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 Judy Lever; Dr
William Molloy
Ontario Medical
Association
Dr Albert Schumacher
Ms Barb LeBlanc
Regional Geriatric
Programs of Ontario
Dr Rory Fisher
Registered Nurses
Association of Ontario
Mrs Doris Grinspun
Concerned Friends of
Ontario Citizens in Care Facilities
Ms Lois Dent
Ms Freida Hanna
Running to Daylight
Foundation
Ms Jane Hawtin
Ms Sharon Deutsh
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)
Mr Joseph Spina (Brampton Centre / -Centre PC)
Clerk / Greffière
Ms Donna Bryce
Staff / Personnel
Mr Andrew McNaught, research officer, Research and Information
Services
The committee met at
1002 in committee room 1.
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 Acting Chair (Mr
Wayne Wettlaufer): Good morning. I'd like to call the
meeting to order. I would hope this morning that we can give
everybody the consideration they are due, from Ms Lankin to the
presenters, and not get into political posturing today. I think
that this matter is too important.
JUDY LEVER
WILLIAM MOLLOY
The Acting
Chair: With that, I'd like to call our first presenters.
I wonder if you would introduce yourselves, please, for Hansard,
and we'll get on. You have 30 minutes. You can use any or all of
it in your presentation. If there is any time left over, we'll
have questions from the three caucuses.
Ms Judy
Lever: I'm Judy Lever. I'm a clinical nurse specialist
at the Hamilton Health Sciences Corp. My specialty is in
gerontology and my specialty is dementia care. I'm here today
because I feel strongly that we need legislation to monitor
restraint, because I've been working for the last 15 years in my
institution and throughout Ontario, trying to get policies of
least restraint developed and implemented.
We did some research a number
of years ago because of increasing concerns about the degree of
restraint being used in our hospital. We countered restraints in
four different institutions and published this in Humane
Medicine. It's called Prevalence of Physical Restraints in Four
Different Settings and Their Relationship to Medication Use.
In the hospital that I worked
in, of the age-75 population and over, more than 70% of them in
hospital were restrained at 10 o'clock in the morning. They were
restrained with vests that tied at the back and underneath the
bed or around the chair. They were restrained with wristlets,
tying their arms from either side. They were restrained in
geriatric chairs. They were restrained in beds with bed rails up
so that they couldn't get up and go to the bathroom. It was just
quite appalling to me that we could treat our seniors in this
way.
So basically, I did another
study, because we were working to try to get a policy of least
restraint at our hospital; we didn't have one. I worked on a
committee for a couple of years, and it took quite a long time
before I was allowed to do a pilot study where we would examine
the degree of restraint and reduce restraints on a couple of ward
areas in the hospital. We did this over a six-month period of
time, with no real cost to the hospital except for my time and
effort and the staff having to come to education sessions that
were held by me.
Over the six-month period of
time, we were able to reduce restraints by 50% on the two ward
areas, with no increase in falls or significant injuries. We
published this. It's called Reduction of Restraint Use through
Policy Implementation and Education. This was published in
Perspectives magazine, which is the Canadian gerontological
nurses' magazine, in 1995.
Subsequent to that I realized
that if we weren't going to monitor regularly, there might be a
problem. So six months after we finished doing the study on the
two ward areas, I went back in and did a prevalence count of
restraints after there was no emphasis being put on restraint
reduction and no more education. The degree of restraint had gone
back up to a higher level in terms of day-to-day restraints than
there was before I actually started the study. So I realized at
that time that a lot of it was attitudinal and it required a lot
of changing of old habits that die hard. I don't think it has
anything to do particularly with the degree of falls or the
severity of a person's illness when they come into hospital.
As a result of all of that
work, I wrote a booklet called Set Me Free, which is a booklet to
educate staff members on the different reasons why people might
be considered for restraints: people who might tend to fall,
people who have difficult behaviours that are hard to manage, the
habit type of restraint for the older person who just looks a bit
frail and the staff might be concerned that they would injure
themselves somehow.
I documented in this book how to reduce restraints
and use alternative methods. I wanted to use this booklet in a
large, randomized, controlled trial in various hospitals in
Ontario to see whether we could actually get a reduction in
restraints. However, we haven't been able to get funding or go
that far.
I also developed a small
booklet of the same name, Set Me Free, for family members. This
was to be used by health care professionals to introduce the
possibility of restraints and to educate family members about
restraint use prior to having the team discussion about the use
of restraints.
I've brought some of the
alternatives that are available for restraints today that are
quite easy. This one is a stop sign that can be put across a door
that you don't want someone to go through. It's just attached
with Velcro on either side of the door. It looks sort of like a
construction area. For people who are memory impaired this will
often work because, although they are not able to read a sentence
or something, they recognize the common signage and are able to
turn around and go elsewhere. There are also things called hip
guards, which is just one product that's on the market today,
that a person could have put on their hips if they are at high
risk to fall. These are not things that are commonly used in
hospitals today. Instead of using these kinds of alternatives, we
tend to put people in geriatric chairs. We put their bed rails
up, we tie them down and we reduce their mobility. It just makes
it a very bad scene.
Most of the nurses in the
hospitals know that there's a policy of least restraint, and in
most hospitals in Ontario we have policies of least restraint. We
have protocols, but they're not working. So my bottom line today
is that I think legislation is long overdue because we've tried
all the other methods to reduce restraints and we haven't been
successful. We need something to show that we're not
discriminating against seniors in our hospitals. This is really
an issue of seniors more than it is of younger, middle-aged
adults. Seniors are at very high risk, and the numbers coming
into our hospitals today are increasing.
I've brought copies of these
papers. I've also brought a reference list of the most recent
articles to do with acute care and restraints that have been done
throughout the world. There should be legislation to follow this
up.
Dr William
Molloy: My name is William Molloy. I'm a professor of
medicine at McMaster and a geriatrician. I work in acute care
hospitals. I work in the Henderson and Hamilton General, I work
in the Greater Niagara General Hospital and I work in the Willett
Hospital. I work all over the region and I've got fairly
extensive experience in this issue. I co-authored the studies
with Judy, co-authored the book. I had the opportunity some years
ago to be a travelling fellow in Australia and I spent six weeks
literally travelling through every geriatric unit in Australia,
from Tasmania to Perth, right across the country. I've travelled
extensively in Japan, I've travelled extensively in Britain and
Ireland. I do a lot of lecturing and a lot of education.
I can tell you that it's
embarrassing when our colleagues come from Ireland or Britain or
Australia. They come into our hospitals and they shake their
heads. They say, "What the hell are you doing here? What's this
with restraints?"
This is not new. We have the
data. The studies have been done. We did a study in our hospital
showing this is not a cost issue. With education-it's a
philosophy. It's a state of mind for staff: you don't tie up old
people. It doesn't benefit them. It reduces their quality of
life. It humiliates them. It reduces their functional state.
Just imagine we were going to
do this. Can you imagine if we came in here today and picked one
of you at random, we came up and tied you to the chair? Can you
imagine what that would feel like? We would put a jacket on, we'd
zip it up the back, we'd tie you to a chair and we'd leave you
there. Can you imagine how that would feel? That's what a
physical restraint is. It would never be accepted in the prison
system, it would never be accepted with children, but we're doing
it routinely in hospitals.
It's not being done in other
countries. In my experience-we have the data to show you-70% of
older adults aged over 70 in our hospital, a teaching hospital in
Ontario, are in a physical restraint at 10 o'clock in the
morning.
1010
Now you had Mr Bilodeau in
here yesterday. Mr Bilodeau is the CEO of the Sisters of Charity
in Ottawa and he is the chair of the Ontario Hospital Association
task force. I don't know what Mr Bilodeau told you, but when he
walked outside of this room to a press scrum he said, "I don't
think it (the use of restraints) is a major issue, personally."
This is the chair of the task force of the Ontario Hospital
Association who doesn't think it's a major issue. He went on to
say, "My guess is the law would just not be respected because
there would be no more money to do that." This is not about
money. This is not something that costs money. This is a
philosophy in our health care system.
In Ireland and Britain you
have to order bed sides. In Canada, in Ontario, go into our
hospitals, and every bed has a bed side. They're just put up
routinely. Do you know what it's like? It's like you're in
somebody's house and all of a sudden the father comes in and
whips off his belt and starts whacking the children with the belt
and you say, "What are you doing?," and he says, "Well, you know,
physical punishment is good for children," or whatever. It's just
a bad attitude. In Ontario we've tried the policies. This is the
OHA, this is our governing body for hospitals, not only showing
disdain for the issue by saying it's not important but by saying
that even if you pass legislation it will be ignored.
So this is our OHA. You can
get the OMA coming in here and saying, "It's not a doctor's
issue." It is a doctor's issue. It's everybody's issue in the
health care system. If it's my patient, I want to know if
somebody is going to tie him up. I don't want a nurse tying up my
patients. I have to be involved in that decision. It's a doctor's issue, a nurse's issue, a
physiotherapist's issue, an occupational therapist's issue, a
family issue and it's the person's issue. These are frail older
adults. They deserve our respect.
Number one, understand,
physical restraints have never been shown to be effective. They
have never been shown to do the things we think they're doing.
They don't reduce falls. They don't do any of those things. We're
in a bad habit in Ontario. We've tried everything. Please,
please, I beg you. Excuse me, please, I'm asking you. I came to
Toronto from Hamilton this morning. I'm asking you. Don't drop
the ball. Don't delay; don't fuss; don't fudge; don't put it off.
Please, pass this legislation. We need it. Please, I'm asking
you. This is not an issue that we can ignore any more. Please
pass this legislation.
The only thing we disagree
with is the two-hour monitoring. Do it 12 hours. Don't take the
doctor out of the loop. If you take the doctor out of the loop,
it becomes a nurses' issue. Leave the doctor in the loop. Leave
everybody in the loop. Everybody is responsible. Make sure before
we put on physical restraints in this province we get a consent
form, please, because it's not working, and if you think the OHA
is going to do something about it, you just got told nothing's
going to happen. Please, don't drop the ball.
Please, pass this
legislation, because we are so frustrated with this issue, we who
work in geriatrics. I'll just tell you one thing: there are three
people training in geriatric medicine in English-speaking Canada
next year. That's what the morale of geriatricians is like,
because we've not been supported by people like you in these
kinds of issues. We're losing ground. Please, put a mark in the
sand now and say, "From this point on if you're going to tie
somebody up in Ontario you have to document it and you have to do
the minimum," because this is a basic human right. These are
frail, older adults we're talking about. It's your mother and
father, and it's you in a few years down the road. Please, don't
drop the ball. Thank you.
We're open for questions.
The Acting
Chair: Thank you, Dr Molloy and Ms Lever. We have 17, 18
minutes. We have six minutes per caucus and we'll begin questions
with the Liberal caucus. Monsieur Lalonde.
Mr Jean-Marc Lalonde
(Glengarry-Prescott-Russell): Thank you. We'll split the
time between the two of us.
Thank you very much for
coming down and giving us your statement on this very important
issue. I'm really shocked by your comment about Mr Bilodeau and
the article in the paper. I happened to be speaking to Mr
Bilodeau right after his presentation yesterday, and he agreed
with me that most of the physical restraints are due to lack of
personnel and lack of funding. I haven't read the press clipping,
but I will be reading it pretty soon.
