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Appendix 3 – Criteria and questions to ask when considering the possible use of restraint in the acute hospital care setting

2020 Ethical issues linked to legal capacity and decision making (full report)

This is an extract from a text by: Narchi J & Ritzi S (2019). Freiheitseinschränkende Maßnahmen bei Menschen mit kognitiven Beeinträchtigungen im Akutkrankenhaus. Geriatrie up2date, 1(03), 267–280. Translated and reproduced with kind permission from Georg Thieme Verlag KG)

1. Criterion of proportionality

Is the restraining measure suitable, necessary and appropriate for the objectives for which it is to be applied?

  •  Is the restraining measure indicated from a nursing and medical point of view or are personal, organisational and economic interests the primary concern?
  • Are there milder forms of restraining measures that promise the same or greater benefit?
  • Are there alternatives to the restraining measure that promise the same or greater benefit?
  • Is the restraining measure truly effective in preventing the harm that needs to be averted?
  • Is the intensity of the restraining measure appropriate to the situation concerned?
  • Is the duration of the restraining measure appropriate to the situation concerned?

 2. Criterion of non-maleficence

 Does the restraining measure pose a risk of causing other physical or psychological harm?

  • Does the restraining measure pose the risk of a danger to life (e.g. through strangulation)?
  •  Does the restraining measure increase the risk of falling?
  • Does the restraining measure involve any adverse effects on the healthcare situation (e.g. forced incontinence)?
  • Does the restraining measure cause a loss of mobility and independence?
  • Does the restraining measure directly or indirectly imply a form of humiliation?
  • Does the restraining measure evoke mistrust, fear and imbalance of power?
  • Does the restraining measure increase the occurrence of behaviour that is perceived as challenging (e.g. motor restlessness and shouting)?
  • In the case of chemical restraint: Does the drug have harmful or irreversible side effects on body and soul?

3. Criterion of last resort

Have all other possible alternatives to the restraining measure been tried and found to be ineffective, leaving the restraining measure as the last resort?

  • Have all mechanical alternatives to the restraining measure already been explored?
  • Have all non-mechanical alternatives to the restraining measure already been explored?
  • Does the nursing documentation indicate the ineffectiveness of alternative means to the restraining measure (e.g. clear nursing reports, case discussions, protocols of fall events)?
  • Is the restraining measure the last option in the decision-making process or rather the first course of action?

 4. Criterion of self-determination

 Is the restraining measure compatible with the patient's actual or presumed will?

  • Can the patient's actual will be ascertained?
  • Can the patient's presumed will be ascertained?
  •  Has the patient's presumed will been investigated with the participation of the person concerned as well as relatives, caregivers, physicians and nursing staff?
  • What is or was the patient's presumed attitude towards the use of restraint and what reasons is this position based on?
  • How would the patient feel about the use of restraint if he/she knew about the associated health risks and about suitable milder alternatives?
  • Does the patient's biography allow us to draw conclusions about his or her attitude towards restraint?
  • Does the patient verbally or non-verbally communicate approval or disapproval (e.g. repeated shaking of the bed rail or attempts to remove the measure)?


Freedom restraining measures may at first glance still seem indispensable when caring for people with cognitive impairments in hospital. For many, it is hard to imagine professional care without them. Fortunately, however, research is increasingly showing that this need not be the case: It may well be worthwhile to "do without" these measures i.e. to consider alternative interventions which can better meet the needs of people with dementia and cognitive impairments in the acute care hospital setting in a more holistic way.

For a reflected as well as professionally, legally and ethically informed approach to freedom restraining measures, it is important to be familiar with the basic categories, definitions and empirical data on the subject. We hope that this article helps contribute to this.



Last Updated: Monday 08 March 2021


  • Acknowledgements

    The report entitled “Legal capacity and decision making: The ethical implications of lack of legal capacity on the lives of people with dementia” received funding under an operating grant from the European Union’s Health Programme (2014–2020).
  • European Union