Legal Issues of Medical Personnel in Dealing with Aggressive or Agitated Patients

This section includes legal requirements for limiting patients' freedom, requirements for legal protection in order to protect patient / staff safety. 

Personal health care workers, when providing primary or emergency medical care, face the risk of adversely affecting the interests of others, including the right to free movement, natural state or health. These aspects become particularly relevant when dealing with aggressive patients. On the one hand, this is a necessary exercise of a professional duty, notwithstanding the dangers involved, on the other, the protection of the rights and legitimate interests of the medical profession and the guarantee of patients' rights. Article 3 of the European Convention on Human Rights states: "No one shall be subjected to torture or to inhuman or degrading treatment or punishment." The judgment of the European Court of Human Rights in Herczegfalvy v. Austria^[47] is relevant in the context of this article of the Convention. In the present case, the patient, Mr Herczegfalvy, was forcibly given food and neuroleptic treatment, isolated and handcuffed to a special bed for several weeks. He complained that the treatment had been cruel and too long, and that taken together could be considered as inhumane and degrading treatment, which had even contributed to his deterioration. In response, the Austrian State argued that the nature of the treatment was determined by the behaviour of Mr Herczegfalvy. It did not see any breach of the convention on the one hand that therapeutic methods should be used and, where necessary, coerced to protect the physical and mental health of patients who are wholly incapable of making medical decisions, so, it must be decided by medical institutions in accordance with recognized rules of medical science, and in such cases the medical principles laid down are, in principle, decisive; on the other hand, patients are nevertheless protected by Article 3 of the Convention, which lays down no requirements and must be convincingly demonstrated that such a medical necessity is required. These arguments set out in the European Court of Human Rights judgment are also related to the principle of constitutional proportionality - that the rights and freedoms of individuals should not be restricted beyond when it is necessary to achieve legitimate and public interest objectives. The Constitutional Court has noted that the legal concept of private life is related to the legitimate expectations of the private life of a person; if a person commits criminal or other acts contrary to law, unlawfully interferes with the interests protected by law, hurts individuals, makes impact on society and the State, he or she understands or must understand that it will result in a corresponding reaction to the violation by public authorities. The person may be subject to coercive measures that will have a certain effect on their behaviour; the offender does not and cannot expect to have his or her privacy protected in the same way as non-offenders^[48]. It can be inferred from these constitutional provisions that human rights may be restricted, but only by law and provided that they do not restrict rights beyond what is necessary to achieve legitimate and public interest objectives. 

 In the context of the content in question, the distinction between the Amendment Act of Mental Health Care Law No. I-924, effective since May 1, 2019, which legally limits the rights of patients with mental and behavioural disorders, has been legally enshrined. It should be noted that the term "mental and behavioural disorder" as used in this legislation is defined as a disorder of a person's thinking, behaviour and/or feelings caused by the use of biological, psychological, social or psychoactive substances as defined in the current classification of illness and disorder.^[49] According to the International Statistical Classification of Diseases and Disorders, various disorders are classified into, inter alia, mental and behavioural disorders, which include various diseases such as schizophrenia, mental retardation, unspecified mental disorder, etc., and other symptoms and signs related to cognitive perceptual features, emotional state, and behaviour such as hallucinations, irritability, anger, physical rage, and etc. ^[50] It follows from these statements that the limitation of patients' rights extends not only to the diagnosis of a mental disorder or illness, but also to cases in which a person's behaviour is not diagnosed with a mental illness but has a distinct, inadequate emotional state and behaviour. On 29 May 2019, for the implementation of this law, the Minister of Health approved the Order on the Application of Physical Restriction Measures for Patients with Mental and Behavioural Disorders and the Procedure for Monitoring the Application of Physical Restriction Measures, which specifies the application of physical restraint measures. ^[51] Under this legislation, physical restraint measures may be applied to patients with mental and behavioural disorders during hospitalization or providing emergency care if other measures are ineffective or inaccessible and are based on at least one of the following:

1) to protect a patient with mental and behavioural disorders from potential harm to their health or life;

2) in order to protect personal health care institution staff, other patients and other persons from possible harm to their health, life and/or property, as well as to possible damage to the property of the personal health care by a patient with mental and behavioural disorders.

Types of physical restraint:

• hand restraint (with the human body force),
  
• special measures of physical restraint,
  
• the isolation of a patient with mental and behavioural disorders in a separate room.
  

Physical restraint (body force) may only be applied initially and for the shortest possible period, pending the application of other physical restraint measures, provided that the grounds for physical restraint continue to apply. Physical restraint (body force) should be used to prevent the patient being injured and causing physical pain to the patient.

Special means of physical restraint may be used only by means of instruments specifically designed for that purpose and having proof of their purpose and security. These tools must be used in accordance with the manufacturer's instructions and the rules of use approved by the body. They must be aimed at preventing the patient from being injured and causing physical pain to the patient.

Patient isolation may only be applied in a room that meets the following requirements:

1. the room must be safe for the patient: all furniture and objects must be secured, without sharp corners or other details, which can easily injure or injure the patient; all panes must be safety glass;

2. It is recommended that the room be fitted with patient-friendly sanitary ware, a window with natural light and a clock.

3. It is possible to install and use additional facilities to help the patient calm down, such as soothing music, displaying soothing images, etc.

Persons entitled to impose physical restraint:

1. a psychiatrist or a paediatric psychiatrist;

2. in cases of immediate physical restraint - mental health nurse or ambulance health care professional;

3. other employees of the health care institution have to apply physical restraint measures, who must have received training or in-house instruction on professional management of aggressive and violent behaviour of patients and procedures of physical restraint.

Process and duration of physical restraint.

Personal health care staff should protect the privacy and dignity of the patient by asking other people to leave the room before physical restraint is applied, if this is not possible, to use screening during physical restraint. Physical restraint should be exercised verbally and the patient should be persuaded not to oppose physical restraint.

When special physical restraints are prescribed or the patient is isolated, the psychiatrist should assess the necessity of the physical restraint at least every 1.5 hours and note this on the patient's observation sheet. If an extension of the measures of physical restraint is necessary, the psychiatrist doctor shall state on the patient's observation sheet the reasons for the extension of the measures of restraint. Mental health nurse at least every 0.5 hour assesses the patient's state of health and completes the observation sheet of the restrained person. During the period of physical restraint, the patient should be constantly monitored either directly or through a special room window or other means by the health care provider. It is recommended that you talk to the patient during the exercise of the physical restraint and explain that the physical restraint is used to protect him or her from the threat. If the grounds for physical restraint are no longer available, as well as the person's health and/or life is threatened, the application of the physical restraint shall be immediately terminated by a physician- psychiatrist. Upon termination of the physical restraint, the psychiatrist shall note this on the observation sheet of the patient undergoing the physical restraint. Upon termination of physical restraint, the psychiatric physician or nurse should explain to the patient why they have been subjected to the treatment, discuss possible self-monitoring strategies to prevent the threat, and, if appropriate, other treatments.

Review questions:

1. What does mental and behavioural disorder mean?
   
2.  In what cases is physical restraint possible?
   
3.  What are the types of physical restraint and the elements that characterize it?
   
4.  Which entities are entitled to apply physical restraint?
   
5.  What can be the duration of physical restraint?
   
6.  What is the legal requirement for a physical restraint proceeding?