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 the inappropriate use of restrictive practices

On 1 July 2021, amendments to the Aged Care Act 1997 and Quality of Care Principles 2014 came into effect. These were designed to regulate and strengthen restrictive practices arrangements for Australian Government-funded (approved) residential aged care providers.

These amendments:

• improve safeguards for care recipients
• strengthen requirements for the use of restrictive practices in residential aged care facilities
• strengthen reporting requirements for all approved providers about restrictive practices.

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

The Aged Care Clinical Advisory Committee supports reducing the use of restraint in residential aged care. The Committee provides expert advice on clinical policy and legislative oversight.

Other initiatives to minimise the inappropriate use of restrictive practices include mandatory:

• reporting of the inappropriate use of restrictive practices through the Serious Incident Response Scheme (SIRS)
• reporting on use of all restrictive practices (excluding chemical restraint) through the National Aged Care Mandatory Quality Indicator Program (QI Program)
• adherence to the Aged Care Quality Standards.

A restrictive practice must only be used as a last resort to prevent harm to a care recipient or others after considering how it impacts the care recipient. Providers must trial and document alternative strategies prior to using any restrictive practice. Additional support is available to manage behaviours that may pose a risk to the care recipient or to others.  

Dementia Support Australia (DSA) provides services to support people living with dementia experiencing changes in behaviour. 

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 assist staff to understand the causes of behaviour change and ways to avoid or reduce them. 

Provider responsibilities 

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

Approved providers using a restrictive practice must:

• use it as a last resort to prevent harm to a care recipient or others after considering how it impacts 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
• ensure 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 Aged Care Rights
• monitor and regularly review its use.

Approved residential aged care providers must include a Behaviour Support Plan (BSP) in the existing Care and Services Plan for all care recipients that:

• show behaviours of concern
• undergo assessment to see if they need restrictive practice
• have restrictive practices applied to them.

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

The ACQSC gathers and assesses information on the use of restrictive practices to ensure approved providers are using restrictive practices in line with:

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

See the ACQSC’s website for more information to support approved providers meet their requirements around restrictive practices.

Informed consent for restrictive practices

There are strict requirements for the use of restrictive practices in residential aged care. Informed consent needs to be given by the:

• care recipient, or
• a RPSDM, if the care recipient lacks capacity to give that consent.

A RPSDM is a person or body that can give informed consent to the restrictive practice. They can also give consent to the prescription of medication in the case of a chemical restraint. Consent must follow the laws of the state or territory in which the care recipient is receiving aged care.

Interim arrangements for consent to restrictive practices

The Quality of Care Principles 2014 include a hierarchy of who can consent to the use of a restrictive practice. Persons or bodies can consent on behalf of a care recipient of residential aged care services when: 

• they cannot consent themselves
• there is no explicit legal avenue under relevant state or territory laws to appoint a RPSDM
• an application to appoint a RPSDM has been made, but there is a significant delay in deciding the application.  

There are 5 levels of the hierarchy:

1. Restrictive practices nominee – an individual or a group of individuals:
   • nominated by the care recipient
   • able to give informed consent to the use of restrictive practice for the care recipient if the care recipient lacks capacity
   • has agreed in writing, and
   • has capacity to give that consent.
2. Partner – the partner of the care recipient, 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 or friend who was carer – a 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 or friend who was not the carer – a person who has:
   • a personal interest in the welfare of the care recipient
   • a close continuing relationship with the care recipient
   • agreed in writing to act as the RPSDM, and
   • capacity to give consent.
5. Medical treatment authority – an individual or body:
   • appointed in writing under the law of the state or territory where the care recipient receives aged care, and
   • can give informed consent to provide medical treatment (however described) to the care recipient if the care recipient lacks capacity to give that consent. 

The hierarchy is an interim measure to allow time for state and territory governments to amend their consent and guardianship laws.

The hierarchy was originally intended to remain in place only until 1 December 2024 before sunsetting. However, to ensure that all states and territories will have appropriate consent and guardianship laws in place, the hierarchy’s application period was extended to 1 December 2026.

For more information on consent to the use of restrictive practices please see the:

• frequently asked questions
• information for providers
• case studies
• substitute decision maker decision tree.

Medical practitioner responsibilities

Like aged care providers, medical practitioners working with care recipients must always consider and protect their safety and wellbeing.

Medical practitioners must trial and document alternative strategies in the care recipient’s clinical record before prescribing psychotropic medications. Guidance materials are available to support medical practitioners:

• Psychotropic medications used in Australia - information for aged care 
• prescribers working in residential aged care.

Before an approved provider uses a chemical restraint, a medical practitioner must have:

• assessed the care recipient as posing a risk of harm to themselves or others
• assessed that the chemical restraint is necessary as a last resort
• discussed the medication’s proposed benefits, options, and risks with the care recipient or their RPSDM and sought their informed consent
• conveyed that they have received informed consent for the prescribing of the medication to the approved provider in an agreed way
• prescribed the medication.

Approved providers may ask a medical practitioner to perform the above tasks and give evidence for the use of a restrictive practice. The approved provider will then document this in the care recipient’s BSP.

How medical practitioners can help

Medical practitioners perform an essential role in the care of residential aged care recipients and in minimising the inappropriate use of restrictive practices.

There are many ways practitioners can help approved providers meet the requirements and ensure care recipients are safe and well, including:

• checking for any contribution of current medication to confusion, sedation or other side effects potentially causing distress or behaviours of concern
• identifying and documenting the risk of harm to self or others that medication used as restraint seeks to address
• communicating the decision to prescribe medication with the aged care provider and relevant staff
• seeking informed consent from care recipient or the RPSDM and communicating this consent with the provider
• outlining the monitoring required for side effects that might occur
• clarifying the need for ongoing review of effectiveness and impact and when this will occur
• clearly stating the conditions when ‘as needed’ (PRN) sedating medications can be used
• regularly reviewing medications, especially psychotropics, so that deprescribing can occur as early as possible
• communicating with other current or past prescribers where indications for their prescribing and responsibilities for review are not clear.

Related information

The ACQSC has resources for:

• medication management, which also aim to reduce inappropriate use of chemical restraint
• minimising the use of restrictive practices
• lodging complaints or raising concerns about the quality of care or service provided to people receiving Australian Government-subsidised aged care.

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 assist staff to understand the causes of behaviour change and 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
• Prescribing psychotropic medications to people in aged care – information and resources
• 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