Coercing people with dementia

A report from Sweden caught my eye.  In Sweden, the law forbids restraining older people with dementia  in hospitals and care homes.  A newspaper, Expressen, has argued that this is unrealistic and unmanageable – they argue for “common sense”.  “It’s a crazy system in which members of staff can be punished by law for caring for confused elderly patients if the supervisory authorities find out about it.”  (The report is here, in Swedish – the first link, in English, has most of the point, but I fed the article through Google Translate to get the gist.  The translation says that allowing people greater personal freedom is “dangerous and inhumane”.)

This led me to a fascinating research paper in Nursing Ethics, published in 2013.   (I have only given the Pubmed reference in the link – the full article is restricted to subcribers.)  Based on qualitative, open questions, the research identifies three main classes of response.  Coercive measures include mechnical restraints such as bed guards, safety belts and locks, non-mechanical restraints (mainly by nursing staff) control through medication, and electronic surveillance.  Preventative measures cover the same sorts of thing, but used with consent or for limited periods.    Then there are strategies to adapt to greater freedoms for people with dementia – extra staff, better training, risk assessments and adapted procedures.   It seems that many of the respondents do, knowingly, break the rules in some respects.

It doesn’t follow, however, that this is bad law.   To be effective, a law has to be enforceable.  Once  adjustments are made for ‘reasonable’ breaches, it becomes difficult to know when the law applies and when it doesn’t.    No-one is going to prosecute a nurse who takes a patient by the arm to lead them back to the ward – but if the law is changed to allow for that, and a few hundred other possible actions, it won’t work at all.  The substance of the Swedish law is right – people need to be treated with dignity and some personal autonomy.  The more vulnerable the person is, the more that protection is needed.

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