Dr Molloy:
Can I just respond to that one? This was a study we did in a ward
in our hospital, where we did not increase funding. We went in
and educated the nurses at the bedside about the use of physical
restraints and we put a policy in. We reduced physical restraints
within a couple of weeks by 50%. There was no increase in falls;
there was no increase in medication use. Nothing else changed. It
was just a shift in philosophy. It's simple.
The things we're talking
about are not expensive. We're not talking MRIs and CAT scans.
We're talking simple stop signs. We're talking simple creative
strategies. It has been done in just about every other health
care system in the world, but we're just not doing it in Ontario
and it's a disgrace. So Mr Bilodeau should maybe read up on
this.
Mr Lalonde:
I mentioned yesterday that I often visit nursing homes. I have
nine in my riding and I've seen those signs that you showed us a
while ago. You said that at the beginning you had 70% of the
people of 65 or 70 years of age-
Dr Molloy:
Age 75 and older.
Mr Lalonde:
-and over who were physically restrained. Then, after six months
of surveying, you found out that it came down to about 50%.
Dr Molloy:
Fifty per cent of that. We reduced it by 50%.
Mr Lalonde:
What have you done to reduce it down to 50%?
Dr Molloy:
Education. Judy went in and sat with the nurses and said, "This
person is in a physical restraint." The intervention was very
interesting. Judy will tell you. It was freaky interesting what
happened. We call it the cafeteria effect. Listen to this; it's
very interesting.
Judy went in and we gave the
nurses a lecture on it and nothing happened. We showed them the
policy and nothing happened. When Judy actually went in and stood
at the bedside and said, "This is how you get this person out of
restraint," physically went through the motions and showed them
the assessment and how they did it, then the physical restraints
came down. Very interestingly, in the ward that was the
control-we had one ward where we did the intervention and the
other ward was the control that we were following-it came down
simultaneously in the other ward. As soon as the nurses started
talking to each other, they taught each other in the same
hospital, and restraints came down even where we weren't doing
the intervention. Even nurses talking to each other in the
cafeteria could teach each other how to reduce the physical
restraints. This is not a cost issue, honestly.
The other thing-
Mr Lalonde:
Just quickly. I have another one before Mrs Di Cocco-
Dr Molloy:
Even if it were a cost issue, would it be OK to tie up old people
to save money?
Mr Lalonde:
Would you say at the present that we need to meet with organized
labour to have more access to visitors? Because going through the
documentation we received before we started this public hearing,
I read that places that have a lot of visitors tend to reduce the
number of times that you have to physically restrain the
residents of different nursing homes.
I remember that at one time
organized labour didn't like to have too many visitors who would
help the nurses or staff
to occupy the patients. Would you say that at times we need to
sit down with organized labour and discuss those matters with
them?
Ms Lever:
Those kinds of matters are discussed at a local level on a
regular basis. In the hospitals I work in, I don't think there is
any issue with people coming in to provide recreation, to provide
a church service, to provide other things that will keep the
persons busy and out of trouble. In fact, we use family members
quite extensively, as long as we're able to, to sit with people.
The more we can get them to do that, to use those kinds of
interventions, the less times that we might need to have someone
in a restraint.
Some people think that when
you put somebody in restraint, it releases the staff to go off
and do other things. But I'm here to tell you that almost all of
the coroners' cases involved with restraints are because
restraints were used, not because they were not used. People get
strangled. Restraints are not safe. There is an attitude out
there that if we put the person in restraints, we can leave them
for three or four hours and not bother coming back to them. These
people strangle themselves, fall over backwards in the chair and
damage themselves quite badly. They become incontinent, they get
pressure sores, they get all kinds of things because of lack of
attention.
If we just let them get up
and move around and take-I mean, there is a risk to everything
that we do in life. If we walk from that building to this
building across the road, we take the risk that we could have a
fall on some ice on the road or we could get run over by a car
that comes around the corner too fast and we didn't see them.
1020
When we get people like that
in hospitals, we tend to think we can protect them from every
kind of misadventure that would be possible. We have to remember
that old people at home, out in the community, fall at a
tremendous rate. It's not going to be any different when they
come into hospital. We can't prevent people from having injuries.
All we can do is have the safest kind of environment we can and
then let people take their risks.
You'd rather be told you can
go ahead and cross the road if you want to, not let somebody tell
you, "Oh no, don't cross the road. You might get hit." It's just
the same as telling an old person, "Don't get up out of the
chair. You might fall."
Dr Molloy:
It's an issue of consent. It's an issue of what you choose to do.
Do you choose to be tied into a chair in case you might fall, or
do you choose to say, "Let me get up and walk. I recognize I can
fall. It's OK, it's my choice or my family's choice"? That's all
it is. And guess what? Most people would choose to take the risk
of falling because it keeps them active, rather than tying them
up in a chair. Studies show that by tying people up in chairs,
you reduce their activity, you reduce their function, you
increase incontinence, you increase depression, you increase
frustration and you take away their dignity.
If you never want to have an
accident, then stay in that chair for the rest of your life,
because you're never going to fall. None of us would choose it,
but the hospital, because of some weird kind of system, ties
people up to protect them. In fact, it's counterproductive.
The Acting
Chair: Thank you. We've used up the Liberal caucus
time.
Ms Frances Lankin
(Beaches-East York): I have a number of questions that
flow from your presentation. First of all let me express, along
with the rest of the committee, our appreciation of your coming
and presenting to us today.
Yesterday in the Ontario
Hospital Association presentation they pointed out that one of
the problems in assessing a bill such as Bill 135 is that we lack
data about the use of restraints in acute care hospitals in
Ontario.
I have a couple of questions
with respect to that. You have a study that was done in an acute
care setting that is shocking, as far as I'm concerned, in the
numbers that were revealed. Did the OHA take that information?
Did it influence their policy or their procedures? Did they do
anything with your study at all?
Dr Molloy:
Ms Lankin, first of all we don't lack data. They don't know the
data. There's a difference. The data are out there. Anybody with
eyes can see it. Walk through our hospitals, look at the
bedsides, look at the old people in restraints, look at the
people in geri-chairs tied to railings, look at them tied with
sheets by their groin; it's out there. The fact that they don't
have data tells you the complete disregard they have for the
issue. Why haven't they got data? Is that our problem? We have
data; they're published. They're published in the Canadian
journal.
Ms Lankin:
Did those published data have any influence on hospital policy at
the Ontario Hospital Association level?
Dr Molloy:
They never contacted us. Nobody ever was interested. This Mr
Bilodeau-look at it. It's not a major issue and it's going to be
cost-I mean, this shows a complete lack of knowledge about this
issue. These comments are frightening, actually.
Ms Lankin:
One of the other things we heard is that there are some sectors
where we do have data being collected, in the long-term-care
sector, for example, and in the chronic care sector. The Ontario
Hospital Association pointed out the statistics that are
collected there show a decrease in the use of restraints in the
chronic care hospital sector. It wasn't said, but the committee
is left to wonder, would there be a parallel decrease in the use
of restraints in the acute care sector over the same period of
time?
Dr Molloy:
The reason there's a decrease in use in long-term care is because
there was legislation. The reason there was a decrease in use in
the States was because of OBRA. Other countries have shown that
legislation will reduce the incidence. Either you have it in your
culture, in your philosophy, in your health care system or you
have to legislate it. That's the reason it happened in the
States, and we need it in the hospitals. That's why we're telling
you, please don't drop the ball. Please don't defer this, please
don't put this off for another five years, because in five years' time
I'm not coming back. None of us is coming back. You won't have
geriatricians.
This is a big issue for us.
It's a fundamental human rights issue for older adults. Please
don't drop it. The reason you have to get legislation is because
we have failed with every other thing we've tried. There's no
teeth to anything. It frightens me that even before you pass your
legislation, the head of the OHA task force is telling you
they're going to ignore it anyway. What complete disregard for
the process we're going through. That's really not acceptable.
This is what you're dealing with. You're going to tell me that
these people are going to go ahead and follow up with this when
they tell you they're even going to ignore legislation.
Ms Lankin:
Dr Molloy, you made reference to the work you've done over the
years and extensive travel in Japan, Australia and the United
Kingdom. We heard from presenters yesterday, the Ontario
PsychoGeriatric Association, Dr Janice Lessard and others, that
in terms of international comparisons in Canada-not just Ontario
but in Canada-we restrain patients at a much higher rate than the
United States, and the United States is worse than the UK. I know
one of the committee members yesterday asked for a bit more
information about those comparisons. Based on your experience,
can you tell me what the state of use of restraints is in other
international jurisdictions?
Dr Molloy: I
can tell you that in Ireland they have to request bed sides. If
you want to put up a bed side, you have to go and request it.
Ms Lankin:
Are these bed rails, when you say "bed sides"?
Dr Molloy:
Bed rails, yes, the bed sides. In Ontario they're routine on
every bed. Every time I come to see an old person-I can do this
in my sleep-I have to put down the bed sides. Please, before you
do this, walk into a hospital and look at all the old people
sitting with the bed sides up. They're restraints. They can't get
out. They try it crawl out the bottom and they fall. Nurses just
routinely put up bed sides and then they're tied in. This was 10
o'clock in the morning when we did our study. At night, many of
these people are tied in, but it's not everywhere; it's in
pockets. Some hospitals, some units have no restraints. It
depends on the people.
Ms Lankin:
Could you tell me about what happens in the UK?
Dr Molloy:
In Britain this doesn't happen.
The Acting
Chair: Thank you, Ms Lankin. Government caucus.
Dr Molloy:
It doesn't happen in Britain. It doesn't happen in Ireland. It
doesn't happen in Australia. It just doesn't happen. They just
don't use them. If you went into a British hospital, an Irish
hospital or an Australia hospital looking for restraints, you
couldn't find one.
Mr Joseph N. Tascona
(Barrie-Simcoe-Bradford): Dr Molloy, can I ask you a
couple of questions? Having been a graduate of McMaster
University, I can understand a little bit about the medical
community. My nephew went there and now he's at the U of T
medical school. McMaster University is an outstanding
institution.
Dr Molloy, I want to ask you
a few questions about the role of a doctor in this legislation.
You've read this bill. Under subsection (3) there are situations
where the restraint can be used, and you've made a big point of
the consent. In this process, the consent to use restraint is
given by the patient or a substitute decision-maker. Also, one of
the criteria is that the use of restraint is ordered in writing
by a physician. Is there a situation where there's a dispute in
here if there's no consent given but the doctor wants that
restraint to be put forth? How do you deal with that in a
situation where there is one exception? It says where it's
"necessary to prevent serious bodily injury to the patient or to
others," that's one exception. It doesn't say who would make the
decision, but I would presume it would be the physician who would
make that decision.
Dr Molloy:
We do it routinely in the health care system. If somebody gets
acutely ill, we give emergency treatment. You could see where a
physical restraint could be used as an emergency treatment, and
it could be applied by a nurse or a doctor. That could be easily
written into policy, that if the doctor's not available or can't
come and do the assessment, the nurse could do it and then, as
soon as possible, the doctor would become involved. These are
technical issues. That could be done routinely, and I don't think
anybody would argue with that. But I think the long-term, routine
use of physical restraints is what we're getting at. Nobody
argues that in an acute crisis, an acute delirium, an acute
problem full stop-a person has a broken hip or someone wants to
get out of bed-we can use physical restraints. We're not being
unrealistic here. The routine use of physical restraints in our
acute care system is what we're trying to get at.
