NPM in psychiatric hospitals – part III

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Note：This article is one of the NPM TRAVELBOOK series written by Mr Pavel Doubek and invited by Covenants Watch (CW), Taiwan. The original text was written in English and was translated by Yi-Ching Tsai, CW’s researcher.

Author／Pavel Doubek (Czech scholar and lawyer formerly working at Czech NPM)
Translator／Yi-Ching Tsai (Researcher of Covenants Watch)

In 2002, a child placed in a net bed died when an iron rod fell off. In 2006, a woman with mental disability swallowed her excrements and got suffocated in the net bed. In 2012, another woman suffering from psychosis strangled herself on a broken net bed in a psychiatric hospital.

These three sad events introduce our present story, which will focus on the uses of means of restraint (coercive measures) in Czech psychiatric hospitals.

We are talking about any use of physical force, tools, medication, and isolation to restrict or suppress the movement of a patient with the aim to calm down the patient whose dangerous behaviour poses an immediate risk to himself/herself or other people.

Although the means of restraint are usually an integral part of psychiatric care around the world, their use increases the risk of abuse and negative side effects. As noted above, they may also result in serious injuries and death.

Naturally, they are often associated with the suffering of the patient– not only the physical pain and harm resulting from immobilization but also helplessness, loneliness and humiliation. They also go against the doctor-patient relationship and undermine the therapeutic effect of treatment.

Types of restriction and its use in the Czech psychiatric hospitals

Most of the international human rights mechanisms, both universal and regional, acknowledge the restraints as a form of deprivation of liberty. ^[1] They should be considered only for a legitimate purpose as the last resort, and should always be used for the shortest possible time.

This is reflected in the Czech law as well, under which the restraint measures can only be used to prevent the imminent threat to the life, health or safety of the patient or other persons when less restrictive measures are insufficient. As long as the reasons for their use no longer exist, the restraint must be ended immediately.

The Czech Health Services Act recognizes six legal ways of restricting a person in movement in the psychiatric hospitals: (a) holding the patient, (b) use the protective belts/straps, (c) placing patient in net bed or (d) isolation room, (e) use a protective jacket or waistcoat, (f) administration of psychopharmaceuticals or other medicinal products.

The law requires that any use of restraint must be indicated by a medical doctor (in urgent solutions by another paramedical professional with consequent approve by a doctor), with measures to prevent damage to the patient’s health, under the supervision of healthcare professionals, and is documented in patient’s medical records.

In addition, a patient or his legal guardian must be clearly informed about the reasons for their use.

Evaluating the uses of restraint, in particular the grounds and proportionality from a human rights perspective remains a challenging topic for medical and legal debates.

The Committee on the Rights of Persons with Disabilities even calls for absolute prohibition of the use of means of restraint, as it found that “those practices are not consistent with the prohibition of torture and other cruel, inhuman or degrading treatment or punishment of persons with disabilities”.^[2]

Although the Czech National Preventive Mechanism (NPM) has never determined the legal uses of restraints mentioned above has crossed the threshold of ill-treatment during its visits at psychiatric hospitals, still it has found several risky practices, especially with regards to some of the “mechanical” and “chemical” means (i.e. use of belts, jackets, administration of psychiatric drugs).

These are exactly what I wish to raise for discussion and reflection in this article, and I will mainly refer to the standards set by the European Committee for the Prevention of Torture (CPT).

Note 1：The international human rights mechanisms on torture prevention include the UN Committee against Torture (CAT) and the UN Subcommittee on the Prevention of Torture (SPT). In the European region, there are the European Committee for the Prevention of Torture (CPT) and the European Court of Human Rights (ECHR). More about the international standards please see the Subcommittee on Prevention of Torture (SPT).

Note 2：The committee does not explain, however, how to address the emergency situation in a psychiatric hospital, if all less intrusive means prove to be ineffective. See the Committee on the Rights of Persons with Disabilities, “Guidelines on article 14 of the Convention on the Rights of Persons with Disabilities: The right to liberty and security of persons with disabilities”, from the Report of the Committee on the Rights of Persons with Disabilities (A/72/55).

Mechanical restraints: groundless and excessive use of straps

The Czech NPM has repeatedly examined the use of straps to fix the patient’s arms and legs to the bed, which is a common mechanical mean worldwide.

Although they should be used only to address the imminent threat, the NPM revealed that straps are commonly used from 20 hours to 3 days in Czech psychiatric hospitals. In some cases, the duration of restraints even lasted up to 5 and 7 days.

The patients’ medical records and interviews with medical personnel show that there was a tendency to prolong patient restraint for preventive reasons. Several patients told the NPM monitors that they understand the reasons why they were restrained, but could not understand why they were restrained so long since they were no longer dangerous. 

The NPM emphasized that “after so many hours of restraints, it is no longer possible to distinguish whether the restlessness of the patient is caused by his or her psychotic state or whether it roots in the frustration of restraint itself.”

It further recommended that if it is not possible to end the restriction within a few hours, the medical staff must adopt an additional measure to speed up the termination of the restriction, for example, by creating a protected environment for the patient, ensuring permanent supervision, or increasing the availability of staff in the ward.

