Restrictive practices in aged care – a last resort

Restrictive practices in residential aged care

A restrictive practice is any action that restricts the rights or freedom of movement of a care recipient. 
There are 5 types of restrictive practices:

1. chemical restraint
2. environmental restraint
3. mechanical restraint
4. physical restraint
5. seclusion.

Learn more about the types of restrictive practices.

Minimising inappropriate use of restrictive practices

Amendments to the Aged Care Act 1997 and Quality of Care Principles 2014 that regulate and strengthen restrictive practice arrangements for approved residential aged care providers took effect on 1 July 2021.

These amendments:

• improved safeguards for care recipients
• increased responsibility on residential aged care providers
• strengthened responsibilities on the use of any restrictive practice in a residential aged care setting.

Additional legislative amendments were made through the Aged Care and Other Legislation Amendment (Royal Commission Response) Act 2022. These further strengthened consent requirements to address gaps in state and territory legislation on the use of restrictive practices. 

In May 2020, the department re-established the Aged Care Clinical Advisory Committee to support reducing the use of restraint in residential aged care.

Many objectives of the committee have been delivered including:

• improved data capture (of risperidone) through the Pharmaceutical Benefits Scheme (PBS)
• the Chief Medical Officer writing to 28,500 prescribers of residential aged care recipients
• a multifaceted industry education program for general practitioners and residential aged care services run by NPS Medicine Wise
• appointment of a Senior Practitioner within the Aged Care Quality and Safety Commission
• strengthened legislative requirements that apply to residential aged care providers on restrictive practice use.

The committee continues to provide expert advice on clinical policy and legislative oversight. Other initiatives to minimise inappropriate use of restrictive practices include mandatory:

• reporting of inappropriate use of restraint through the Serious Incident Response Scheme (SIRS)
• Quality Indicators (QI) on physical restraint and medication management
• Aged Care Quality Standards.

Provider responsibilities 

Providers must consider the rights and protection of care recipients at all times and comply with legislative obligations.

Approved providers using a restrictive practice must make sure to:

• use it as a last resort to prevent harm to a care recipient or others, and after considering how it may impact the care recipient.
• trial and document alternative strategies before considering a restrictive practice.
• use it in the least restrictive form and for the shortest time needed
• the care recipient or the (RPSDM) gives informed consent fo
• the care recipient or the restrictive practices substitute decision-maker (RPSDM) gives informed consent for the use of the practice
• only use it in line with the rights and responsibilities of care recipients outlined in the Charter of Rights
• monitor and regularly review its use.

Providers must include a Behaviour Support Plan (BSP) in the existing Care and Services Plan for all care recipients:

• that demonstrate behaviours of concern
• being assessed to see if a restrictive practice is needed
• where a restrictive practice is being used.

Informed consent for restrictive practices

There are strict requirements for the use of restrictive practices in residential aged care. They must only be used where informed consent to the use has been given by either:

• the care recipient
• the restrictive practices substitute decision-maker (RPSDM) – if the care recipient lacks capacity to give that consent.

A RPSDM is a person or body that, under the law of the state or territory in which the care recipient is using aged care, can give informed consent to the restrictive practice (or to the prescription of medication in the case of a chemical restraint).

To support providers in some jurisdictions where there is no explicit legal avenue to allow for a RPSDM, interim amendments to the Aged Care Act 1997 were made through the Aged Care and Other Legislation Amendment (Royal Commission Response) Act 2022 to enhance safeguards for the use of restrictive practices.

Interim arrangements for consent to restrictive practices

The Quality of Care Principles have been amended to include a hierarchy of persons/bodies who can consent to the use of restrictive practices on the care recipient’s behalf. This can only be used when: 

• they cannot consent themselves
• there is no explicit legal avenue under relevant state or territory laws
• no one is appointed as the RPSDM due to delayed applications.  

The hierarchy will only be in place until 1 December 2024. A new mechanism will be included in the new Aged Care Act.

This will ensure restrictive practices are only used with appropriate consent to protect the health, rights and dignity of older Australians in residential aged care.