Mr Tascona:
Yes. That point really struck me when you talked about the
situation of 10 o'clock onward where, if people are aged 70 and
older, the physical restraints go on. Why is that happening?
What's the philosophy behind that? You experienced it. I know
this is a philosophy issue, because we heard that from the OHA
too, in terms of clinical care, in terms of how you want to deal
with this issue.
1030
Dr Molloy:
I'll let Judy answer the second bit because she talks for nurses,
but let me just tell you what it used to look like in some of our
acute care wards. In our hospital we have really cleaned up our
act now because of the work of Judy and committees that have
really tried to do it. We used to go into the wards at 10 o'clock
in the morning. Every old person is getting up out of bed. They
are in the bed with the Posey on at night. They are literally
tied into the bed and they've got the double bed sides up. In the
morning, they take off the Posey restraint, which is the physical
jacket and the ties, they take down the bed sides and they put
them in the geri-chair. They are locked in so they can't get out
of the geri-chair, and if they try to slide down, they get a
sheet and tie them by the
crotch to the thing so they can't slip down. Then the old person
starts shaking the geri-chair. You've seen it, right? They are
shaking the geri-chair. So what they do now is tie the geri-chair
to the railing. You literally go into the ward and there's a
lineup of people in geri-chairs tied by sheets to the railing.
I've seen those literally in the last couple of months.
Mr Tascona:
The question is, why are they doing that?
Dr Molloy:
Because the nurses think this is normal care for old people.
Mr Tascona:
What kind of care are they providing?
Dr Molloy:
That's what's happening in our hospitals. That's what we're
telling you. Judy could maybe comment on why nurses do this. Once
you change their practice, they stop doing it. What we're telling
you is, we've tried every way we can to stop it, but Judy will
tell you why the nurses do it.
Mr Tascona:
Judy, on that, you indicated you have a book. Are you going to
provide that to the committee? Are you in a position to provide
that to the committee?
Dr Molloy:
We're going to leave it with you.
Mr Tascona:
The other thing is, how is that distributed?
Ms Lever:
People buy that. It's distributed if I or Dr Molloy go and do
talks, wherever we're going to go. We both lecture quite
extensively across Ontario; Dr Molloy certainly more than I do.
It was published-a little article in this, Untie the Elderly.
It's an American publication through Kendal Corp, who advertise
this, and as a result of that advertisement, I got a lot of
people from the US writing in to get booklets from me.
Mr Tascona:
The availability is essentially through you or-
Dr Molloy:
We did 1,000 copies about five or six years ago. We still have
about 100 left. We're hoping to sell off the last hundred to do a
next edition, because the next edition hopefully will have this
legislation and the consent forms and the stuff we've learned in
between. The money we get from it goes into a hospital fund, an
education fund. How much do you have in the fund?
Ms Lever:
I have about $1,500 in the fund now-
Dr Molloy:
-to pay for the next edition.
Ms Lever:
-to purchase things like these, to use for demonstration purposes
and to go ahead with lectures. Plus, it will be the foundation
for the next publication, which should probably be from a better
press. This was McMaster press, so it is available through
McMaster press, but in limited numbers.
Mr
Tascona: Can I ask another-
The Acting
Chair: I'm sorry, that's all the time we have.
Mr
Tascona: Just one final comment: I appreciate the
comments you're making that this is a philosophical issue in
terms of clinical care; it's not a cost issue. We heard that
yesterday too.
Dr Molloy:
It's not.
The Acting
Chair: Thank you, Dr Molloy and Ms Lever.
ONTARIO MEDICAL ASSOCIATION
The Acting
Chair: Our next presenters are from the Ontario Medical
Association. Please identify yourself for the purposes of
Hansard. You have 15 minutes in which to make your presentation.
You can use all or any part of it. If there is any time left
over, we will open the floor to questions from the caucuses.
Dr Albert
Schumacher: Good morning. I am Albert Schumacher. I'm
president of the Ontario Medical Association and a family
physician from Windsor. With me is Barb LeBlanc, from the OMA
staff, who is here to assist me during the question and answer
portion of this morning's presentation.
First of all, I'd like to
commend Ms Lankin for raising this very important quality-of-care
issue. Although we've come a long way in clinical practice in
terms of dealing directly and openly with issues around patient
constraint or patient restraint, it's helpful to revisit our
approach from time to time in order to ensure that we're
providing the best possible care for our patients and ensure a
safe hospital environment for all patients, staff and
visitors.
The OMA wishes to
acknowledge up front the work that has been done by the
Registered Nurses Association of Ontario and the Ontario Hospital
Association since the introduction of this bill in November of
last year. The OMA has been in close contact with each of these
organizations and supports the general approaches being taken to
improve our current practice regarding the restraints and the
best possible practices in the future in this area.
In turning to the specifics
of the legislation, I'd like to emphasize to the committee that
the OMA strongly supports the drive to improve patient care
underlying the proposed amendments, but we have a number of
concerns about the implications of Bill 135 as it is drafted in
terms of its effect on hospital care and medical practice.
In canvassing physicians'
input for my remarks today, it became evident there was no clear
consensus around medical versus non-medical restraint under the
bill as written, and it would create some ambiguity in terms of
actual practice. If I understand the thrust of Bill 135
correctly, I believe it would represent a significant change in
practice for many hospitals. Based upon the input that the OMA
has received, it seems to me we must take a more comprehensive
approach to the restraint issue, which captures various types of
restraints used in various circumstances. We need to start with
clear definitions of both mechanical and chemical restraint, in
addition to distinguishing between the use of restraints versus
safety devices, in order to ensure that the work we are doing is
meaningful in actual practice.
Traditionally, physicians'
main role relating to patient restraints involves those
restraints used for medical purposes. The use of non-medical
restraint, where it occurs, is largely a matter left to the
professional judgment of the registered nurses within the
confines of the applicable hospital policies and procedures in
each institution. In some hospitals, however, there is no
distinction between medical and non-medical restraint. Unlike
nurses, who are on the
floor on a constant basis, physicians are not always on the
floor, let alone in the hospital.
Given that the type of
restraint addressed in Bill 135 is, by definition, unplanned and
situational, it is more likely than not that a physician will not
be on hand to personally assess the situation and order the
restraint. In addition, the requirement that the restraint be
ordered in writing implies that the written order must be in
place before the patient can be restrained. If so, it is totally
impractical. The OMA believes that legislation cannot substitute
for clinical judgment and that explicit hospital policies
outlining least-possible-restraints options would better serve
Ontario and move towards a restraint-free hospital model.
1040
Bill 135 requires that a
restraint be applied only by a person who is trained to do so and
is also trained to identify and resolve situations that may
otherwise require the use of a restraint. The OMA agrees that
those who apply restraints must be trained and be able to do so.
It is unclear, however, that the person applying the restraint
would necessarily be trained to assess the alternatives to the
restraint that are available and appropriate. The OMA believes
that these two skill sets should be delinked.
Bill 135 states that
restraints may be used for a maximum of two hours, unless a
physician reassesses the patient and he or she gives a new
written order. This would necessitate a direct, face-to-face
encounter between the patient and the physician, according to the
rules relating to assessment under the OHIP schedule of benefits.
The burden upon physicians to come to the hospital every two
hours, day or night, is unreasonable and has been the subject of
negative comment by virtually every physician who has reviewed
Bill 135. The OMA recommends that this section be
reconsidered.
The bill further requires
that the physician chart the order for the restraint and the
types of less restrictive restraints considered by the physician
and the reasons they were not specified in the order. This
requirement is not consistent with accepted medical charting
procedures. One of the most important things that a physician
does in his or her daily practice is to make decisions about
diagnosis and treatment. This decision-making is the essence of
what is taught in medical school and what is required for good
patient care. It is inappropriate and unrealistic, however, for
physicians to be mandated to chart all of the considered but
discarded options concerning care. This would make medical
charting overly time-consuming and result in charts that are
incomprehensible, which would ultimately have a negative impact
on patient care. The OMA recommends that this section also be
reconsidered.
Bill 135 requires each
public hospital to have written policies and procedures with
respect to restraint, to post them in all rooms and provide them
to each patient on admission. The OMA believes that this is
reasonable to mandate, that the board of trustees of every
hospital be required to ensure that it has policies and
procedures with respect to the use of restraints. We recommend
that such a clause be added to regulation 965 under the Public
Hospitals Act.
The OMA suggests that the
section relating to dissemination of policy and procedures be
rewritten to state that, "Every hospital shall provide a copy of
its policies and procedures governing the use of restraints to
any person upon request." This is a more practical approach than
that outlined in Bill 135 and would also allow hospitals more
flexibility with respect to communication on the subject. For
example, some hospitals may wish to incorporate a comment
relating to restraints in their patient bill of rights or in
other standardized patient handouts.
In summary, the OMA
believes that the issues relating to the use of restraints are
more appropriately dealt with by hospitals and the professionals
involved in their use, including nurses and doctors, than in
legislation. We respectfully suggest, therefore, that the only
legislative amendments the Public Hospitals Act requires at this
time are an amendment to regulation 965 of the act to require
each hospital to have a policy and procedures with respect to the
use of restraints and a second clause that requires hospitals to
make the policy available to those who wish to see it.
Again, the OMA does not
want to minimize the need to address the issues that have been
raised by Ms Lankin in Bill 135. On the contrary, we want to
clearly support the development and the enforcement of
comprehensive least-restraint policies in hospitals, along with
the necessary education of the relevant professional staff.
I thank you very much for
your attention. Barb and I would be pleased to use our remaining
time to answer any of your questions.
The Acting
Chair: We have about two or two and a half minutes for
each caucus, beginning with Ms Lankin.
Ms Lankin:
Thank you, Dr Schumacher. I appreciate you being here today on
behalf of the OMA. I want to say first of all that a number of
people have talked about the issue of the two-hour reassessment
and I think there are some practical concerns that need to be
addressed. I do think, however, we have to come to some decision
about the question of accountability for ongoing use of
restraints. One of the things we've heard in evidence is that too
often when people are restrained for a particular situational
occurrence, the restraints are left on. Part of that is policy
and education, but there are also issues of accountability.
In your presentation, you
talk about the non-medical restraint and where it occurs, and
that it's largely left to the professional judgment of the
registered nurse. In fact, much of what I've heard-not in
testimony here but in work that I did in preparation for the
bill-is when an elderly and perhaps frail individual presents
himself at a hospital through emergency, what is pretty standard
is a doctor's standing order on a chart of PRN: physical
restraint if necessary. That follows that person through the
system at that point in time. In fact, the nurses look to the
chart to find if there is a PRN. There's actually a medical order
that is being written, but by an emergency room physician who isn't there and involved
in the ongoing care.
My question about it simply
being medical versus non-medical is, what happens once a patient
is restrained? What we've heard is that there's increased
agitation, it leads to increased depression, to incontinence, to
pressure sores, to increased use of medication of sedatives,
increased cognitive impairment, increased motor skills
impairment-the iatrogenic consequences of the use of restraints.
Those are medical concerns that flow from the use of restraints.
So to take the doctor, as we just heard in the previous
presentation, out of the loop becomes very problematic in terms
of the ongoing medical care of that patient. Could you address
that for us?
Dr
Schumacher: Sure. Barb, would you like to?