The CPT provides recommendations on the use of mechanical restrains:

• Patients under restraint should always be face up with the arms positioned down.
• Straps must not be too tight and should be applied in a manner that allows for the maximum safe movement of the arms and legs.
• The vital functions of the patient, such as respiration and the ability to communicate, must not be hampered.
• Patients under restraint should be properly dressed and, as far as possible, be enabled to eat and drink autonomously and to comply with the needs of nature in a sanitary facility.

It’s also a common practice in Czech Republic that the medical personnel may ask the police for assistance in emergencies when they are not able to pacify relentless patient by themselves.

The Czech NPM has also paid attention to this issue, and it has found that in some hospitals, the police were called just as to enforce the authority of the hospitals staff over “disobedient” patients.

The NPM stressed that the presence of police in the psychiatric hospital is negative to the doctor-patient relationship and the therapeutic effect of treatment. Further, since the police officers are usually not trained in pacifying people with mental disability, police intervention could be extremely risky for the health and life of a patient.

Case in point would be a patient with a mental disability who died for a heart attack after being paralyzed by police taser in Czech psychiatric hospital in 2015.

Criticism of the net beds

There is another mechanical mean of restraint that is highly controversial but is still allowed in the Czech Republic: the net bed. It’s a bed that is bounded on all sides by a metal structure that is woven with a net. On one side, the barrier can be opened or closed and locked.

Since the Health Service Act considers the net bed as a means of restraint, it must be used as a measure of the last resort with limited duration and patient must be under continuous supervision.

However, as I mentioned in the previous story, the NPM revealed that the hospital personnel often do not consider the net bed as a means of restraint, or even standardize it as part of the standard therapeutic procedures.

In some hospitals, the patients stay in net bed for a prolonged period of time. For instance, a medical record noted: “A 50-year-old patient […] for years, is living in a net bed”.

In other hospitals, the caring staff did not feel a need to subject patient to continuous supervision, because (as they claimed), the net bed is a safe environment and thus do not require that rigorous observation compared to patients in “open regime”.

Nevertheless, the cases of patients who have died in the net bed prove the opposite. This measure may be extremely dangerous, especially when the hospital fails to continuously supervise the patient. There is also a high risk of excessive use, as it may be used as a measure that eases a work of caring staff.

That is why the Czech NPM along with the international monitoring bodies have for a long time urged Czech authorities to prohibit net beds in all psychiatric institutions. The CPT is calling on their prohibition “under all circumstances”.

The UN Committee against Torture (CAT) further condemns the absence of investigations into the ill-treatment and deaths of persons confined to cage and net-beds, including suicides.^[6]

It is worth to mention that this issue drew significant attention of media including criticism by world-known writer J. K. Rowling. She even sent a letter to the Czech president and prime minister.

This international pressure resulted in a significant decrease in net beds, however, the Czech NPM has revealed that they are still in use in some psychiatric hospitals.

Irregular drug administration: treatment or chemical restraint?

Administration of psychiatric drugs with the aim to calm down relentless patient is considered as a chemical mean of restraint. Therefore, it must be subjected to the same legal standards and procedural guarantees as to any other coercive measure.

The CPT has recommended that only approved, well-established and short-acting drugs should be used. It has further emphasized that “the side-effects that medication may have on a particular patient need to be constantly borne in mind, particularly when medication is used in combination with mechanical restraint or seclusion.”

The Czech NPM has a rich experience with the use of this type of restraint in places of detention, as it commonly occurs not only in psychiatric hospitals but also in institutions for long-term patients and elderly homes.

As the NPM emphasizes, it is necessary to distinguish the situations when a medicine is used as “treatment” or as “restraint”. The patients’ consent is the key element to consider.

If a patient refuse to take the drug, but the drug is still administered in a bid to avoid imminent harm, then the medication loses its “treatment status” and must be considered as “a mean of restraint”.

In practice, medical doctors (usually the psychiatrists) tend to prescribe patients with mental disabilities an ad hoc administration of a psychiatric drug, especially considering the irregularity of their symptoms.

The doctor often prescribes such medication in broad terms (e.g. “two pills of Lexotan in a need of anxiety”). Since the psychiatrists are not available 24 hours, then it is usually the nurse who must consider, whether the patient is already suffering from anxiety to be given Lexotan.

The NPM pointed out that such a broad prescription “profuturo” and irregular/ad hoc administration raises the risk of misuse and excessive use of psychiatric drugs. It therefore suggests that psychiatrist should clearly specify the situations that justify the use of particular medicine.

The NPM further suggest, that despite the psychiatrist’s prescription, each use of the irregular psychiatric drug should be discussed with him (at least via a phone call).

Having discussed some of the means of restraints and their controversies, as well as all the other challenges and dilemmas we have explored in the previous two articles, we can see how difficult it is for the National Preventive Mechanism to assess the treatments and conditions in the psychiatric hospitals.

Sometimes the moral, legal and practical debate of the human rights standards is still going on and it may be really frustrating that consensus is hard to form.

Undoubtedly, the real, on-site observations and experiences that the NPM gathers during its regular visits to diverse places of detentions can provide invaluable input for the discussion that will eventually lead the human society to progress.