Course content – PFLEGE-16
The modules of this course – work through them in order.
12. Module 11 · Avoiding FEM, law & ethics
12.1. In depth: who decides, and what works instead
Who decides, and what works instead
Avoiding FEM
| Instead of FEM | Alternative |
|---|---|
| Bed rails/physical restraint | Low-floor bed, floor mat, sensor mat |
| Locking in | Safe circular routes, accompaniment |
| Sedation | Understand the cause/need (Module 4) |
| Preventing movement | Enable safe movement |
The illusion of safety through FEM
A widespread misconception is that FEM (bed rails, physical restraint) increase safety – e.g. prevent falls. Studies show the opposite: FEM do not reliably prevent falls, can even make them more dangerous, and cause harm of their own. Examples: a person who climbs over a bed rail (because they want to get up and the rail prevents normal getting up) falls from a greater height and is injured more severely than in a fall from a normal bed. Physical restraint can lead to serious injuries (strangulation!), panic, deterioration of the person’s condition and loss of dignity. FEM also promote decline (immobility → muscle wasting, contractures, pressure ulcers, further loss of strength/balance → paradoxically greater risk of falling, Course 08) and restlessness/anxiety (the person does not understand the restriction, feels trapped, panics). The ‘safety’ provided by FEM is therefore largely an illusion – it creates new, often greater dangers and suffering. Real safety comes from understanding and addressing the causes (why does the person want to get up/walk away?), enabling safe movement, environmental design (low-floor bed, floor mat, sensor mat, safe routes), fall prevention (strength/balance, Course 18) and relationship/safety. For care staff it is important to know this and to stand up for it – including towards relatives or colleagues who demand FEM ‘for safety’. The professionally and ethically correct answer is not restriction but enabling safe freedom. Programmes to reduce FEM (e.g. ReduFix) have shown impressively that FEM can be greatly reduced without falls/injuries increasing – on the contrary, residents become more active and more content, and are cared for with greater dignity. Avoiding FEM is therefore not only a legal and ethical requirement but also professionally better care. It requires a change of thinking, creativity and sometimes courage (against the reflex to restrict), but it is worthwhile for the freedom, dignity, health and quality of life of people with dementia.
This message is central: protecting freedom and dignity, avoiding FEM – that is ethics in practice and at the same time the professionally better, safer care.
A path through the law: who must be involved?
The legal rules can feel abstract at the bedside. Figure 11.1 turns them into a path with three questions. It is a thinking aid, not legal advice. The path starts by asking whether a measure limits free movement at all. If it does, the next question is whether the person can understand the measure and freely agrees. If so, their own consent is the basis, but you still look for alternatives, record it and review it often. If the person cannot give such consent, someone must decide for them: a person holding a power of attorney or a legal custodian (rechtliche Betreuung). For a longer-lasting or regular measure in a facility, this person also needs the approval of the custodianship court (Betreuungsgericht), as section 1831(4) BGB provides (Bundesministerium der Justiz, n.d.-a).
The dashed box in Figure 11.1 covers genuine emergencies. Section 1831(2) BGB allows a measure without prior approval only if waiting would create a danger, and then approval must be obtained at once afterwards (Bundesministerium der Justiz, n.d.-a). The general emergency rule in section 34 of the Criminal Code (StGB) says that an act to avert a present danger can be justified if the protected interest clearly outweighs the interest harmed and the act is an appropriate means (Bundesministerium der Justiz, n.d.-d). Both rules are narrow: a risk that returns every night needs a plan, not a repeated emergency.
Alternatives in depth: ask why the person wants to move
Every FEM answers a question that has not been asked: why is the person doing this? Figure 11.2 lists six common ones with first alternatives. Some alternatives need equipment, others cost only time. A sensor mat is useful only if someone comes when it sounds.
Read Figure 11.2 from left to right, as in a conversation: what do I see, what could it mean, what could I try first. A person in pain may be called “restless” and then sedated, when what is needed is a doctor’s review.
When relatives or colleagues ask for restrictions
Requests for bed rails or other measures often come from fear: the son who could not bear another fall, the colleague who has to cover twenty residents. Do not argue about the principle first. Acknowledge the worry (“You are afraid she will be hurt”), explain what the risks are (climbing over rails, loss of strength) and offer a concrete alternative with a time to review it. Relatives who are not the legal custodian or attorney generally cannot consent on behalf of the person (Module 10).
The legal frame in Germany
- Section 1831 of the Civil Code (BGB) regulates deprivation of liberty and FEM for people under legal custodianship. Paragraph 4 applies the court-approval rules to mechanical devices, medication or other means that restrict a person in a care home or hospital for a longer period or regularly (Bundesministerium der Justiz, n.d.-a).
- Section 239 of the Criminal Code (StGB) makes unlawful deprivation of liberty an offence (Bundesministerium der Justiz, n.d.-c).
This course does not give legal advice for individual cases. Ask your manager and, where needed, the custodianship court or a legal advisor.