Ms Barb
LeBlanc: You're right. A number of our physicians have
raised that very issue. But the thing we were trying to get to
here is that we probably need to talk about all the aspects of
restraints. What we found, in parsing them out, non-medical
versus medical, was that some hospitals handle them as a whole
and others do it in the ways you've talked about, with the PRN
order, and still others use nursing protocols. So we agree that
we have to look at restraints taken as a whole. We need to
consider their physical and medical impacts and we need to ensure
that the entire team is part of the decision-making-nurses and
doctors.
Mr Raminder Gill
(Bramalea-Gore-Malton-Springdale): Thank you, Dr
Schumacher, for being here this morning. One of the things that I
think Dr Molloy implied earlier is that because of the restraint
problems, a lot of people are getting out of geriatric practice
or they're not going to be studying geriatrics any more. Do you
have any comment on that?
Dr
Schumacher: We don't have enough geriatricians with that
specialty and interest, and I think that goes along with many of
our manpower and human resources problems in the province.
Certainly part of that is that we need more training spots and we
need to encourage graduates to look in that area, especially with
our aging population.
I can't specifically
comment on the ebb and flow in that specialty today. I wasn't
prepared to do that and I can't confirm his numbers. But
certainly working with the elderly is difficult. Many of our
other patients are difficult as well. I'm not sure where we are
in that particular realm of the crisis.
Mr Gill:
In your opinion, the restraint side of things is not affecting
the so-called specialization, or do you think it might have?
Dr
Schumacher: I think that the restraint problem is a
significant problem in hospitals. Some institutions, as we heard,
I think deal better with it than others. Certainly having a
preprinted order sheet like on the tonsillectomy order sheet and
having restraints on there is not in anyone's interests. I
certainly agree that where you need to have an order for a
restraint, especially in an acute care facility, it needs to be
evaluated. Then, not necessarily in two hours but certainly the
next day, it should be on the list to see what you can do to undo
this and make other arrangements. So yes, it is a problem.
We just heard some of the
solutions that have been tried in local hospitals, and certainly
that effort needs to be there. As our population ages and as the
people who are now left in hospital, as we do more as
outpatients, are sicker, are frailer and have more complex
problems, the issues surrounding confusion, whether transient or
longer-term, are going to become a greater problem, especially
for those hospitalized people.
Ms
LeBlanc: There's one other thing as well. As the
psychiatric hospitals begin to shift and more of that patient
population moves into the general hospitals, certainly issues
around restraint will be relative to them as well.
The Acting
Chair: Thank you. We'll move to the Liberal caucus.
1050
Ms Caroline Di
Cocco (Sarnia-Lambton): Just two quick questions. Can
you give me a sense of what non-medical restraint is considered
to be? Secondly, in the medical profession, how much time is
spent in the actual discussion of this application of restraints
or the whole issue of when it's used and why it's used and all of
that? How much time is allotted in the education of the medical
profession when it comes to this issue?
Dr
Schumacher: I can only answer on a personal basis when I
think back to medical school. I can remember spending a morning
talking about restraining patients. Most of that dealt with the
acute psychiatric patient, someone who was psychotic or
hallucinating and delusional, in the proper management of them,
to protect them and the staff and so forth. I would have to say,
from memory, that's where most of it came. I can't comment on the
current curricula.
To go back, on the issue of
medical versus non-medical, when I first read it, I thought that
non-medical must mean the surgical stuff we do in the OR when we
strap someone to the table so they don't fall off when they're
unconscious. So I think we need to define that better, because
even there, there is some uncertainty about what our terminology
is. I guess you could consider the bed rails a restraint, but in
the unconscious patient, somebody who is coming out of
anaesthetic, we restrain them so they don't pull out their tube
or we tie their hand down so they don't pull out an IV line.
There are a lot of those kinds of things that go along with
certain aspects of operative and critical care which I don't
think we're necessarily addressing here. I'm not the best person
to define that.
The Acting
Chair: Dr Schumacher and Ms LeBlanc, thank you very much
for your presentation this morning.
REGIONAL GERIATRIC PROGRAMS OF ONTARIO
The Acting
Chair: We now move to our next presenters, the Regional
Geriatric Programs of Ontario. Good morning. Would you please
identify yourself for the purposes of Hansard. You have 15 minutes in
which to make your presentation. You can use any or all of it. If
there is any time left over at the end, we will move to the three
caucuses to ask questions.
Dr Rory
Fisher: Thank you, Mr Chair. I am Rory Fisher. I am a
geriatrician. I'm the chair of the Regional Geriatric Programs of
Ontario. These are based at the five health science centres and
they provide specialized geriatric services specifically for the
frail elderly. Willie Molloy, my colleague, is the acting
director of the Hamilton regional geriatric program. It's a
little difficult following in Willie's footsteps. I think Willie
has kissed the Blarney stone, and you have seen evidence of
that.
I would like to make some
comments generally about things, and look at the legislation
specifically by putting it in the context of the overall
situation.
I would like to start with
a quotation from one of my colleagues, Don Redelmeier, in an
article in the Canadian Medical Association Journal a week ago:
"The hardest problems to solve in medicine are the ones where no
one recognizes that anything is wrong." I think when it comes to
the management of the frail elderly, that is the issue with our
health care system at the moment. Our health care system really
is predicated on the needs of providers and not on the needs so
much of the clients. Now, with the demographics that we're facing
of an aging population, the utilization in the health care system
is focused more and more on the frail elderly, and that is going
to increase both with the demographics and with the changing
health care delivery system allowing us to do much more outside
of the acute hospitals. It's these frail elderly who are the
target population for restraints, and I think it's the tip of the
iceberg of the problem that we're facing.
The population, as you
know, is going to go up from 12% over 65 to 22% by the year 2041.
The population that is increasing most rapidly is the old old,
those over the age of 85. It is this population that has the
highest incidence of cognitive impairment. The problems that
we're facing in our acute hospitals are the frail elderly
becoming confused from the acute problems that bring them into
hospital. Then they are being restrained to provide, often, the
treatment that was mentioned by my colleague from the OMA: to
give them intravenous fluids or to put tubes in and things of
that nature. So we really need to change the focus to prevent
using some of these interventions and to manage them differently
medically, and therefore decrease the need for the interventions
which in turn lead to the people being restrained.
When it comes to this aging
population, it's undoubtedly the single most significant
challenge facing our health care system, and we're not
approaching it. Obviously there has been a decrease in funding
for our health care system, but just to replace that, doing what
we've been doing in the past, isn't going to meet the changing
needs of the population in the future. In the same way that wars
are too important to be left to generals, I think the health care
system is too important to be left just to health care
providers.
I know many of my
colleagues are concerned about legislation to change our
practice. In the best of worlds, we would hope that we would take
the lead and make the changes ourselves, but we haven't seen this
happen. We see that most of the medical and hospital
establishment is very conservative and, like the generals,
usually fight the last wars. Our medical and hospital
establishment is still working in the past on a different
paradigm of health care delivery and they haven't focused, to
change, on the needs of the patients they're dealing with now.
That does need a sea change. We have to focus on making our
hospitals friendly for the frail elderly, not friendly to the
health care providers. In making them friendly for the elderly
and introducing measures that would be preventive of delirium, we
would decrease the need for restraints.
This can be done readily.
There have been studies in the States by Inoye, who, looking at
the prevention of delirium, was able to do that. If you prevent
delirium, you'll prevent the need for restraints. Currently, at
Sunnybrook we're looking at a model to try to develop processes
to decrease the instance of delirium, and they have a care plan
at the University of Alberta where we want to work with them to
look at this. If you prevent this by developing the friendly
environment, you will have the frail elderly more active. They'll
be functionally more able, they'll develop fewer falls, less
incontinence, as well as less delirium.
Unfortunately, our acute
hospital is a hostile environment for frail elderly. There are
studies which show a decrease in abilities of the elderly by just
being in hospital, by the environment that we develop, which is
focused on treating the disease, not the patient. So you may
immobilize the patient and restrain them so you can get
antibiotics into them, but by doing that you engender and induce
the side effects and problems that result from restraints. So our
whole focus on disease, rather than patients, fits into this
concept of restraints.
Coming from a British
background, it was a great shock coming to Canada 30 years ago.
Some of my other colleagues, British geriatricians who came here,
used to write papers and give presentations at that time, "Free
in Britain, Restrained in Canada." It's a great regret that 30
years later, things have not got any better. Indeed, one sees
them getting worse. Undoubtedly, the pressures on our health care
system have really increased in recent years. I think that some
of the effects of that are related to the use of restraints.
With regard to some of the
specifics, I think the issues regarding the physician involvement
are important, and obviously they have to be involved in
decisions that are related to people who are their responsibility
at that time. I think we have to be conscious of the
practicalities that the OMA pointed out.
1100
At Sunnybrook we have had a
good system of least restraint in action for some years and
physicians aren't involved in the initiation of that, so that
system has worked. Another thing that has happened at Sunnybrook
has been that in moving
to the least restraints they have moved to bring many sitters to
come in and sit with the disturbed patient. This has been helpful
in decreasing use of restraints, but it has also been very
costly. So this humane intervention has had an adverse effect on
the hospital's budget, which in turn has led to this initiative
to look at getting at the cores of these restraints and trying to
decrease them.
So, Mr Chairman, I would
put this into an overall context. We are looking at a major
democratic change. Our hospitals and our medical establishment
have not altered their approach and still want to go on doing
things in the same old way, and that's not going to work. I think
we are going to need to be called to account by the Legislature
as to how we're spending the taxpayers' dollars. In the United
States that has had to take place, and maybe it will have to take
place and this is just the first step of some other interventions
to make us refocus on the needs of the frail elderly.
Thank you, Mr Chairman.
The Acting
Chair: We have a little over a minute for each caucus.
We'll begin with the government caucus.
Mr Joseph Spina
(Brampton Centre): Thank you, Dr Fisher, for taking the
time today to give us your opinions, your perspectives. The
concurrent theme seems to be that, I gather, a lot of the issues
consistently be one of attitude and loose policies, inconsistent
policies. Like Ms Lankin's, my parents were in the same
situation, with my late dad a couple of years ago and with my
mother just most recently. Fortunately, they were in a northern
Ontario hospital which displayed, I think, a very fair and
consistent and compassionate policy.
Your colleague Dr Molloy
indicated that there are few geriatricians at this point who are
trying to deal with the situation and, as you clearly indicated,
with the increasing demographics and the aging baby boom
population, of course, this will put a far greater amount of
pressure on these issues. Other GPs or GPs and specialists versus
geriatricians, can that be resolved? Can legislation really
change an attitude, I guess, is perhaps a more general question,
and would that somehow help in having more geriatricians come on
board over time if there was a legislated policy?
The Acting
Chair: Mr Spina, it might help if we keep our questions
short considering we have very little time. You've used up all
your time for questioning. We move to the Liberal caucus,
Monsieur Lalonde.
Ms Lankin:
I just wonder, given the fact that Dr Fisher has come to be with
us and to present his expertise today and given that the next
presentation was cancelled, if we might extend this time just a
little bit to allow him to answer Mr Spina's question?
The Acting
Chair: If all the caucuses agree I think we can do
that.
Interjection: Agreed.
Dr Fisher:
The first question regarding the numbers of geriatricians: there
are currently 68 in the province of Ontario. Our estimated
current need is 170 and that's conservative. This doesn't take
into account the aging population in future.
I think they're two
separate issues. One is the need to increase the number of
geriatricians and the other team members for specialized
geriatric services, and we certainly need to do that.
