Prohibited Restrictive Practices There is a range of restrictive practices that are prohibited and not to be used by providers of disability services.These practices conflict with person-centred principles, are demeaning and unacceptable. They also represent a risk to people’s human rights, personal dignity and safety. Psycho-social Restraints Restrictive Practice Example Potential Risks Recommended Controls Prescribing Practitioner Consent • Demeaning tone of voice. • Threatening negative consequences – “…if you do that again, you are not…” • Manipulation. • Punishment being used by staff. • Emotional trauma. • Risk to human rights and personal dignity. education, supervision and management. Not to be used. Not to be used. • Leaving people in bed. • Putting people to bed early. • Punishment being used by staff. • Loss of freedom. • Denial of activities. • Emotional trauma. • Escalation of behaviour (secondary to boredom). • Risk to human rights and personal dignity. Staff education, supervision and management. Not to be used. Not to be used. • Immobilisation of mobility devices: – use of brakes – disengaging • Deliberately delaying or failing to charge the battery of the device. • Punishment being used by staff. • Loss of freedom. • Denial of activities. • Emotional trauma. • Escalation of behaviour. • Risk to human rights, personal dignity and choice. Staff education, supervision and management. Not to be used. Not to be used. Trial
Withholding basic human rights: • Food/drinks* • Shelter/warmth/cooling • Clothing, shoes • Person’s goods/belongings* • Positive social interaction • Favoured activity • Communication devices. • Punishment being used by staff. • Loss of freedom. • Denial of activities. • Emotional trauma. • Escalation of behaviour. • Diminished capacity to communicate needs, etc. • Risk to human rights, personal dignity and choice. Staff education, supervision and management. Not to be used. Not to be used. *Restricting or removing access to certain types of or amounts of food/drink and/or goods/personal belongings may be appropriate in certain circumstances. Refer to section on . Aversive Interventions Restrictive Practice Example Potential Risks Recommended Controls Prescribing Practitioner Consent • Application of electric shocks to the person. • Use of spray to the face. • Punishment being used by staff. • Loss of freedom. • Denial of activities. • Emotional trauma. • Escalation of behaviour. • Diminished capacity to communicate needs, etc. • Risk to human rights, personal dignity and choice. • Physical harm. Staff education, supervision and management. Not to be used. Not to be used.
Restrictive Practice Example Potential Risks Recommended Controls Prescribing Practitioner Consent and Endorsement The use of restrictive clothing Only considered a mechanical restraint when the person objects to its use and requires powers as per Section 32 (1) (c). • Emotional trauma. • Violation of human rights. • Loss of independence and/or skills (for example, self-toileting). • Continence review. • of least restrictive alternatives. • Use correct size. • Minimise use. • Regular review and of alternatives. • Conduct risk assessment. PBS practitioner: Develops the PBSP, contributes to the risk assessment. Medical practitioner/psychiatrist the restrictive practice is being used to administer medical treatment): Prescribes the medical treatment and contributes to the PBSP and risk assessment as required. Consent: Person with capacity to give consent or their appointed guardian with relevant powers as per Section 32 of the Guardianship and Administration Act 1993. Endorsement: The delegated restrictive practices compliance officer. Restrictive Practice Example Potential Risks Recommended Controls Prescribing Practitioner Consent and Endorsement
Restrictive Practice Example Potential Recommended Controls Prescribing Person(s) Consent and Endorsement Detention Actively preventing a person from leaving accommodation usually requires relevant powers as per Section 32 (4) (b) and Section 32 (4) (a). This gives authorisation to detain the person at the place they have been directed to live or stay. • Loss of freedom and choice. • Escalation of behaviour. • Physical injury. • Emotional trauma. • Injury/death in the event of an emergency. • Risk to human rights. • Conduct risk assessment. • Adherence to PBSP. • Planned accompanied outings/access to community. • Regular monitoring. • Modify environment to prevent injury. • Emergency protocol. • Electronic keypads/ where required. • Regular review. PBS practitioner: Develops the PBSP, contributes to the risk assessment. Medical practitioner/ psychiatrist (where the restrictive practice is being used to administer medical treatment): Prescribes the medical treatment and contributes to the PBSP and risk assessment as required. Consent: An appointed guardian with relevant powers as per Section 32 of the Guardianship and Administration Act 1993. Endorsement: The delegated restrictive practices compliance officer. Seclusion Confining a person to a locked room or area against their will require relevant powers as per Section 32 (4) (b). • Self-harm. • Emotional trauma. • Escalation of behaviour. • Injury/death in the event of an emergency. • Risk to human rights and personal dignity. • Deprivation. • Conduct risk assessment. • Document and undertake regular frequent monitoring including welfare checks. • Adherence to the PBSP. • Time limited. • Modify environment to prevent injury. • Regular review. PBS practitioner: Develops the PBSP, contributes to the risk assessment. Medical practitioner/ psychiatrist (where the restrictive practice is being used to administer medical treatment): Prescribes the medical treatment and contributes to the PBSP and risk assessment as required. Consent: Person with capacity to give consent or their appointed guardian with relevant powers as per Section 32 of the Guardianship and Administration Act 1993. Endorsement: The delegated restrictive practices compliance officer.
