May 17, 2019

Physical restraints should not be allowed in aged care, medical expert tells royal commission

Professor Joseph Ibrahim gave an impassioned hearing at the royal commission on Thursday, delivering a damning assessment of Australia’s aged care system, and laying down his suggestions, based on decades of research, for improvements.

Prof Ibrahim is a consultant specialist in geriatric medicine, who teaches and researches patient safety and aged care at the Institute of Forensic Medicine and is head of the Health Law and Ageing Research Unit at Monash University.

Prof Ibrahim investigated the causes of death in nursing homes reported to the coroner between 2000 and 2014, and found 22,000 deaths had occurred in residential nursing home from a total 230,000 deaths.

Of these, 3,289 were from injury and 18,000 were natural cause deaths.

Prof Ibrahim questioned why these deaths were reported to the coroner.

“As most people would know, deaths reported to the Coroner usually have some unusual aspect to them, and we remain curious to this day as to why 18,000 natural cause deaths have been reported,” he told the royal commission.

Only 39 deaths reported to the coroner were the result of complications of clinical care, which “beggars belief”, he said.

Professor Ibrahim said it was costly and difficult to get data for his studies from the Department of Health and the AIHW.

“Linkage of data”, for example between hospitals and ACFI, would be “incredibly helpful”, he said.

Aged care should be a place to enjoy your remaining time

Prof Ibrahim said there is no agreement on what aged care is.

“You can’t measure something if you can’t define it, and the beauty for the Parliament and for the Government and for the Health Department is if it’s not defined, you can’t ever do anything wrong because you can switch your definition or what you think the role is. And you will have seen from residential aged care is on one hand it’s a palliative care unit when you want it to be, and then the next minute it’s a brokerage or concierge service for people to go skydiving.

“The product of residential aged care is death, and deaths occur one third every year and so it seems that residential aged care is working well because every year 35 50,000 people die and that’s what we expect so things are happening smoothly,” he said.

Aged care should be a place that people can enjoy, he said.

“I believe that residential aged care is a place where older people should be able to go and enjoy their life.”

“I would have thought at that point in life you deserve to have something decent happen to you, and so I think that residential aged care should have the goal that it’s a place where people can at least enjoy their last few months or years before they die,” he said.

Aged care not a home

Mr Peter Bolster, read a transcript to Prof Ibrahim about the fact that residential aged care facilities are not a ‘home’, they are an institution.

Prof Ibrahim said there are different populations in aged care and each has different requirements.

“There are at least three populations that access residential care at the moment: those that enter and die quickly within a month to six months; those that are there for more than three years and some more than six years; and then there’s a middle group. The needs of the residents are different and so some residents need a home-like atmosphere with – activities is the wrong word, but they need somewhere to live because they need help with their personal care and they need to be able to have a purpose to their lives.

“Other people are frail, needing palliation and palliative care with high-end nursing care and pain management. And then there’s a large group of people who have multiple chronic diseases that need fine-tuning, regular clinical assessment to make sure that they’re in optimal health to enjoy their life.”

“We haven’t actually asked older people what they want and if we have asked them, we haven’t listened,” he said.

Profit often the motivation in aged care

Prof Ibrahim said the purpose of building nursing homes often appears to be profit.

“We’re designing things based on… square footage because the square footage of your room determines your ingoing fee and what you can charge people. So if I’m being charged extra for a window and double for two windows, then the decision about the build is not from the residents’ point of view; the drive for the build is really for profit,” he said.

What is ‘safety’ in aged care?

Prof Ibrahim said aged car facilities are promoted as a place where residents will be ‘safe’, but he said that sometimes isn’t necessarily true.

“If you think that’s safe, well, that’s safe, but that does not mean no harm will befall you,” he told the royal commission.

Suicide in aged care needs more attention

Prof Ibrahim said suicide was a topic that is not being adequately addressed in aged care, and that needs to change.

“Residential aged care was not considered an at risk population [for suicide], so there were no interventions there,” he said.

New assessments will help, he said, but more work on “prevention” needs to be done.

Sexual abuse reporting needs follow up

Prof Ibrahim said the government reports on sexual abuse in aged care, but does not make use of the data.