There was an expert panel
forum that met in November with stakeholders from around the
province, called by the policy division of the Ministry of Health
and Long-Term Care. I understand recommendations from that
regarding policy for specialized geriatric services for the
province have gone forward to cabinet, so some resolution of that
would be helpful.
There is the second issue
of the services for all the elderly, as distinct from specialized
geriatric services, and your point regarding family physicians
and other health professionals is very well taken. We have to
advance on two fronts: one is to provide the support and
infrastructure and funding for the development of specialized
geriatric services with geriatricians and others; and second is
to change the whole environment of all health care professionals
to attune them, educate them and put them in an environment which
will focus on the needs of the frail elderly. We can do that by
better training at an undergraduate level and also at a
post-graduate level.
It is going to be very
difficult, as Dr Molloy said, to attract physicians to look after
the frail and elderly. If we have 20,000 more long-term-care beds
put in place, I think it's going to be very, very difficult to
entice physicians to provide the care to those beds.
Mr
Lalonde: Thank you, Dr Fisher, for giving some of your
time to explain to us at what point we are. It's getting to be
very scary when you say that by the year so-and-so probably 22%
of the people are going to be restrained, if I go with the
average age that we'll have at that time.
If I just look at yesterday
and one of the statements we had about the 80-year-old lady in
Mississauga who had to be physically restrained, we tend to see
that more and more of those people are going to be physically
restrained because families are getting smaller, people are
moving to Ontario with fewer relatives than we used to have, so
we have no one to take care of those elderly in hospitals. It's
getting to be scary-for myself, probably 15 years from now-the
fact that we politicians know the rule that we might end up being
physically tied up to a rail because we will not accept the
restrictions that are going to be applied to us.
Could you tell us today
what should be done immediately to try and eliminate or reduce
the number of physical restraints that we see in hospitals?
Dr Fisher:
Certainly this legislation would lead the way. I think we have to
ensure that the hospitals develop standards and policies which
will minimize the use of restraints, but also go further to
introduce educational approaches that will minimize the need. In
looking at the aging population, I don't think we necessarily
have to be pessimistic. I think we're going to see a major part
of the aging population
that is going to be physically and mentally much healthier than
the aging population in the past. We have the paradox, though,
that we will have this minority of people who will be disabled
physically and mentally who will require the support system,
hopefully in the community rather than in hospitals.
I think we have to ensure
that our hospitals are suitably designed and function to minimize
the use of restraints and maximize the functionability of the
frail elderly in those circumstances.
Ms Lankin:
Thank you, Dr Fisher. It's delightful to see you again and I
appreciate your coming here today. I am very concerned about the
issues you raised with respect to the lack of professionalized
geriatric services in the province and the lack of geriatricians
and specialists. I had the occasion last fall in health estimates
to speak rather extensively with the minister about this. I'm
quite sure that the minister of the day recognized the concern
and, through the expert panel that you referred to and some other
measures that were implemented, was beginning to look at this. I
assure you that I will follow up with and have a conversation
with the new Minister of Health, because I think there is a
looming crisis. I find it just horrifying. I know other members
of the committee would love it if some time we had an opportunity
to look just at this issue, because I think there is a major
public policy question there.
1110
Specifically on the bill, I
want to assure you that some of the details of the bill I
recognize require amendment. I have sought the opportunity to
work with the ministry, if the ministry in the end is accepting
of the bill, to find the appropriate and acceptable wording.
I want to ask you to
respond to some things that have been said, in particular by the
Ontario Hospital Association but also by others. Mr Bilodeau, who
presented yesterday, was quoted in the newspaper as having said
to the media that he didn't see the use of restraints in acute
care hospitals as a major problem. He talked before us about a
lack of data, an inability to really know whether restraint use
was common or increasing or decreasing. He also referred to the
fact that where we do have data in chronic care hospitals, the
numbers show that the use of restraints is decreasing. Others
have told us that is because legislation was put in place
governing long-term-care facilities and that, while you can't
legislate attitude, you can legislate behaviour and often,
through education that is accompanying that forced change in
behaviour, attitudes will change. Could you tell us, is this a
problem in our acute care hospitals? Are restraints being used
or, as is my view, overused? Could you comment on the state of
affairs?
Dr Fisher:
I think there's no question that they are being overused. I think
legislation introduced in the United States has led to a decrease
in the utilization of restraints in acute care facilities and I
would see it doing the same in this province. Again, one would
prefer, in the best of all worlds, to do things differently. But
if legislation is the way to start the change, then I think it
would be better for the frail elderly of this province if we had
legislation.
The Acting
Chair: Thank you, Dr Fisher.
REGISTERED NURSES ASSOCIATION OF ONTARIO
The Acting
Chair: Our next presenter will be the Registered Nurses
Association of Ontario. You can begin any time.
Mrs Doris
Grinspun: My name is Doris Grinspun and I'm the
executive director of the Registered Nurses Association of
Ontario. We are a professional association representing a broad
spectrum of over 15,000 registered nurses who work in a variety
of settings throughout the health care system. We welcome the
opportunity to speak with you regarding Bill 135, An Act to amend
the Public Hospitals Act to regulate the use of restraints that
are not part of medical treatment.
The issue of restraints use
has serious implications for patient rights and patient safety
and is one in which registered nurses have a great deal of
involvement and concern.
It is clear that the
legislation proposed by Ms Lankin was structured with the intent
to protect patients by setting very strict requirements for
restraints use in hospitals. This is laudable. We applaud the
intent of the legislation and the goal Ms Lankin has in mind. We
support the intent of this proposed legislation and we commend Ms
Lankin for bringing attention to this very critical health care
issue.
It is the opinion of RNAO
that the more effective legislative approach will be an amendment
to regulation 965 of the Public Hospitals Act mandating hospitals
to have a least-restraint policy. This approach will ensure that
restraints in Ontario are used as a last resort and only to
protect a patient's safety or the safety of others. It will also
ensure that when restraints are necessary, the type or length of
use will be the least restrictive possible.
The most effective way to
facilitate that option of a least-restraint policy in all
hospital settings is by ensuring the policy is grounded in
evidence. Thus, it is RNAO's recommendation that such a policy be
based on best-practice guidelines that have been developed
through an exhaustive research review and the input of a broad
range of experts in the field. It is also critical that all
best-practice guidelines have directions for the practice setting
integrated into the guideline itself. Only in this way will
policies based on best-practice guidelines be actually utilized
and sustainable.
The decision to place
restraints on a patient is not made easily and in fact it is in
general made by a nurse. It is a complex decision in which the
health care provider must weigh the balance between patient
rights, patient autonomy and patient safety. The decision-making
regarding the use of restraints within the hospital sector lies
squarely within the registered nurse's scope of practice, and
thus we take full accountability and responsibility both ethically and otherwise for
the issue and we take it very seriously.
RNAO very strongly believes
that restraints must never be used to resolve system and human
resources failures-for example, staffing shortages-nor should
restraints ever be used for the convenience of the care provider.
Adequate staffing, appropriate skill levels and educational
support-for example, for alternatives to the use of
restraints-are essential to high-quality care and are, as such,
critical components of any best-practice guideline
development.
Let me refer to three
specific issues that we are especially putting emphasis on. One
is accountability, the second is the decision regarding use of
restraints and the fact that it lies within the nursing scope of
practice, and the third is the utilization of the best-practice
guideline as the basis for a least-restraint policy.
Accountability: We are
strongly supportive of the underlying theme of accountability
evident in the proposed legislation. Accountability to those who
are receiving care and their families must be at the core of any
legislative initiative. There are several types of accountability
that must be considered in order to ensure that the use of
restraints optimizes patient safety and well-being.
First of all, the Ministry
of Health and Long-Term Care is accountable for ensuring that
adequate funding flows to the delivery of care within our health
care system. The ministry must also ensure the development and
implementation of standards that will enable all Ontario
residents to receive high-quality care. The support shown by the
Ministry of Health for the best-practice guideline development
for nursing in several clinical areas is an example of this
accountability. I'm referring here to the best-practice guideline
project initiative funded by MOH to RNAO, and I will speak more
about that later.
The hospital and other
health care agencies-because we do not think this issue is only a
problem in the hospital sector-should be accountable for
implementing a least-restraint best-practice policy based on
best-practice guidelines in their facilities, as well as ensuring
adequate staffing to deliver high-quality and safe patient care
so that restraints indeed are never used as a replacement for
staffing.
The individual care
provider is equally accountable. For registered nurses this means
incorporating the appropriate care standards into our practice.
In the use of restraints this means utilizing the College of
Nurses of Ontario's Guide on the Use of Restraints and we also
recommend the utilization of best-practice guidelines that we do
not have at this point on a least-restrictive practice.
Let me also address the
issue of the fact that restraints do not require a doctor's
orders, nor should they require a doctor's orders, but is
actually a component of the nursing scope of practice. It is the
nurse who has the greatest contact with and knowledge of the
person. To decide when you need the restraints, not only do you
need to know the clinical condition, you also need to know many
ethical and personal characteristics of that patient and also the
wishes of that family when a patient cannot put forward his or
her own wishes. It is the nurse who has the most knowledge of the
comprehensive needs of that individual. Even if there are orders
in place, it is the nurse who decides which type of restraints to
put on and how long to put them on and who actually monitors the
use of restraints in the long run. Doctors don't come every 15
minutes to change orders or to look at the restraints. Therefore
we want to take full accountability for the practice and we also
want to have best-practice guidelines for that practice.
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Let me tell you a bit about
what we mean by best-practice guidelines and what we have done
with the 17 best-practice guidelines that are either already in
the final stages of evaluation in this province or in the
development phase. These are guidelines which have three types of
recommendations: substantive recommendations, which deal with the
clinical aspects of practice; contextual recommendations, which
deal with the recommendations related to the context of the
environment in which the nurses practice-issues like staffing
patterns, continuity of caregivers etc are part of the contextual
recommendations; and also educational recommendations, which in
the case of restraints will be the ethical and clinical issues
entailed in the decision to put restraints on a patient or, more
importantly, the alternative methods and approaches nurses can
use so there is less need for the use of restraints. That's what
the best-practice guideline will do, and then you use that as a
baseline for a least-restraint policy which, in our view, we
absolutely should have as a regulatory change.
In summary, we are
recommending:
That regulation 965 of the
Public Hospitals Act be amended to mandate all hospitals to
establish and implement a least-restraint policy. This policy
should affirm that restraint use is within the scope of nursing
practice. Otherwise, it will not really be effective.
That the Ministry of Health
and Long-Term Care fund the development of a least-restraint
best-practice guideline. The guideline will serve as the basis
for hospitals to develop their least-restraint policy, and we
will be pleased to either lead, as we have done with 17 other
guidelines, or participate in such an initiative.
Third, that all hospitals
be required to develop and implement a least-restraint policy
that is based on the least-restraint best-practice guidelines.
Let me tell you, several hospitals in the province do have
least-restraint policies that are being put into implementation
now. But we are saying all hospitals require that, and unless we
have a regulatory change, probably it will not happen.
That hospitals should be
made accountable for putting in place the necessary structures
and supports to enable nurses and other health care providers to
exercise sound clinical and ethical judgment in implementing the
least-restraint policy. This includes adequate staffing and
continuity of caregivers; the latter is essential when you want
to use less restraints.
Fifth, that a comprehensive approach to education
in both hospitals and nursing education programs be implemented
to support ethical and clinical decision-making. The topics
should include patient rights, patient safety, restraint
utilization, alternative approaches and least-restraint
policies.
