Here is the clinical scenario: You have an inmate in your facility who is running his head into wall, bull-like, at full speed. He then backs up and does it again. He may be suicidal. He may be high on meth. He may just be a jerk throwing a tantrum. But he will not stop just because you have asked him to.
How should we stop this patient from hurting himself?
What would you do in this situation? It seems to me that there are only three options for how to deal with this inmate.
- Do nothing! Let him hurt himself if he wants.
- Physically restrain him in a restraint chair or on a board.
- Administer sedating medications as a form of chemical sedation.
These three responses clearly are different in the risk of a bad outcome. And there are two possible bad outcomes to consider. The first is the medical risk. Which approach is most likely to result in a serious injury to the patient? The second is the legal risk. Which approach is least likely to result in a successful lawsuit?
I hope that no one reading this would opt to do nothing. You simply cannot continue to let this inmate run his head against the wall. The risk of a bad outcome, both medical and legal is just too high. On the medical side, I personally am aware of three cases where inmates running their heads into the wall of their cells fractured their necks. One was left a quadriplegic. The risk of legal action is also high. In fact, this could be Deliberate Indifference: You knew that running his head into the wall could potentially result in serious injury and yet you did nothing to stop him. I will leave the Deliberate Indifference question to the lawyers, but even without this, the threat of a nasty lawsuit following such an injury is almost inevitable.
So the prudent action, both medically and legally, is to restrain this patient in some way. But which method of restraint is safer for the patient? Which method of restraint is safer legally?
In my strongly held opinion, restraint by chemical sedation is safer than prolonged physical restraint for those who are a threat to injuring self or others. I have several reasons for believing this.
- Chemical Sedation is the community standard of care in the other two areas of medicine that also routinely restrain patients who are a threat to self or others. Those two areas are Emergency Medicine and Inpatient Psychiatric medicine.
- Prolonged physical restraint, for example in a restraint chair or board, carries significant risks of injury, including death. Chemical sedation is much safer.
- As long as the chemical sedation is done properly, there is less risk of successful legal action with chemical sedation than with prolonged physical restraint.
Chemical Sedation is the Community Standard of Care
I practiced in a busy emergency department for many years before I came to correctional medicine. There, chemical sedation is routinely practiced. Every Emergency Department does chemical sedation routinely. It is not controversial in ERs at all. I was taught how to do chemical sedation in my ER residency. It is an Emergency Medicine “Core Competency.” Chemical Sedation is discussed in every major Emergency medicine textbook. As a matter of fact, physical restraint is viewed in Emergency Medicine as a tool to facilitate chemical sedation rather than a viable option on its own.
It is a similar situation in inpatient psychiatric hospitals. I have asked several psychiatrists whether they leave dangerous inmates in a psych hospital physically restrained for long periods of time. The typical response is to laugh and say “No. They get sedated.”
I’m not sure why chemical sedation has such a bad reputation in some quarters of the correctional medicine world, because it is the Standard of Care for patients who are an acute danger to self or others elsewhere in medicine. Why is this so? It is because:
Chemical Sedation is Safer than Prolonged Physical Restraint
Unfortunately, I cannot point to any published studies that show that chemical sedation is safer than prolonged physical restraint. That is because there are none. However, I personally know of at least five cases of death from physical restraint. The mechanism of death in these cases has ranged from suffocation to acute pulmonary embolism to “excited delirium.” The point is that prolonged physical restraint carries substantial risks that range from minor (contusions, abrasions, broken bones) to serious (death, loss of limbs from too-tight restraints).
On the other hand, I am not aware of any deaths from chemical sedation, whether in an Emergency Department setting or in corrections. I actually have never heard of any serious complications from chemical sedation. There may have been one somewhere and I am just not aware of it. If you know of such a case, please contact me!
Chemical Sedation Carries Less Legal Risk Than Does Prolonged Physical Restraint
Again, there are no published studies on the incidence of lawsuits after restraints. I have spoken to several different Risk Management experts on the subject, both in Emergency Medicine and Correctional Medicine, and they have unanimously agreed that chemical sedation of a dangerous patient carries less legal risk than does prolonged physical restraint.