Compelling a Person to Comply with Medical Treatment That is, concealing medication in food/drink, taking blood from a person against their will and giving injections to a person against their will. Where the treatment is regular psychiatric treatment it is generally more appropriate to consider applying for a community treatment order through SACAT. Section 32 (1) (c) of the Act states: …may, by order, authorise the persons from time to time involved in the care of the person to use such force as may be reasonably necessary for the purpose of ensuring the proper medical or dental treatment, day-to-day care and well-being of the person. Restrictive Practice Example Potential Risks Recommended Controls Prescribing Person(s) Consent and Endorsement Hiding medication in a person’s food or drink (including via PEG feeds) For the primary purpose of overriding consent as the primary purpose (as distinct from preventing the risk of choking). • Loss of freedom and choice. • Emotional trauma. • Conduct risk assessment. • Adherence to the PBSP. • Regular review. PBS practitioner: Develops the PBSP, contributes to the risk assessment. Medical practitioner/psychiatrist (where the restrictive practice is being used to administer medical treatment): Prescribes the medical treatment and contributes to the PBSP and risk assessment as required. Community nurse (where involved in the administration of the medical treatment): Contributes to the PBSP and the risk assessment as required. Consent: Person with capacity to give consent or their appointed guardian with relevant powers as per Section 32 of the Guardianship and Administration Act 1993 or relevant court order. Endorsement: The delegated restrictive practices compliance officer. Restrictive Practice Example Potential Risks Recommended Controls Prescribing Person(s) Consent and Endorsement
The use of physical force In order to administer medical treatment (such as, holding a person to take blood against their will, give injections to a person against their will or force a person to undergo a medical procedure) requires relevant powers as per Section 32 (1) (c). • Loss of freedom and choice. • Emotional trauma. • Injury • Threat to human rights and personal dignity. • Conduct risk assessment. • Adherence to the PBSP. • Regular review. • Use of familiar staff. PBS practitioner: Develops the PBSP, contributes to the risk assessment. Medical practitioner/psychiatrist (where the restrictive practice is being used to administer medical treatment): Prescribes the medical treatment and contributes to the PBSP and risk assessment as required. Community nurse (where involved in the administration of the medical treatment): Contributes to the PBSP and the risk assessment as required. Consent: An appointed guardian with relevant powers as per Section 32 of the Guardianship and Administration Act 1993 or relevant order. Endorsement: The delegated restrictive practices compliance officer. Restrictive Practices Requiring the Consent of an Appointed Guardian, Substitute Decision-maker or Person Responsible (other than staff of a disability service provider who cannot consent to chemical restraint) Chemical Restraints Chemical Restraints: Restrictive practices requiring the consent of an appointed guardian, substitute decision-maker, or person responsible (other than staff of a disability service provider who cannot consent to chemical restraint). This list is not exhaustive. If a person resists or objects to the administration of any medication, then the additional consent of an appointed guardian with relevant Section 32 powers is also required. of a disability service provider are unable to consent.) Note: Where a medical practitioner or psychiatrist has prescribed medication for the purposes of managing a person’s behaviour (as distinct from prescribing evidenced-based pharmaceutical treatment for a diagnosed medical/psychiatric condition or pre-procedural sedation for the primary purpose of reducing the person’s anxiety about a procedure), a PBSP must also be created to support management of that behaviour. The PBS Practitioner authorised to draft the PBSP must liaise with the prescribing medical practitioner or psychiatrist to ensure optimal integration of the two strategies (medication and behaviour support plan) and support the minimisation of medication being used for behaviour management.