Sixth, measures should be
taken to improve working conditions and develop strategies that
respond to nursing human resource needs in hospitals. Restraints
are not the solution for system problems or deficiencies in human
resources.
In conclusion, the RNAO
acknowledges Ms Lankin's outstanding support for the most
vulnerable patients in our hospitals today and her personal
commitment to instituting changes in our health system that
support patient rights. RNAO believes that all hospitals in
Ontario must develop and implement a least-restraint policy,
supported by best-practice guidelines, education and research in
order to deliver the highest quality of care that meets the needs
of all patients. We thank you for the opportunity to dialogue
with you. I will be happy to answer questions.
The Acting
Chair: We have about 45 seconds for each caucus,
beginning with the Liberal caucus.
Mr
Lalonde: Just quickly, according to the fourth paragraph
of your statement here, would you say that restraint is used
because of a shortage of staff at the present time or a shortage
of funding?
Mrs
Grinspun: I would suggest that on some occasions that's
the case, and I would suggest very strongly to you that that
would be a problem for the nursing profession and for the nurses
who are engaged sometimes in those practices. Nurses are caught
in very terrible situations. For six years I was a director of a
large institution in this province and I had very heavy
discussions with colleagues in the practice setting. When they
are caught in a situation that because of staffing issues they
may need to use restraints, even if it's not very restrictive
restraints, like side rails, if you are following ethically
what's best for the patient and clinically what's best for the
patient, not only ethically but clinically-we do know that
restraints exacerbate behavioural problems. So it's not a
solution; it's a band-aid approach. It should not be used for
staffing issues.
Ms Lankin:
Thank you. I appreciate very much your presentation. I think the
issue of professional accountability and a doctor's order versus
a nursing order is a very important one for us to grapple with,
and I have to admit to you that I'm flummoxed by the differing
advice that we are given. I think your recommendation that it is
a whole-team, multidisciplinary approach is what we would want to
see, and maybe some of the best practices and protocols will
address that. I also want to indicate that I have written to the
minister in support of RNAO being funded to do a best-practice
study in this area. I think that would be very valuable.
In two parts of your
presentation you make reference to the fact that we know the use
of restraints increases in the evening and during the night.
We've heard many people say that it is not an issue of staff
convenience that restraints are used. We know there are also
clinical reasons why there might be increased use or perceived
need at nighttime. Someone referred to the sundowner effect in
terms of cognitive impairment.
Mrs
Grinspun: Correct.
Ms Lankin:
But this is a phenomenon that you've experienced and that RNAO
accepts, that there is-I'm going to use a value-laden word-an
overuse of restraints, and that this overuse occurs even more
frequently during the evening and nighttime in our acute care
hospitals?
Mrs
Grinspun: Yes, there is a higher utilization-and that's
well documented in the research in other countries as well-of
restraint on evenings and nights and probably weekends too. But
evenings and nights is specifically because of a combination
between exacerbated behavioural and cognitive impairment and the
impact not only with sundown but sometimes some of the
medications that we give that we don't give them at appropriate
times, like diuretics etc, and then the combination between that
and decreased resources for sure.
That's not to say that
always as a blank statement you need to hugely increase the
resources in a unit. It depends which type of unit you are
dealing with. If you are dealing with an ICU, for example, you
have the same type of human resources in the evening and night as
in the day, because of the type of care that patients require.
Most likely in a unit with patients who suffer from Alzheimer's
or other conditions of dementia, you should have similar patterns
during the day versus during the evening, unless you have a lot
more activities done during the day. But you probably should have
higher numbers in the evening and night because we know that the
behavioural conditions and cognitive disturbances tend to
exacerbate. We know that not only in the hospital sector. So that
is the case, and that's something we need to attend to.
I do not think that
staffing alone will resolve the issue of the use of restraints.
That's why we are extremely supportive of the change to
regulation and the need to develop a best-practice guideline that
will then support the development of a least-restraint policy in
the hospital sector. It is a combination of staffing, practice
behaviours and knowledge, and that's why for us the issue of
education is hugely important, so that people receive the proper
support to make ethical and clinical judgments. There are also
many changes today compared to 20 years ago, not only clinically
but also ethically. Twenty years ago families would prefer that
the person not fall and that the person be restrained. Today we
are a lot more respectful of patients' rights, and I applaud
that.
1130
So it's a combination of
many factors. I think that's why it's so important not just to do
the least-restraint policy, which is one component that will
mandate that we have that, but that it be based on the
best-practice guidelines that get updated every three to five
years based on the most current knowledge to date. Otherwise, you
will have a problem again in 15 years, even with the regulations
and the staffing.
Knowledge changes, knowledge of how to approach-I
don't want to say "treat" because behavioural conditions, and
it's an area of expertise of mine, is an approach; it's not a
treatment. Those things change and there is a lot that we need to
learn and maintain our practice for all disciplines, to really
decrease the use of restraints and enhance the quality of life of
people.
The Acting
Chair: The government caucus?
Mr Gill:
Thank you for your presentation. It's interesting that in terms
of health care delivery in hospitals, doctors and nurses are the
major players. Both of you this morning, the OMA and the RNAO,
have said-unless you consulted each other before you made the
presentation.
Mrs
Grinspun: No, but we were pleased that they named
us.
Mr Gill:
That's good. Instead of Bill 135, you're both stating that
perhaps the Public Hospitals Act, regulation 965, should be
amended. Both of you have said that there is no need, basically,
for the act but there is a need to address the restraints through
education, through least-restraint guidelines. You're not saying
that we need the act but that we need to amend reg 965.
Mrs
Grinspun: I was not at the presentation of my colleagues
from the OMA, so let me refer to why they would choose this
approach versus the other and I think it will help you to
understand if it's similar to the OMA's. We certainly are asking
for a change to the Public Hospitals Act and its regulation 965.
Let me be very clear about that. Without that, you will not have
permanent changes in practice. The reason we chose a regulation
versus the legislative change is basically because of my
explanation of the best-practice guideline, because you will be
updating that regulation every three to five years as things
change, from ethical knowledge, from patients' rights knowledge,
from clinical approaches. That's the beauty of a best-practice
guideline. Also because it incorporates more than having a
doctor's order or having a nurse's order, for that matter; it
incorporates the issue of the clinical knowledge through
substantive recommendations, contextual knowledge through the
contextual recommendations and what types of models of care
delivery you need to have patients less confused and therefore
needing less restraints, and the education, on-site education, to
health care providers for best-practice guidelines. That's our
rationale for that.
Mr Gill:
Considering that, Mrs Grinspun-
The Acting
Chair: Thank you, Mr Gill. Your time is up; I'm sorry.
Mrs Grinspun, thank you very much for appearing before the
committee this morning.
Mrs
Grinspun: You are very welcome.
CONCERNED FRIENDS OF ONTARIO CITIZENS IN CARE
FACILITIES
The Acting
Chair: Our next presenter is the Concerned Friends of
Ontario Citizens in Care Facilities. I would remind the caucus
members that if they wish to have an answer from the presenters,
with the severe time allotments, it might be necessary to keep
your questions brief.
Good morning. Please
identify yourselves for the purposes of Hansard. You can begin at
any time. You have 15 minutes in which to make your presentation.
You can use all or any part of it. If there is any time left
over, the members of caucus would like to ask you questions.
Ms Lois
Dent: Thank you. My name is Lois Dent. I'm the president
of Concerned Friends of Ontario Citizens in Care Facilities. With
me, I have our recent past president, Freida Hanna.
Concerned Friends is a
volunteer consumer organization dedicated to improving the health
care in long-term-care facilities in Ontario. We have been in
existence for 25 years and we have consistently advocated for
policies and procedures that address the problems confronting
residents in long-term-care facilities.
About seven years ago, we
participated in meetings with the Ministry of Health regarding
new standards and criteria for long-term-care facilities. These
standards included policies governing the use of restraints. We
believe the policies put in place at that time have been very
effective in reducing the incidence of injudicious and abusive or
even dangerous use of restraints. We're aware and we know of
instances where these policies are not always followed, but with
the written standards in place staff can be cited for
non-compliance. In our experience, it has helped not to eliminate
but to reduce the incidence of abuse. So we support the standards
and criteria for the use of physical restraints in long-term-care
facilities. For your information, we distributed a copy of the
regulations in the long-term-care system.
It's clear to us there is a
need for similar legislation to cover the use of restraints in
acute care hospitals. It needs to be ensured that they are used
only when necessary to protect the patient or others from serious
injury. There needs to be a written doctor's order and it needs
to be ensured that consent has been obtained, except in emergency
situations.
We strongly support the
requirement that the staff applying the restraint be properly
trained, that the patient be monitored and have his or her
position changed regularly, and there must be full
documentation.
In summary, we endorse Bill
135 because it meets the need for a written policy on the use of
restraints in hospitals. We note that the amendment speaks only
to physical restraints. It doesn't address the use of chemical
restraints, which is an area that may also need
consideration.
I'd like to just add a
personal experience that I had when I was in hospital myself. The
bed beside me was empty. During the night or late part of the
evening, an elderly woman was brought in. She had fallen and
broken, I believe, her hip and had had the required treatment.
She was very agitated and upset. She didn't seem to speak
English. She was moaning and they couldn't seem to communicate
with her. She was put in the bed next to me and restrained. The
nurse said that was to keep her from pulling at her bandage. She tossed
and turned and moaned all night long. At about 6 o'clock the next
morning or early the next morning, a nurse specialist-and I'm not
sure exactly what a nurse specialist is-came in, went to her bed,
took off her restraints and spoke to her calmly. It turned out
she could speak English. When she was reassured, she understood.
She was able to tell this nurse the name of her son so they could
contact her son, and she was fine from then on. Why couldn't this
have happened when she was first put into this room? If somebody
had taken the time to speak to her, to reassure her, to make sure
that she could communicate with someone, she probably would not
have needed to have spent that terrible night under
restraint.
Just by chance I happened
to see this about five years ago, so it must happen a lot. We do
know that having legislation doesn't completely solve the
problem, but it goes a long way to making people aware of it and
making changes. It's a start. Thank you.
1140
The Acting
Chair: Thank you very much. We have two minutes per
caucus, beginning with the NDP caucus.
Ms Lankin:
I truly appreciate your coming forward. I recall the work you did
seven years ago, when the Ministry of Health was doing its
consultations on changes in the long-term-care sector, and the
role you played in the recommendation for a legislative
protection or a legislative regulation around this issue of the
use of restraints in long-term-care facilities.
We heard, for example, from
the OHA yesterday and then a chronic care facility, that numbers
show there has been a decrease in the frequency of use of
restraint. Other experts have told us that it is directly related
to the fact that there is a legislative base on which good
policies have been built and good education has been done. You've
alluded to the fact that you think there has been an impact as a
result of that. Could you just elaborate on that a little bit
more from the perspective of your organization? Do you have fewer
complaints about restraints? How are you aware that the
legislation has had a positive impact?
Ms Dent:
We get calls from family members and sometimes residents of
long-term-care facilities. We used to get more complaints-I think
maybe you would corroborate that-about restraints. They used to
use them much more frequently than they do now. We still do
sometimes-it hasn't completely solved the problem-and sometimes
they are absolutely necessary. But it's interesting that the
number of concerns we hear has substantially decreased.
Mr Jerry J.
Ouellette (Oshawa): First of all I'd like to
congratulate Ms Lankin for having the OHA enter into that review
policy, their commitment the other day, that they had a chance to
do that. I have a couple of quick questions.