“All I know is what is in the annual reporting requirements the Department has to do according to legislation, and they provide a one paragraph summary saying the number of incidents that have occurred. There’s no state breakdown. There’s no breakdown of nature. There’s no breakdown, whether it’s resident or staff perpetrated. There’s no explanation as to whether they’ve used that data or fed it back…

“I would happily analyse that data for free if it was provided to our team,” he said.

The reporting exclusion for people with cognitive impairment “makes no sense,” Prof Ibrahim said.

“The exclusion for people with dementia makes no sense because the people with dementia are the ones at the greatest risk, and so we set up a system which is not accountable to anyone,” he said.

Use of physical restraints “ought not be allowed”

Prof Ibrahim said the use of physical restraint in aged care is “disrespectful and really ought not be allowed”.

“The only possible justification is if there’s an imminent threat to life that you might restrain someone.”

“It beggars belief that it still goes on in aged care,” he said.

Greater risks in respite care

Prof Ibrahim said his finding that respite care can be a dangerous option for people “caught us by surprise”.

“Respite care is for the carer, not for the person who is in respite,” he said, noting that it is “really important” to have strategies to help carers because over 50 per cent of carers have physical or mental health issues related to the “burden of caring”.

“But if I take a person from their home, from their loved one who knows them intimately, knows their habits, their likes and dislikes, they know the layout of the house, they know where the step is, they know where the lights are, they know where the toilet is, they know when to take their medicines, and I take them to a strange new place where there is noise and people I don’t know who say things in ways I don’t know, with a layout I don’t understand, with no indication where the toilet is, who aren’t giving me my medicines on time or the way that I normally like it, it should be no surprise that I will slip or fall or become incontinent or become distressed or want to leave,” Prof Ibrahim said.

Prof Ibrahim said similar risks apply in all healthcare, but the risks there are managed, whereas the risks are not managed in respite care.

Managing ‘unexplained absences’

Prof Ibrahim said he supports an “open door policy” in aged care.

“It just makes no sense not to have a policy that allows people freedom of movement,” he said.

Aged care residents are “stateless”

Prof Ibrahim said the residents of Australia’s aged care system are “stateless”.

“Parliament does not care about people in residential aged care. If they truly care, they would do something,” he said.

Prof Ibrahim said nurses are the best clinical specialty to work in residential aged care, rather than doctors, but that more cross-training with allied health services – such as speech pathologists, physiotherapist, and occupational therapist – can “make a difference to a person’s life.

“If it wasn’t for the nurses in the aged care system and the people there now, the whole thing would just be a complete catastrophe,” Prof Ibrahim said.

Image: Aged Care Royal Commission.

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  2. Finally someone is talking the same path that my boss has be talking about the the past 20 yrs

  3. The only reason why people are restrained endlessly in Aged Care is because there are no staff to actually sit with them and ensure that they don’t wander off or fall over. The reason why there are no staff is because corporate providers have turned Aged Care into a business and it is cheaper to tie someone up than it is to employ the cheapest staff. PRN sedation and restraint are grossly over used because if a resident falls over they can be seriously injured or even die. You don’t need a Royal Commission to understand this.

  4. Thanks for your positive comments regarding nurses in Aged Care professor.
    I agree as a RN with extensive experience in this field that restraint use is certainly not ideal however you and all others who have spoken on this subject fail completely to suggest any alternative.!

    This is extremely frustrating for experienced staff who know the reality of what is involved as compared to academics who only comment from a distance.

    In the current system if all restraints are removed with current staffing levels many residents will continually (often numerous times in one day) end up on the floor and injured, often severely.
    I’ve seen this occur literally thousands of times.

    When bed rails were removed in my last facility they won many accolades in Accreditation but the fact that falls out of bed substantially increased was conveniently overlooked.

    It also was disgraceful how a bed rail or other restraint to maintain safety was even classified as a ‘restraint’ in the true sense of the word as most of these residents were unable to mobilise independently and also had cognitive impairment and had no or very little idea what they wanted so they certainly were not being ‘ restrained’ from carrying out a legitimate task!

    The only way this can change is to probably triple staffing levels so no one resident with short term memory loss and impaired mobility is ever left alone even for 30-60 seconds as this is the memory span of many residents.
    The bottom line is that Federal Government will never fund what everyone wants as the ‘ideal’.


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