Restrictive Practice Example Potential Risks Recommended Controls Prescribing Person(s) Consent and Endorsement Anti-convulsant medication When not prescribed for epilepsy management or a relevant psychiatric diagnosis (for example, bi-polar affective disorder, schizophrenia, schizoaffective disorder) such as: • Carbamazepine • Sodium Valproate • Lamotrigine. Refer to individual product information, but may include sedation, causing swallowing difficulties (dysphagia), falls and pressure areas leading to ulsers. Refer to the individual product information but generally should include: • Observation including monitoring for side effects (when medication commenced, increased, or ceased). • Awareness of toxicity symptoms. • Regular medical review. PBS practitioner: Develops the PBSP, contributes to the risk assessment. Medical practitioner/ psychiatrist (where the restrictive practice is being used to administer medical treatment): Prescribes the medical treatment and contributes to the PBSP and risk assessment as required. Community nurse (where involved in the administration of the medical treatment): Contributes to the PBSP and the risk assessment as required. Consent: Person with capacity to give consent or their relative or guardian. If the person is resisting or objecting to the medication, the consent of an appointed guardian with relevant powers as per Section 32 of the Guardianship and Administration Act 1993 is also required. Endorsement: The delegated restrictive practices compliance officer. Anti-histamines When prescribed for the principle purpose of sedation, for example: • Phenergan • Vallergan. Refer to individual product information, but may include: • Sedation (causing dysphagia, falls and pressure areas). Refer to the individual product information but generally would include: • Observation including monitoring for side effects (when medication commenced, increased, or ceased). • Awareness of toxicity symptoms. • Regular medical review. PBS practitioner: Develops the PBSP, contributes to the risk assessment. Medical practitioner/ psychiatrist (where the restrictive practice is being used to administer medical treatment): Prescribes the medical treatment and contributes to the PBSP and risk assessment as required. Community nurse (where involved in the Consent: Person with capacity to give consent or their relative or guardian. If the person is resisting or objecting to the medication, the consent of an appointed guardian with relevant powers as per Section 32 of the Guardianship and
administration of the medical treatment): Contributes to the PBSP and the risk assessment as required. Administration Act 1993 is also required. Endorsement: The delegated restrictive practices compliance officer. Restrictive Practice Example Potential Recommended Controls Prescribing Person(s) Consent and Endorsement Anti-psychotics When there is no relevant psychiatric diagnosis, for example: • Olanzapine • Risperidone • Quetiapine • Haloperidol. • Aripiprozale • Chlorpromazine • Pericyazine. Refer to product information but may include: • Extra-pyramidal side effects that include: Drooling Stiffness. • Sedation (causing dysphagia, falls, and pressure areas). • Agitation. Refer to the individual product information but generally should include: • Observation including monitoring for side effects (when medication commenced, increased, or ceased). • Awareness of toxicity symptoms. • Regular medical review. PBS practitioner: Develops the PBSP, contributes to the risk assessment. Medical practitioner/ psychiatrist (where the restrictive practice is being used to administer medical treatment): Prescribes the medical treatment and contributes to the PBSP and risk assessment as required. Community (where involved in the administration of the medical treatment): Contributes to the PBSP and the risk assessment as required. Consent: Person with capacity to give consent or their relative or guardian. If the person is resisting or objecting to the medication, the consent of an appointed guardian with relevant powers as per Section 32 of the Guardianship and Administration Act 1993 is also required. Endorsement: The delegated restrictive practices compliance officer.