We've heard a number of
presenters recommend who should decide whether a patient should
be restrained or not. Do you have any idea? Should it be the
nurses, should it be the physicians who determine that or do you
have a position on that?
Ms Dent: I
don't think we're qualified to say that.
Ms Freida
Hanna: The families have to be consulted in long-term
care. Families are consulted and sometimes families want the
resident restrained. It's up to the staff to talk to them and
give-
Mr
Ouellette: Do you think, though, that the family should
be the final ones who make the decision, or should it be the
physician's decision, or should it be nurses who make that
decision?
Ms Hanna:
It has to be with the information shared with the family, if
there is a family member. Some residents do not have family,
therefore it has to be a nurse's or a doctor's decision.
Ms Dent:
But consent is very important here. I think we need to have
consent-
Ms Hanna:
In the hospital, I would think.
Ms Dent:
Yes.
Ms Hanna:
Consent of the patient.
Mr
Ouellette: I have another quick question, if there is
any time remaining. I know Mr Spina has a question. Are you
familiar with the crisis intervention training that was mentioned
yesterday by one of the presenters? If so, do you believe it's
successful in helping to determine whether nurses are able to go
out to assist? It was a training program that was brought forward
that was mentioned.
Ms Dent:
In hospital?
Mr
Ouellette: Yes.
Ms Dent:
No.
Mr
Ouellette: Do you know of any other training programs
that are available?
Ms Dent:
Specifically around restraint?
Mr
Ouellette: Yes.
Ms Dent:
I'm not familiar with what is available, but I notice it says in
this bill that it's important that the people administering the
restraints be trained in how to do this. I think this is a very
important part of the bill. Nurse practitioners, of course, are
another possibility here, that they have additional training. It
may be that they would have the qualifications to issue an order,
as well as physicians, but that isn't an area that I think we're
really able to comment on.
Mr
Ouellette: Yes. One of the presenters mentioned the
crisis intervention training and other groups have not heard of
it. That may be one of the problems, that there is training
available out there, according to the presenter, that other
groups and organizations haven't even heard about.
The Acting
Chair: Mr Spina may have another question, but he'd have
to use the Liberal time, and I don't think the Liberals want to
give that to him.
Ms Di
Cocco: It's through discussion with Frances Lankin that
I certainly became aware of this whole issue of patient restraint
and I have to say that it's one of those areas that I truly was
not at all educated on. I had no idea. I had assumed that these
things are all in place and that there's a criterion of sorts or
some kind of value judgment that's made very, very-how do I say
it?-thoughtfully before any of this is used. But obviously, from
some of the testimonies that I've heard, that isn't the case.
You talked about a case, a
personal situation that you witnessed, I guess. Did you hear a
reason as to the rationale for restraining the person who was
there? I'm quite curious.
Ms Dent:
The reason was that they were afraid. Because she was so upset
and agitated she was pulling at her bandages and they wanted to
prevent her from pulling off the bandages.
Ms Di
Cocco: And you have said that-I mean it's through your
advocacy, I guess, that long-term care has some sort of policy in
place in this regard. Can you just elaborate for me on the
difference between before your advocacy and what you see now in
long-term care and the fact that there is legislative
regulation?
Ms Dent:
There are very specific standards. There are about 19 or 20
points-criteria-that need to be met in long-term-care facilities
when restraints are applied. It's very clear who has the
responsibility, who does it, for how long, that they must have
training and that they must use the least restrictive restraint.
This is because it's there in writing that if a family member or
someone sees that restraint is being used inappropriately they
have a place to go. They can go and complain and it has to be
rectified, because it's there in writing.
Ms Di
Cocco: So there's a process of asking why this is
happening or there's a process of accountability, I guess?
Ms Dent:
Yes, exactly. The accountability is right there.
The Acting
Chair: Ms Dent, Ms Hanna, thank you very much for your
presentation this morning.
RUNNING TO DAYLIGHT FOUNDATION
The Acting
Chair: Our next presenter is the Running to Daylight
Foundation. Would you please identify yourselves for the purposes
of Hansard. You have 15 minutes in which to make your
presentation; you can use all or any part of it. If there's any
time left over we'll ask the members of the caucuses to split the
remaining time.
Ms Jane
Hawtin: My name is Jane Hawtin. Some of you know me as a
member of the television/radio broadcasters, but I'm here as an
honorary board member for the Running to Daylight Foundation, the
Ben Globerman Memorial. With me is Sharon Deutsh, who is a parent
representative with the foundation. You may want to hear some of
her comments because she has the hands-on knowledge of what's
happening in some of the hospitals where she goes in to try and
help the patients.
Let me just say how happy I
am to be here to support Frances Lankin and her bill. I am
representing the foundation so I'm going to stick to the script,
because otherwise I'll start yakking the way I usually do and I
don't think that would help anybody.
This foundation was created
in memory of Ben Globerman of Ottawa. Its purpose is to provide
elderly persons in Toronto and Ottawa with patient
representatives. These representatives work toward ensuring that
the elderly receive access to the highest-quality care, whether
it's in hospital or in the community. As I said, Sharon is one of
those patient representatives.
The foundation was formed
by Mr Globerman's family as a result of what they believe was
treatment that did not meet acceptable standards of care,
treatment that they feel did not meet such standards simply
because Mr Globerman was elderly, because he had a multiplicity
of health issues and because, in the words of the family, "the
system just felt he wasn't worth it."
I came to the foundation
because of my own experience when my father went to hospital at
age 86 after being very healthy, but he declined quite quickly.
Ironically, the restraint issue wasn't one, but now in retrospect
I realize it should have been because my father was also
restrained because he had been put on an inappropriate medication
in the incorrect amount which was causing him hallucinations.
Luckily, with our family we had the economic resources that we
could simply be there 24 hours a day, which meant that we
insisted on these restraints being taken off.
1150
The real issue and why I
came to this organization was because of my experience of four
days in a row being pressured-and "pressure" is the right word-by
a doctor to put a "Do not resuscitate" order on my father. I'm a
pretty assertive person. I was still made to feel guilty that I
was not willing to put that on, because I really felt that he was
going to have a chance to rally, which he did. We have to ensure
that everyone gets the right quality of care.
But our experiences, both
the Globermans' and mine, are not unique. Since the launch of the
foundation in October 1999, Running to Daylight has received many
e-mails, telephone calls and letters from families, not only in
Ontario but right across the country, telling their own horror
stories. These include concerns about DNRs, patients with
stroke-like symptoms being denied CT scans, patients being
starved to death, antibiotics being withheld from patients
experiencing pneumonia and elderly patients with congestive heart
failure being abandoned on wards for days.
The humiliation and
brutality that Frances Lankin's mother went through is
symptomatic of a larger issue. It's symptomatic of a health care
system that too often places little or no value on the elderly,
and discounts their dignity, their intelligence and their right
to have the same commitment to care at 80 that they would receive
if they were 18.
The foundation's concern is
that ours is quickly becoming a health care system that too often
lacks compassion. It rushes to judgment, it writes people off,
and an elderly person's prognosis is being based only on their
diagnosis and has nothing to do with their emotional, psychological or spiritual
makeup. Ladies and gentlemen, this is ageism at its ugliest.
The majority of our health
care professionals are skilled and caring. They are people who
are dedicated to helping their patients recover, but there is a
strata within the system that doesn't meet these expectations,
and it is this that we have to take measures to guard against.
Whether the horror stories represent 10% or 20% or 30% of what is
actually happening to the elderly who are admitted to hospital,
anything more than zero is unacceptable. Everyone who uses our
health care system, which was once thought to be the best in the
world, must have the chance to battle their illness and optimize
their chances for survival and recovery. Everyone in the province
of Ontario, irrespective of their age, gender, medical history or
presenting problem, must be guaranteed, without reservation,
access to the highest-quality health care, and that includes not
being restrained according to the whim of the service
provider.
We have heard in previous
statements over the past few months about the relationship
between the cutbacks in nursing and other health care resources
and the inappropriate use of restraint. We believe that this is
no doubt the case and, while not an excuse for such behaviour, it
is something that needs to be looked at.
How then can we, as
citizens living in one of the progressive countries in the world
and with such a health care system that should be model for all,
ensure that people like Frances Lankin's mother never have to go
through that again? The answer lies not only in the passing of
Bill 135 but in the establishment of standards for all health
care practices, in the appropriate funding for organizations to
meet those standards, in the establishment of rigorous monitoring
mechanisms to determine if those standards have been met and in
the implementation of swift and effective remedial measures if
they aren't.
The Running to Daylight
Foundation believes that the fact that the legislation outlined
in Bill 135 has never existed for public hospitals is symptomatic
of a larger issue. It is symptomatic of a system that too often
lacks accountability to those who use health care services and to
their families. It is symptomatic of a system that is preoccupied
with meeting financial targets rather than medical ones. In
reality, people don't judge the health care system by a 10%
increase in spending, or 20% or any other percentage. The
increase doesn't mean anything. All the patient knows is that if
he or she has to suffer the pain and humiliation of waiting 10
hours for a staff doctor in an ER, they're not going to care that
they were triaged by a nurse within 15 minutes.
What the average person on
the street wants is a guarantee that when they or their loved
ones receive care, that the services will be available in a
clinically appropriate manner and time, that the services will be
responsive and delivered with compassion, concern and courtesy,
and that they will not be the brunt of apathy or insensitivity,
even if the provider is a victim of depleted resources or has
some kind of personal bias.
To those who would argue
that Bill 135 is too intrusive or burdensome, that it
micromanages the health care system, that it's going to cost too
much or might be better accomplished through education or
self-monitoring, let me say this: we have to be taking every
opportunity we have to augment the intent of the Canada Health
Act through legislation and standards. This is not the time to
weaken our foundation for national medicare but to strengthen it.
Wherever we find the flaws, we have to ensure that the solutions
are entrenched in laws and standards, and if such standards
result in greater financial commitment, so be it. We would argue
that it's a price that most of us would be willing to pay,
especially after you go through this experience with someone who
is elderly. We would not be adjusting the standards to what we
are willing to finance but rather adjusting the finances needed
to meet the standards.
We have some problems: the
cutback of approximately 10,000 nursing positions and the crisis
we face in being able to hire them back; the number of elderly
people who are having to experience the gruelling schedule of
nighttime dialysis-they aren't getting home until close to
midnight; many patients are having to travel to the United States
for cancer treatment, and suffering devastating trauma and
loneliness because their families can't afford to go with them.
The many horror stories that our foundation has documented are
happening, not because we have too many safeguards built into the
system but because we don't have enough.
There's another point. Why
would we expect the health care providers to regulate themselves
if that hasn't worked in the past? The guidelines for the use of
restraints were put forward by the Ontario Hospital Association
in the early 1990s-guidelines: up to the discretion of the
hospital to implement and monitor-and the research shows the
guidelines or policies are not being observed or not monitored,
not everywhere.
The implementation of
legislation and standards should be viewed not as micromanaging;
the implementing of legislation and standards is about management
and accountability for the health care system. Legislation
standards must exist to manage the managers. While it's true that
the responsibility for guaranteeing access to the highest-quality
care is a responsibility for all of us-the funders, the planners,
the service providers, the professional associations, the
consumers, the media-the ultimate responsibility has to lie with
the government. The buck has to stop somewhere.
What happened to Frances
Lankin's mother is a travesty. We must take the issue very
seriously and resolve it quickly, effectively and without
reserve. It's not about politics; it's about humanity and about
morality.