Here is one example. I contacted Rick Bukata and Greg Henry, who together publish Risk Management Monthly, a publication on how to reduce medico-legal risk in Emergency Departments. I asked them about the legal risk of administering chemical sedation to a dangerous patient against his will. This was their response:
“Jeff Keller has malpractice concerns about the patient who is sedated against his/her will. This situation is not likely to be problematic if the patient is being sedated because he or she poses a danger to self or others, and if the reason for sedation is meticulously documented. A physician might be at greater medicolegal risk if he or she fails to sedate a problematic patient who is placing the staff in jeopardy.”
After talking to several Risk Management experts in Correctional Medicine about this subject, I am unaware of any successful lawsuits arising from chemical sedation of an incarcerated inmate who was an acute danger to self or others. Once again, if you are aware of such a lawsuit, I want to know about it! Please contact me!
I believe that the legal risk of restraining an inmate depends on two factors. The first is harm. If a patient has been harmed by the restraints, he is more likely to sue and is more likely to be successful. So the method of restraint least likely to injure the patient is the safest legally. Chemical sedation is safer than prolonged physical restraint and so is safer legally as well.
The second factor is that the sedation was done on the right patient (one who is an acute danger to himself or others) and that this was documented properly.
In fact, chemical sedation is very like administering any medication. You must have the right patient, give the right medications in the right dosages, do the right monitoring and follow-up care, and document in the right way. If you do all of that, your legal risk will be low. More details on that later.
What does your facility do for out-of-control inmates who are a threat to themselves or others? Chemical sedation or prolonged physical restraint? Please comment!
We have recently started using chemical sedation in restrained patients who have a medical or mental concern. A policy has been adopted that allows for chemical sedation for both the inmate’s and staff safety. We have inmates, even restrained, who continue to cause safety concerns such as rocking our restraint chair hard enough to almost knock themselves over. Our most prescribed medication for chemical sedation is IM haldol in one arm and IM benadryl in the other. They soon decide they would rather go to their cell and sleep it off than continue to be beligerant/self destructive. Our MHNP can then re-evaluate them the next day when things have calmed down.
Good for you! I will address this in a future post, but I don’t think you need the Benadryl. If you are going to add a second agent, Ativan is a better choice.
There is a difference in why the inmate is behaving in this manner.
“He may be suicidal. He may be high on meth. He may just be a jerk throwing a tantrum.”
In the first two instances (suicidal, meth, or – to add my own – manic) a reasonable case can be constructed that the behavior is the result of some [mental] health process and falls into the province of health care staff. However, when the behavior is not [ok you got me you may have to make that assessment first – but often enough it is clear at onset] that falls in the province of correctional staff. While we do have a duty to [provide] care for health related items – we are not obliged to engage in addressing inmate misbehavior. We would not ‘take down’ an inmate who was involved in a fight – though we may suture the cuts later – that would be a corrections function.
There are no studies that I am aware of – though (newspaper) articles exist about inmates who have died while in restraints / chairs; few in number. What seems critical in those situations is the level of attention devoted to the individual who is restrained. When corrections follows established protocol and medical does periodic assessments all seems well. Whenever restraints are used by medical / mental health though things change – most states have very detailed requirements that must be followed to the exact letter or BIG trouble follows – even if you are trying to protect the patient / others. We do not restrain – corrections does – they have a safety / security responsibility and can restrain (without the same constraints).
Chemical restraint to satisfy corrections for behavior that is not symptomatically driven would not be appropriate. One change I have noted locally is a ‘shift’ in correction administration / supervisory thinking – “You have to give him / her something because I don’t want any of my staff to get hurt.” Yet, the individual has a long history of assault related behavior and NO mental health diagnosis (other than being a butt head). I do not want officers or any other staff hurt either – yet it seems that there is some absence of correction procedure to manage the non-mental health assaultive inmate.
Chemical sedation – in an appropriate case with a (at least provisional) diagnosis is very straight forward. A real problem in this setting could be the ability to safely monitor the patient – preserving airway, ensuring repeated vital signs, etc. One ‘rule of thumb’ I use is no treatment is accomplished in the facility unless we have the capacity to address any potential poor outcome. So, unless you are in a large facility with appropriate resources, it would also follow that the individual should be referred out post haste. Additionally, after assessment, if there is no diagnosis – there should be a clear process for the withdrawal of health care staff responsibility.