Restrictive Practice Example Potential Recommended Controls Prescribing Person(s) Consent and Endorsement Benzodiazepines May be prescribed short-term for severe symptoms in a number of conditions (including anxiety, psychosis, bi-polar, schizophrenia, epilepsy, severe obsessive compulsive disorder (OCD), and periods of medication changeover). At times, Benzodiazepines may be prescribed long-term for some chronic psychiatric conditions. Some common Benzodiazepines are: • Diazepam • Clonazepam • Temazepam • Midazolam (when not prescribed for seizure management) Medazolam and other sedatives can be used to override consent to, and/or enforce compliance with medical treatment. If this is the case, then this requires relevant powers as per Section 32. Refer to individual product information but may include: • Respiratory depression • Excessive sedation • Confusion • Disinhibition/ agitation. • Midazolam can cause rapid and severe respiratory depression. to the individual product information but generally would include: • Observation including monitoring for side effects (when medication commenced, increased, or ceased). • Awareness of toxicity symptoms. • Regular medical review. • Avoid continuous use. Medical practitioner or psychiatrist. Consent: Person with capacity to give consent or their relative or guardian. If the person is resisting or objecting to the medication, the consent of an appointed guardian with relevant powers as per Section 32 of the Guardianship and Administration Act 1993 is also required. Endorsement: The delegated restrictive practices compliance officer. Restrictive Practice Example Potential Risks Recommended Controls Prescribing Person(s) Consent and Endorsement
Hormonal manipulation (male) (When used for the primary purpose of reducing a person’s sex-drive.) to the individual product information but generally may include: • Change in secondary sexual characteristics. • Depression. • disease. • Reduction in sex drive. • Loss of fertility. Refer to the individual product information but generally should include: • Counselling prior to use. • Careful initial titration. • Regular review of dosage. • Regular review of need for therapy. PBS practitioner: Develops the PBSP, contributes to the risk assessment. Medical practitioner/ psychiatrist (where the restrictive practice is being used to administer medical treatment): Prescribes the medical treatment and contributes to the PBSP and risk assessment as required. Community nurse (where involved in the administration of the medical treatment): Contributes to the PBSP and the risk assessment as required. Consent: Person with capacity to give consent or relative or guardian. If the person is resisting or objecting to the medication, the consent of an appointed guardian with relevant powers as per Section 32 of the Guardianship and Administration Act 1993 is also required or authority provided via a relevant court order. Endorsement: The delegated restrictive practices compliance officer. Restrictive Practice Example Potential Risks Recommended Controls Prescribing Person(s) Consent and Endorsement
Anti-depressants Very rarely used as a chemical restraint. Most commonly would be amitriptyline, which is sometimes used as a behavioural restraint due to its sedative properties. Refer to product information, but usually: • Sedation. • Falls. Refer to the individual product information but generally would include: • Observation including monitoring for side effects (when medication commenced, increased, or ceased). • Regular medical review. Medical practitioner/ psychiatrist (where the restrictive practice is being used to administer medical treatment): Prescribes the medical treatment and contributes to the PBSP and risk assessment as required. PBS practitioner: Develops the PBSP, contributes to the risk assessment. Consent: Person with capacity to give consent or their relative or guardian. If the person is resisting or objecting to the medication, the consent of an appointed guardian with relevant powers as per Section 32 of the Guardianship and Administration Act 1993 is also required. Endorsement: The delegated restrictive practices compliance officer. Environmental Restraints (this is not an exhaustive list) Note: It is important to note that a ‘person responsible’ as defined under the Consent to Medical Treatment and Palliative Care Act 1995 cannot consent to restricting or preventing free access to food/drink/other items owned by the person for whom they are consenting. However, an appointed guardian for lifestyle can consent to the restriction of certain food/drink/other items for health safety and/or welfare reasons even when the person objects. However, in circumstances where force or significant coercion is required to prevent access to the desired item(s) consideration may be given to powers as per Section 32 of the Guardianship and Administration 1993, usually Section 32 (1) (c). Restrictive Practice Example Potential Risks Recommended Controls Prescribing Person(s) Consent and Endorsement
Bed • Strangulation. • Falls. • Conduct risk assessment. • Lower bed. • Use floor padding. • Use knee brace or remove canopy when client is sitting in bed. Physiotherapist, occupational therapist or registered Consent: Person with capacity to give consent or their guardian, substitute decision-maker or person responsible. If the person is resisting or objecting to the restriction then relevant powers as per Section 32 of the Guardianship and Administration Act 1993 must be obtained. See section on . Endorsement: The delegated restrictive practices compliance officer. Restrictive Practice Example Potential Risks Recommended Controls Prescribing Person(s) Consent and Endorsement Devices used to assist the person when eating, drinking, during oral hygiene procedure, including posture restraining devices • Emotional trauma. • Loss of dignity. • Physical injury. • Conduct risk assessment • Follow meal time management plan/support plan. • Explain prior to use. • Limit use. • Ensure adequate padding. Speech therapist, physiotherapist, occupational therapist or registered nurse. Consent: Person with capacity to give consent or their guardian, substitute decision-maker or person responsible. If the person is resisting or objecting to the restriction then relevant powers as per Section 32 of the Guardianship and Administration Act 1993 must be obtained. See section on . Endorsement: The delegated restrictive practices compliance officer.