We urge you to lend your
support to Bill 135 in the spirit in which it's been formulated.
The line between being well and being ill in hospital is as thin
as a razor's edge. Let us not forget that any one of us in this
room could have experienced what Ms Lankin's mother did, and
without adequate legislation and standards established, we could
encounter it in the future. Augmented by education and training, such legislation and
standards are the way to a brighter future.
The Acting
Chair: We have approximately one and a half minutes per
caucus for questions. I would remind the members to keep your
questions short.
Ms Lankin:
Mr Chair, sorry; once again I want to indicate to members of the
committee that I will be moving a motion that I think will
eliminate the need for us to resume this afternoon. So perhaps we
might be able to add a few minutes on at this point and allow
committee members to ask a couple of questions of the
presenters.
The Acting
Chair: There would have to be unanimous consent.
We'll give you two more
minutes. We begin with the government caucus.
Mr
Tascona: I'll be brief because I want to deal with Ms
Lankin's motion on this. We've heard from a broad section of the
community with respect to this issue. Obviously it's important
that this issue has been raised, and we appreciate that. That's
part of the reason we have public hearings, to get input on
everything.
What we've heard this
morning is a philosophy in terms of how you provide care. It's
not a cost issue; it's a philosophy issue on how you provide
clinical care. That's what we're hearing from the experts, the
doctors and other people who are legal practitioners. They never
raised it as a cost issue. So I want to put that forth to you in
terms of the health care system. It's more whether you know the
legal right, whether you apply it properly in terms of what
health care is going to be provided, the issue of consent and the
issues that have been raised in the bill.
I'm just making a comment.
I really don't need any response to that. That's what we've been
hearing throughout the process and certainly Hansard is available
on that. So I would urge you to read that in terms of what we've
been hearing here today.
Ms Hawtin:
Am I allowed to respond to that?
The Acting
Chair: Of course.
Mr
Tascona: I'm not looking for a response on that, but if
you wish.
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Ms Hawtin:
Sharon may want to respond to it. I'm aware of that, but I don't
think a lot of the people in the field would necessarily agree
with that, especially if you see what happens at nighttime.
Restraints are used more often at night when there are fewer
nurses available.
The reason we've formed
this foundation and the reason we feel patient representatives
are needed is that not everyone can afford, the way we could, to
have someone there 24 hours a day when someone goes to hospital.
In a lot of cases that's needed, and part of that is because of
cutbacks.
Mr
Tascona: We're not hearing that. I want to be clear with
you. It's been a clinical care issue in terms of whether you
respect the rights of the individual or not. I'll share that with
you. I'm not going to debate it with you.
The Acting
Chair: Members of the Liberal caucus.
Ms Di
Cocco: I'm going to start off by agreeing to disagree
with those comments. I have heard it is an attitude of how we
provide care. On the other hand, it's a reality that if you don't
have personnel dealing with that needed care of watching over the
patient-and I agree, I hear this a lot-people who have the means
can have somebody there all the time, either their family or
whatever. I think it's a combination of both. It is the attitude
of how we provide services, and maybe you can either expand on it
or respond to it. It's both the attitude and also this sense of
just fixing dollars rather than the need of personnel. Yes, there
is a shortage of nurses and there is a shortage of health care
workers. That's been augmented, I believe, by policy and for
other reasons. Again, we're not here to debate it, but I believe
that's the reality.
You've obviously formed a
group for a specific reason. Can you tell this committee if
you've seen changes? This bill I hope is a change for the better
in how we provide services, but can you tell me if you have seen
changes in the last four or five years that have impinged maybe
on the quality of health care with the elderly in this
province?
Ms Hawtin:
Sharon is better able to answer that.
Ms Sharon
Deutsh: I think there have been changes over the last
four or five years, and maybe even longer, actually, but there
definitely is less staffing available out there. However, elderly
people are being shortchanged. I think that has increased over
the years where, if you have a 30-year-old person coming in
versus an 80-year-old, that 30-year-old will more than likely get
better care versus an elderly person.
A lot of the cases I have
dealt with are elderly patients who have gone into the hospital
in an acute care setting, sometimes in long-term care, and they
have either been overmedicated or underassessed. There's been
very little communication that's taken place between the
physician and the family and the patient, if the patient is able
to communicate-sometimes they're not at that level-and these
patients are being pushed to the side, so to speak.
Ms Hawtin:
You had a letter from a family member who said they felt that
their father would have starved to death if you had not been
there.
Ms Deutsh:
Yes.
Ms Hawtin:
Because he wasn't being properly fed.
Ms Deutsh:
In this particular case, the gentleman was being overmedicated to
the point that I guess you could compare that to being physically
restrained. The trays would be brought in in the morning, put on
the table and then they'd come back in, he wouldn't have touched
them and the trays were taken away at that time. Then, later on,
when the sister was able to come in, did not have the finances or
the resources to have somebody at this patient's bedside, she
would attempt to feed him, and he was either too sedated to
swallow his food or, if he was a little bit less sedated, he
would gobble it up like he hadn't seen any food all day. This is
a very common situation that is arising in the hospitals.
Ms Lankin: I want to say to
you, Mr Tascona, that throughout this I have attempted to present
the information that I've uncovered in looking at this as a
systemic problem that has existed for many years in the province.
I think that it is fair comment to say that whenever there are
stresses and strains in the system, something of this nature
might be exacerbated and we have heard that. I have to disagree
with you in terms your assessment of all we've heard. I think the
RNAO presented in their view that in part there is a relationship
to staffing levels. That for me is not where we as a committee
need to start because this issue, I think highlighted by the
foundation that's presenting here, is one of cultural treatment
of our seniors, and it's something that is not related to
government or government ideologies and political parties in any
way. I think times must change and it's something we have to
grapple with.
I had the opportunity to
meet with the founder of Running to Daylight and am very
supportive of the goal of establishing a system of patient
representatives. You may know that I had an opportunity to
participate in a government that looked at establishing an
advocacy commission because there was a belief that there was a
need for some people in our society to have access to advocates.
Could you tell us what, as a patient representative, your finding
is and what the goal is with respect to a program of patient
representatives in the province?
Ms Deutsh:
The main goal of the patient representative is to increase the
elderly person's access to high-quality health care through
representations of the patient. Part of that goal is also to help
empower the family and the patient, so if we can empower through
guidance and communication and help to communicate with other
staff in the hospitals, then that is one level of our role as a
patient rep.
The other role is to come
into the institution or to meet with the families and assess what
their needs are and then to take that into the setting and
discuss with the medical personnel the care and try and devise a
goal for this patient's care in a non-adversarial way. What it
does is allow the family to be able to communicate their
concerns, hear the medical concerns and hopefully create a plan
that is going to enhance the care of that elderly person.
Does that answer your
question?
Ms Lankin:
Yes, thank you. I just want to say thank you very much for your
foundation's support of this legislative initiative. We're
hopeful to work through and find the right kind of language that
will meet some of the legitimate concerns that have been raised.
I remain committed to having at the base of this initiative a
piece of legislation that guarantees rights. I appreciate your
support.
The Acting
Chair: Ms Hawtin and Ms Deutsh, thank you very much for
your presentation this morning.
Ms Lankin, you were wishing
to make a motion?
Ms Lankin:
Yes, I'd like to place a motion on the table and then, if I may,
speak to the rationale for it: that clause-by-clause
consideration of Bill 135 commence when the standing committee on
Legislative Assembly resumes regular committee meetings during
the spring sitting of the Legislature.
The Acting
Chair: Could we have a copy of that motion?
Ms Lankin:
Yes. Mr Chair, if I could speak to that motion? I would
appreciate any comments, thoughts or discussion that may
ensue.
As I indicated yesterday in
opening comments, there has been tremendous goodwill shown by
members of all political parties toward this legislative
initiative and I think we want to sort out what's the best way to
go forward. The former Minister of Health had expressed interest
and had assigned a parliamentary assistant to work with me and
there was discussion of having someone within the policy or legal
branch of the Ministry of Health that I might have access to to
talk about the specifics of the bill, some of the provisions that
you've heard people talk to: doctor's order or nurse's order, two
hours monitoring or 12 hours monitoring, a range of those sorts
of things; how much detail is in legislation and how much is in
regulation-some of the comments you heard from the OMA and the
RNAO.
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As I indicated, as a
private member working with legislative counsel to draft this,
MPPs' offices do not have the same access to legislative counsel
or to the policy machinery that exists within the ministry. So
that's an important next step to get to.
I have not had the
opportunity, since the cabinet shuffle last week, to pursue this
issue with the new Minister of Health. I'm hoping that support
will be there and will continue. It is clear to me that there
needs to be some time to do more detailed work, hopefully with
the ministry's participation, in terms of any amendments that are
brought forward. I think the committee, all of us, would feel
unprepared this afternoon to deal with specific amendments. I
think we require more support and assistance on policy.
I fully recognize that
there is a possibility that all this might be for naught. Rumours
abound, and the rumour is that there may be a prorogation of the
House. That being the case, it would be necessary for me to
introduce a new bill in any event. This work would not be in vain
and the work I might be able to do between now and then with
representatives of the ministry to develop amendments would also
not be in vain, as opposed to an amendment process that would be
a new bill that would be introduced, hopefully containing those
amendments.
I think it would benefit
the process and the quality of the bill, the legislation we're
going to consider, to have a period now of a month and a half or
so, or whenever the House is called back, to do more substantive
work on the provisions of the bill. Hopefully this committee or,
with a new bill, whatever committee it's referred to, would deal
with that during the spring sitting of the Legislature.
That's the rationale. I
would be interested if Mr Tascona feels that's a reasonable
process or if he has any comments or advice on that.
The Acting Chair: Further
discussion?
Mr
Tascona: I appreciate all the work you've put into this.
I think we've got some very good input on the process. Certainly
if we go to clause-by-clause in the spring, I would anticipate
some notice on the amendments that may or may not be brought
forth so that the members just don't show up for a meeting
without the amendments. That's my only comment on that. I would
anticipate the clerk would make arrangements on that, because I
think the motion we approved the other day says, "Amendments to
the bill will be distributed as available." So I'm anticipating
availability, hopefully before the commencement of
clause-by-clause.
Ms Lankin:
I will certainly give you that undertaking, Mr Tascona.
Mr
Tascona: In that vein, I have no difficulty with
supporting the motion.
The Acting
Chair: Further discussion?
Mr
Ouellette: Just a quick question regarding the OHA
review. Are you anticipating any outcomes or are there going to
be implications to the amendments, and when is the expected
completion date of the review?
Ms Lankin:
I don't expect that the OHA review will be done in a time period
that would inform the amendments to the bill, other than to say
that it is possible some of the specific detail we're speaking of
may end up reverting to a regulation form, so that the general
prohibitions and the general conditions are set out but the
details of monitoring could be put in regulations. That could
then be informed not just by the OHA review but by the RNAO best
practices and a number of things.
I'm sorry, I can't remember
the expected completion date, but I know it is not in a time
frame that would coincide with the spring legislative
session.
The Acting
Chair: Further discussion? There being none, I will
reread this and then I'll call the question.
It has been moved by Ms
Lankin that clause-by-clause consideration of Bill 135 commence
when the standing committee on the Legislative Assembly resumes
regular committee meetings during the spring sitting of the
Legislative Assembly. All in favour? Passed unanimously.
