MEDICOLEGAL DILEMMAS ON RESTRAINT USE IN DELIRIOUS PATIENTS IN INTENSIVE CARE UNIT

Fizičko ili medikamentno ograničavanje delirantnih bolesnika u jedinicama intenzivnog liječenja (JIL) povezano je s nizom etičkih i medikolegalnih dilema. One najčešće proizlaze iz nedovoljnog poznavanja važećih propisa ili njihove nedorečenosti. Cilj ovoga pregleda je prikazati osnovne stavove medicinske struke povezane s primjenom ograničavanja kao metode u liječenju delirija te pružiti uvid u važeću legislativu na nacionalnoj i međunarodnoj razini. Prema suvremenim spoznajama ograničavanje bolesnika u deliriju, bez obzira je li u pitanju fizičko ograničavanje ili primjena psihoaktivnih farmaka, ima niz potencijalno štetnih nuspojava te mora biti korišteno uz jasnu indikaciju, strogi nadzor i precizno vođenu medicinsku dokumentaciju. Postupanje s delirantnim bolesnikom mora biti u skladu s medicinskom etikom, međunarodnim konvencijama te zakonima i pravilnicima koji reguliraju prava pacijenata. To uključuje opće principe poštivanje digniteta i autonomnosti bolesnika, njegovu pravodobnu obaviještenost i informirani pristanak te poštivanje pravila struke ugrađenih u pisane upute svake bolnice o postupanju s bolesnikom u deliriju. Detaljni medikolegalni okvir promjene ograničavanja delirantnih bolesnika daje Pravilnik o akreditaciji bolničkih zdravstvenih ustanova i to je trenutno najviši važeći standard za primjenu ograničavanja delirantnih bolesnika kako u JIL-u tako i na drugim bolničkim odjelima.The use of physical or chemical restraint in delirious patients in the intensive care unit (ICU) is related to an array of ethical and medicolegal dilemmas. In most cases, they arise from insufficient knowledge of the regulations in force or due to their vague wording. The aim of this review article is to outline the basic views of the medical profession regarding restraint use as a method in the treatment of delirium and to give an insight into the existing legislation at the national and international level. According to the contemporary research, restraint of patients in delirium, whether it is physical restraint or application of psychoactive drugs, has a number of potentially harmful side effects and must be used with clear indications, under strict supervision, and with meticulously kept medical records. A delirious patient must be treated in accordance with medical ethics, international conventions and the laws and regulations related to patient rights. This includes the general principles of respecting the patient’s autonomy and dignity, giving him or her timely information, notification of informed consent, as well as abiding by the rules of the profession integrated in every hospital written instructions on the treatment of a patient in delirium. A detailed medicolegal frame of restraint use in delirious patients is given by the Croatian Hospital Accreditation Rules, which is currently the highest existing standard for restraint use in delirious patients in ICU, as well as in the other hospital departments