There are 5 levels of the hierarchy:

1. restrictive practices nominee – an individual or a group of individuals nominated by the care recipient who can give informed consent to the use of the restrictive practice in relation to the care recipient if the care recipient lacks capacity to give that consent, has agreed in writing, and has capacity to give that consent.
2. partner – who has a close continuing relationship with the care recipient, has agreed in writing to act as the RPSDM and has capacity to give consent.
3. relative/friend who was carer – person who was the carer on an unpaid basis immediately before the care recipient entered care, has a personal interest in the welfare of the care recipient, has a close continuing relationship with the care recipient, has agreed in writing to act as the RPSDM and has capacity to give consent.
4. relative/friend who was not the carer – person who has a personal interest in the welfare of the care recipient, has a close continuing relationship with the care recipient, has agreed in writing to act as the RPSDM and has capacity to give consent.
5. medical treatment authority – individual or body appointed in writing under the law of the state or territory in which the care recipient is provided with aged care, as an individual or body that can give informed consent to the provision of medical treatment (however described) to the care recipient if the care recipient lacks capacity to give that consent. 

Ensuring providers comply with their requirements 

The Aged Care Quality and Safety Commission’s focus is to protect the safety, health and wellbeing of care recipients.  

The commission gathers and assesses information on the use of restrictive practices through complaints handling processes and SIRS.

The commission monitors providers and enforces that any use of a restrictive practice must be in line with:

• legislative obligations
• the Charter of Aged Care Rights
• the Aged Care Quality Standards.

The commission monitors residential aged care providers’ compliance with the restrictive practice requirements. These include having:

• a BSP in place for every care recipient who has a restrictive practice used or applied to them
• policies and processes in place to support appropriate use of restrictive practices, including documentation of consent, for care recipients.

The commission’s website has additional information to support providers to meet their requirements around restrictive practices.

Practitioner responsibilities 

Like aged care providers, general practitioners (GPs) working with care recipients (patients) must consider and protect their patients’ safety and wellbeing at all times.

As a practitioner you must use and document alternative strategies to manage the patient before using a restrictive practice.

Before using psychotropic medication, you must trial and document other strategies in the patient’s clinical record. We have guidance material to:

• support prescribing psychotropics within residential aged care
• support prescribers working in residential aged care.

For an aged care provider to use a chemical restraint a medical practitioner must have:

• assessed the patient as posing a risk of harm to themselves or others
• assessed that the chemical restraint is necessary as a last resort
• discussed the proposed benefit, options, and risks of the medication with the person or their substitute decision maker and seek their informed consent.
• conveyed the fact that informed consent has been received for the prescribing of the medication to the provider in an agreed way
• prescribed the medication.

As a practitioner, an aged care provider may ask you to perform the above tasks and provide evidence in order for them to use a restrictive practice. The aged care provider will then document this in the patient’s BSP.

How practitioners can help

Practitioners perform an essential role in the care of residential aged care recipients (patients) and in minimising the inappropriate use of restrictive practices.

There are many ways that practitioners can help providers to meet their requirements and make sure patients are safe and well:

• check for any contribution of current medication to confusion, sedation or other side effects potentially causing distress or behaviours of concern.
• identify and document the risk of harm to self or others that medication used as restraint seeks to address.
• communicate the decision to prescribe medication with the aged care provider and relevant staff.
• seek informed consent from the appropriate person and communicate this consent with the provider.
• outline the monitoring required for side effects that might occur.
• clarify the need for ongoing review of effectiveness and impact and when this will occur.
• clearly state the conditions when ‘as needed’ (PRN) sedating medication may be used.
• regularly review medications, especially psychotropics, so that deprescribing can occur as early as possible.
• communicate with other current or past prescribers where indications for their prescribing and responsibilities for review are not clear.
   

Related information

The Aged Care Quality and Safety Commission has:

• a range of resources for medication management, which also aim to reduce inappropriate use of chemical restraint
• resources to support providers to identify and minimise the use of restrictive practices.

There are also further resources available through the following organisations:

• Dementia Support Australia (DSA) provides support for people living with dementia who are experiencing changes in behaviour that impact their care or carer. Services include the Dementia Behaviour Management Advisory Service (DBMAS) and Severe Behaviour Response Teams (SBRT).
• Dementia Training Australia (DTA) provides free online dementia training, practical resources and training packages. DTA also provides face-to-face training to providers and the sector. These resources help staff better understand the causes of behaviour change and to find ways to avoid or reduce them.

Resources

For more information, see:

• Types of restrictive practices
• Aged Care Quality and Safety Commission resources to support providers to minimise the use of restraints

• Consent requirements for the use of restrictive practices in residential aged care

• the Guiding principles for medication management in residential aged care facilities
• Six steps for safe prescribing of antipsychotics and benzodiazepines in residential aged care
• Three simple checks to support your residents – for personal care workers in residential aged care.
• Informed consent: What families need to know about antipsychotics and benzodiazepines in residential aged care
• Medication: It’s your choice. It’s your right on the OPAN website.

Contacts