
is to press criminal charges for false imprisonment and for
excessive use of force. There is criminal law that says you can
protect yourself, self-defence, and protect others under your
care up to a reasonable point, but with any excessive use of
force, you've got false imprisonment. I always get them confused:
the other is false confinement. You certainly do have the civil
action, either with respect to assault or false confinement.
Those are civil lawsuits
that we don't often see but we could see every time an illegal
restraint does happen. You would think physicians would be
pleased to have a piece of legislation which maybe gives them
some guidance and direction, and staves off some of those
lawsuits if it can.
But it does absolutely have to be made clear that this is not
your green light to go ahead.
Ms Lankin:
That's right. That language is currently in the Mental Health
Act, a provision that says, "Nothing in this act authorizes the
detention or restraint," and it's impossible to import that
language into Bill 135.
Ms
Szigeti: I make some suggestions of how you could import
that very language. I have given you specific options and ways in
which you might want to consider doing that. I think it's
important. I'm very concerned that physicians will say, "For the
involuntary patient we have the Mental Health Act, and for the
voluntary psych patient or the non-psychiatric medical patient,
we have Bill 135." That worries me.
The Chair:
Thank you very much. The government caucus.
Mr Gill:
One of the things I agree with is you in a sense saying that even
sometimes one restraint is too many. Are you strictly against the
restraints, or in some settings, in some situations, are you
saying that restraints are needed?
1500
Ms
Szigeti: I think I would agree with the current state of
the law. We've got the common law, which tells us that in certain
situations a restraint is going to be required, and that's when
there is immediate risk of serious bodily harm to the individual
or to another person. So there are some cases.
Mr Gill:
Judged by whom? Who judges that immediate harm? Who would judge
that?
Ms
Szigeti: Presumably someone who knows something about
how to assess whether that harm is likely to occur. Whoever has
the appropriate training, not just about whether the harm will
occur but also about alternative measures and how to sort of
de-escalate and prevent that harm. Whether it's a physician or a
nurse-is that the type of question you're asking me?-I don't
know.
Mr Gill:
Yes, that orderly or nurse or doctor, again, subject to-
Ms
Szigeti: I have some concerns about the orderly. Maybe
that's not fair of me. I haven't really turned my mind to this
issue. I think restraint should be pursuant to a physician's
orders, though. Honestly, I haven't given it enough thought. I'd
be happy to give it more thought and let you know when I come up
with something.
Mr Gill:
One more thing, if I may; I would like to have asked this of Mr
Starkman. Perhaps you can answer it, because you represent those
people. He mentioned something about-as I take it, he's on
medication, but he called it being under chemical restraint. I
thought he could make his own decision and could say, "I don't
want it. The restraint is restrictive. Don't put it on me if I
don't want it." He did mention that he is under chemical
restraint, but I thought he could make his own decisions. Can you
explain that?
Ms
Szigeti: Let Mr Starkman explain his own situation. I
think what I heard him say was that-
Mr Gill:
Other people in that situation.
Ms
Szigeti: There's a difference between chemical restraint
and, for example, antipsychotic medication you would be taking as
treatment. You're quite right that when it's treatment, there has
to be appropriate consent. If you're a capable individual in law,
you have the right to refuse that medical treatment, and the fact
that it's psychiatric treatment makes no difference. So if you're
able to understand the necessary information and appreciate the
consequences of refusing treatment, you have the right to refuse
that treatment.
Chemical restraint, though,
the so-called PRN or as-needed injection, most often is not
something for which you do need consent, so it's regularly
administered to my clientele. In some institutions, the PRNs are
delivered at 5 o'clock every day to everyone on the unit.
Mr Gill: I
was thinking more of people who can make their own decisions and
still think they're under restraint, but they're under medication
and if they give that up they know they're going to get into some
serious problems.
Ms
Szigeti: Even people who are entitled in law to make
their own decisions as to whether or not to receive treatment can
be chemically restrained in certain situations, again to prevent
injury to themselves or others, at least notionally. They can be
given a psychiatric medication against their will, even if
they're capable of refusing it. That's the state of the law.
What we're concerned about
is preventing abuses of that, precisely in the same way as
physical restraints are sometimes abused, to include those
prohibitions against staff convenience or punishing the patient,
to prevent the administration of a chemical restraint for those
types of purposes. That's why I'd like to see those sections,
particularly, expanded to include a chemical restraint.
The Chair:
Thank you, Mr Gill. From the Liberal caucus, Mrs Pupatello.
Mrs
Pupatello: Thank you for your presentation. It was very
well prepared. I appreciated your comments at the outset
regarding the sidebar issue of funding. I wonder if you would
offer an opinion: What many of the staff people I've spoken with
in a hospital setting would like to do in terms of care is not
what the system allows them to do, and that's why I keep coming
back to funding issues. They've got the right intentions; they
intend to do well. If they could, they would have handled the
situation differently. It's a matter of the way the system
currently is. It doesn't afford them the luxury of doing what
they ought to do. They're doing what they have to do because of
the system they work in.
That's difficult, because
it's very frustrating for family members across the board. What
was interesting about the gentleman who presented ahead of you
was the examples he gave as recommendations of what not to do, in
terms of "Don't take these elements"-the phones, restricting
visitation, etc. There is an assumption inherent in those
recommendations that family exists, that there are friends, a
network, a social circle around that individual, which often is
not the case when we're dealing with elderly people. They are
often alone and family does not live in the same city.
Even the recommendations coming forward are
subject to the availability of that outside group to come in and
act as advocates in that circumstance. I don't know what advice
you can offer. This is the world we live in, though.
Ms
Szigeti: Right. I'm not suggesting it wouldn't assist
anyone to have better funding, better health care, more staff and
more services available. Of course it would. But I think this
isn't a question of best practices. You don't legislate best
practices. As the OHA recommends, you can sort of leave best
practices at the policy level and leave hospitals or facilities
to individually set their own guidelines for what they would
prefer to see.
What I want to drive home
is that this is a question of illegal versus legal action. Maybe
the nursing staff who doesn't have enough others around her so
she can't monitor or supervise such that a restraint is not
necessary would then still hesitate knowing that the application
of that restraint was going to get her sued. We're talking about
legal situations versus illegal situations. I appreciate there
are pressures on people, but I think what is missing is the
understanding that it's absolutely illegal to do certain things.
Whether they are staffing shortages or a lack of services, I
think if the individual health care provider understands that
some things are legal and some things are not legal, they then
manage their own liability in that regard, quite apart from
everything else.
What I was hoping to do was
refocus on the notion that this is a legal document. It's
legislation. It's about definitions of restraint, permitted or
prohibited, and it's entirely a legal question in that very
narrow scope. I'm just concerned that we not do anything that
muddles that territory more than it already is but rather try to
stay within our objective of reducing and trying to eliminate the
need for restraint.
The Chair:
Thank you very much for your presentation.
I think that's the end of
the presentations today. I want to remind the committee that we
will be meeting tomorrow in committee room 1, rather than in this
room, and that we will commence at 10 am.
