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Case Relevant Findings Youngberg v. Romeo, 457 U.S. 307 (1982)21 Involuntarily committed patients have a substantive right to safe conditions of confinement, freedom from bodily restraints, and some training to protect their liberty interests. What constitutes adequate training is best decided on a case-by-case basis and is best determined by the judgment of a qualified professional. Liberty interest is not absolute, but must be balanced by the need for institutions to protect residents from the danger of violence. “Persons who have been involuntarily committed are entitled to more considerate treatment and conditions of confinement than criminals whose conditions of confinement are designed to punish” (Ref. 21, pp 321-2). Washington v. Harper, 494 U.S. 210 (1990)22 The use of R&S does not constitute a valid alternative to meaningful psychiatric treatment, even in a prison setting involving an inmate who does not want to receive antipsychotic medication. The ruling cited an amicus curiae brief filed by the American Psychiatric Association: “Physical restraints are effective only in the short term, and can have serious physical side effects when used on a resisting inmate, as well as leaving the staff at risk of injury while putting the restraints on or tending to the inmate who is in them … [R]espondent has failed to demonstrate that physical restraints or seclusion are acceptable substitutes for antipsychotic drugs, in terms of either their medical effectiveness or their toll on limited prison resources” (Ref. 22, pp 226-7). Wyatt v. Stickney23 Involuntarily committed patients have a constitutional right to treatment that would cure or improve their mental conditions. The ruling called for adequate (increased) staffing levels and individualized treatment plans. Davis v. Rennie, 264 F.3d 86 (1st Cir. 2001), cert. denied, Rennie v. Davis, 535 U.S. 1053 (2002)24 Staff at a mental health facility can be held to a higher standard than is applicable in correctional settings. “…[T]here is precedent for subjecting the conduct of a mental health worker to a more exacting standard than that of a prison guard controlling a riot” (Ref. 24, p 99). Not every incident of forceful restraint amounts to a violation of the patient's Fourteenth Amendment rights, but force should be used sparingly. “… [F]orce [should] be used as sparingly as possible” (Ref. 24, p 111). Campbell v. Sikes, 169 F.3d 1353 (11th Cir. 1999)25 In a prison setting, evidence of staff members' good faith in applying R&S included compliance with prison procedures for restraints, extensive documentation, and monitoring when restraints were used, including the use of videotaped monitoring. A five-factor test was used in determining whether use of force was excessive. People v. Harvey, 528 N.E.2d 1053 (Ill. App. Ct. 1988)26 A counselor was found guilty of involuntary manslaughter for the death of a teenaged boy who was forcibly restrained to punish him for nonviolent disobedience. The boy aspirated his vomit during the restraint. The court noted that the boy was not assaultive until the staff tried to restrain him. Punitive or custodial use of R&S may be acceptable in correctional or criminal settings, but punitive use in treatment settings violates the patient's constitutional rights. Threlkeld v. White Castle Systems, Inc., 127 F. Supp. 2d 986 (N.D. Ill. 2001)27 A woman, forcibly injected with lorazepam by the physician-defendant in an emergency room, could “make a prima facie case for negligence based on a violation of the [Illinois] Mental Health Code” and also stated a claim for battery because her consent was not obtained for the injection. The patient had been brought to the ER by police officers and was locked in an observation room and restrained. She was upset and crying, but the physician who ordered the shot testified that he did not think that she was a threat to herself or others. He ordered a nurse to give the patient the shot to “calm her down” so that he could talk to her, but he never obtained consent. Case Relevant Findings Scherer v. Waterbury, 2000 Conn. Super. LEXIS 481 (Conn. Super. Ct. February 22, 2000)53 Treatment providers' policies were held to violate the Americans with Disabilities Act (ADA). Crisis center physician had directed that emergency room staff forcibly detain a female patient who grew upset at being asked if she had been raped. There was no indication that the patient had suicidal or homicidal ideation. The patient was placed in seclusion and forced to strip in front of a male security guard. She was not seen by a doctor until more than an hour later, when she was found not to be a danger to herself or others and released by the hospital. Demonstrates importance of trauma-informed care, determining history of trauma, and accurate/thorough risk assessment before ordering R&S. Hopper v. Callahan, 562 N.E.2d 822 (Mass. 1990)54 The patient died when an ectopic pregnancy was misdiagnosed as gastroenteritis, and the patient was placed (and ignored) in a seclusion room. Seclusion orders were continually renewed without examination by a physician, despite continued complaints of abdominal pain. The court wrote: “The two doctors could be found to have applied no medical judgment at all in entering the seclusion orders and to have abdicated any responsibility for investigating Hopper's medical condition, leaving the judgment concerning seclusion and medical care in each instance to inadequately trained, overworked staff” (Ref. 54, p 828). Dolihite v. Maughon, 74 F.3d 1027 (11th Cir. 1996), cert. denied, Dolihite v. King, 519 U.S. 870 (1996)55 The 11th Circuit affirmed the lower court's denial of qualified immunity for a social worker, noting sufficient evidence for a jury to find that she had acted with deliberate indifference toward a teenage patient's self-injurious behavior. The patient was placed in R&S and attempted to hang himself, (causing permanent brain damage) after his observation status was reduced. Social worker had also failed to communicate effectively with other staff about the patient's risk of further self-harm. The patient had engaged in multiple suicidal gestures and attempts before/during hospitalization and had a family history of suicide, but clinicians had not taken his suicidal ideation seriously. He was viewed as “manipulative”; the social worker opined that he enjoyed the “shock value” of talking about suicide. A previous hanging attempt was noted in the time-out record but ignored. Case Relevant Findings Andrews v. Neer, 253 F.3d 1052 (8th Cir. 2001)52 The Eighth Circuit held that the plaintiff's excessive-force claim should be reviewed under the objective-reasonableness standard for cases involving pretrial detainees. “The Eighth Amendment excessive-force standard provides too little protection to a person whom the state is not allowed to punish” (Ref. 52, p 1061). Hospital security aides had used excessive force in restraining a patient, resulting in his death due to airway compression during the takedown. The patient, agitated, backed into a corner and swung a book at those who approached. Security aides responded, but “one of the last aides to arrive at the scene testified that so many aides surrounded [the patient] that [he] could not see him” (Ref. 52, p 1056). New York v. Simon, 157 A.D.2d 508 549 N.Y.S.2d 701 (N.Y. App. Div. 1 Dept, 1990)57 The court upheld the jury's verdict against a nurse for second-degree manslaughter and criminally negligent homicide in a restraint-related death of a psychiatric patient. The patient had undergone a tracheotomy and was grabbing at the tracheotomy wound (acutely agitated). She asked to see a doctor, citing difficulty breathing, and vomiting blood, but the nurse allegedly threatened her with violence if she (the patient) caused further trouble. The patient then engaged in disruptive behavior and was placed in a straitjacket with her feet tied to the bed and was given a sedative injection. During a check, the patient's condition was found to be critical. Code blue was called, but resuscitation failed. An autopsy found numerous R&S-related injuries; cause of death was asphyxiation by mechanical compression. The court commented: “[W]hile [the patient] was certainly agitated … she was not posing any physical threat to others present. Instead, [her] erratic behavior appears to have irritated the hospital staff rather than to have posed a threat, and defendant's violent reaction was an unwarranted response to what can essentially be characterized as annoying behavior” (Ref. 57, p 513). Unpublished case (parties settled), reported by Grant50 A 32-year-old female patient died of asphyxiation while physically restrained face down by several guards and security personnel who had not been properly trained in the safe application of restraint.
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