Thank you for the comments, Al. I agree that appropriate candidates for chemical sedation must be an acute danger to themselves or others. It is inappropriate to administer chemical sedation purely as a disciplinary measure or to make life easier for detention staff. One example would be the screamers. If an inmate is screaming “F*** you!” but is otherwise not harming themselves nor is an acute threat to others, Forced chemical sedation is probably not appropriate. Neither is physical restraint and gagging, for that matter.
However, an inmate with a history of violence who is threatening to harm staff and fully intends to do it–that may be legitimately construed to be an acute threat to the safety of staff and the security of the facility and chemical sedation may be appropriate. I also think that poop throwers, for example, also can be a legitimate threat to safety and security.
It is true that you have a responsibility to document the safe onset of sedation and if your facility does not have the medical staff to do this, the patient may have to be transported to the local ER for chemical sedation.
We have used chemical sedation for the last 15 years here at the Davis County Jail and have always used a combination of Haldol, Lorazepam, and Benadryl. We have recently stopped the Benadryl unless there is a reaction to the Haldol. Our contracted Mental Health Nurse Practitioner started this practice for inmates that were an immediate threat to themselves or others. We have never used this long term and if it needed to be repeated or used longer than 24 hours, our policy is to contact a judge for a court order. We have obtained a court order once or twice in the past but generally this is not necessary as the behavior usually resolves after they have had a good night’s sleep and get started on oral meds. If they are more chronically mentally ill they need longer acting treatment anyway. As for lawsuits regarding chemical restraints, we have had none. In fact I have never even been threatened with a lawsuit for forced medications to protect the life or health of an inmate.
Thank you James. I agree that it is unusual to have to use repeated doses of chemical sedation–and in those cases, it is best to get a court order.
What if there is no full-time nursing?
Thanks for the question, Rebecca. Let’s say a jail without full time nursing has a guy in a restraint chair for five hours. This patient should be evaluated periodically by a nurse for the possible medical complications of physical restraint. If he is sedated chemically, the nurse needs to administer the sedation and then stick around long enough to document the safe onset of sedation (let’s say an hour or so). Either way, a nurse should be there. If a jail has no access at all to medical staff, maybe they will need to send such out-of-control patients to the local ER.
How much Haldol? What if the inmate is on another anti psychotic? Why use benadryl?
Thanks for the question, Mark! All those questions will be answered in upcoming blog posts!
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I’ve been trying to find articles comparing the pros and cons between chemical and physical restraints, with no luck. (I wonder why that is…) But it sounds like even though a chemical restraint is more restrictive than a physical restraint, the overall benefits of safety for both the inmate and staff would make a chemical restraint a better option in most cases?
What about the use of chemical and physical restraints simultaneously and long term?
Hi Jeffery,
I am a Maori comprehensive registered nurse of over 30 years experience initially starting in infectious diseases and acute medicine. In the past 10 years I stepped into psychiatric nursing which I love. The symbolic nature of the picture – a man locked into a confined space who is probably looked into his thought process must be overwhelming for him. To believe that suppression of these thoughts is accomplished through chemical sedation seems absurd. I believe the answer is to lock him into a paddock with acres of land and a hut to retreat is more human. In addition vegetables and fruit (cheap) clean water and an honest caring person that monitors his risk, listens, shows compassion and advocates for his existence in a community is much closer to the answer of wellness. If chemical restraint is necessary I back benzodiazepines in acute situations they are fast acting have less side effects and promote good sleep. 4mg IMI does wonders if psychiatrists have the guts.
Thanks for the comment, Dee. The main issue in my mind is stopping self injurious behavior acutely, which buys us time to then address the underlying reason for the behavior, whether psychosis, mania, drug effect or whatever. Stopping the self injurious behavior should also be accomplished with he least invasive method possible, and in my opinion, properly done chemical sedation is less invasive and has less potential for injury than prolonged physical restraints–like 4-point leathers!