Seat belt/harness/ wheelchair trays • Strangulation. • Other injuries. • Conduct risk assessment • Use pommel or harness. • Prevent loosening of belt. • Use anti-slip material. • Use anti-tipping mechanisms. • Use ‘tilt in space’ chairs. Physiotherapist, occupational therapist or registered nurse. Consent: Person with capacity to give consent or their guardian, substitute decision-maker or person responsible. If the person is resisting or objecting to the restriction then relevant powers as per Section 32 of the Guardianship and Administration Act 1993 must be obtained. See section on . Endorsement: The delegated restrictive practices compliance officer. Restrictive Practice Example Potential Risks Recommended Controls Prescribing Person(s) Consent and Endorsement Bed canopy • Strangulation. • Conduct risk assessment • Lower bed. • Use floor padding. • Use knee or remove canopy when client is sitting in bed. Physiotherapist, occupational therapist or registered nurse. Consent: Person with capacity to give consent or their guardian, substitute decision-maker or person responsible. If the person is resisting or objecting to the restriction then relevant powers as per Section 32 of the Guardianship and Administration Act 1993 must be obtained. See section on . Endorsement: The delegated restrictive practices compliance officer. Restrictive clothing • Impaired skin integrity. • Emotional trauma. • Conduct risk assessment • Continence review. • of alternatives prior to use. • Explain prior to use. Client coordinator. Consent: Person with capacity to give consent or guardian, substitute decision-maker or person responsible. If the person is resisting or objecting to the restriction then relevant powers as
• Risk to human rights and personal dignity. • Loss of skills (such as continence). • Customised to fit. • period of use. • Regular review. per Section 32 of the Guardianship and Administration Act 1993 must be obtained. See section on . Endorsement: The delegated restrictive practices compliance officer. Restrictive Practice Example Potential Risks Recommended Controls Prescribing Person(s) Consent and Endorsement Sensor alarms • Mats – tripping risk, electrocution. • Restriction of free movement. • Conduct risk assessment • Addition of non-slip aids. • Daily check of power cords. • If the sensor mat is used to enable staff to enforce detention then relevant Section 32 powers may also be required. Refer to section on . Client coordinator. Consent: Person with capacity to give consent or their guardian, substitute decision-maker or person responsible. If the person is resisting or objecting to the restriction then relevant powers as per Section 32 of the Guardianship and Administration Act 1993 must be obtained. See section on . Endorsement: The delegated restrictive practices compliance officer. Cuffing or strapping prescribed for safety purposes • Emotional trauma. • Physical injury. • Restriction of free movement. • Conduct risk assessment • Explain prior to use. • Limit use. • Ensure adequate padding. Physiotherapist, occupational therapist or registered nurse. Consent: Person with capacity to give consent or their guardian, substitute decision-maker or person responsible.
For example, during sling transfers for managing involuntary movements. • Use correct size. • Not to be used for behaviour management unless specifically authorised relevant Section 32 orders with 6 monthly review. Refer to Mechanical Restraints. If the person is resisting or objecting to the restriction then relevant powers as per Section 32 of the Guardianship and Administration Act 1993 must be obtained. See section on . Endorsement: The delegated restrictive practices compliance officer. Locked As a safety precaution for people who are at risk of wandering or absconding. • Loss of freedom and choice. • Escalation of behaviour. • Physical injury. • Emotional trauma. • Injury/death in the event of an emergency. • Risk to human rights. • Conduct risk assessment (including fire safety risk assessment). • Adherence to PBSP. • Planned accompanied outings/access. • Regular monitoring. • Modify environment to prevent injury. • Emergency protocol. • Electronic keypads/ locks. Client coordinator. Consent: Person with capacity to give consent or their guardian, substitute decision-maker or person responsible. If the person is resisting or objecting to the restriction then relevant powers as per Section 32 of the Guardianship and Administration Act 1993 must be obtained. See section on . Endorsement: The delegated restrictive practices compliance officer. Splints • Pressure • Pain/discomfort. • Injury to others. • Risk to human rights. • Conduct risk assessment. • Explain prior to use. • Customised to fit. • period of use. • Pain relief. Physiotherapist GP, occupational therapist or orthotist. Consent: Person with capacity to give consent or their guardian, substitute decision-maker or person responsible. If the person is resisting or objecting to the restriction then relevant powers as per Section 32 of the