12. Module 11 · Avoiding FEM, law & ethics

12.2. Application: planning safety without restraint

Application

Planning safety without restraint

This page shows how a team can plan night-time safety for one person without a freedom-restricting measure, and gives phrases to adapt. Your organisation’s procedures, the doctor’s advice and the legal rules apply in every case. The steps are about attitude and approach, not clinical technique.

Worked example: Mr D. at night

Five steps to avoid a restrictionFive steps: from risk to a safe, free alternative1NoticeWhat is the risk,when, how often2UnderstandWhy does he get up?Pain, toilet, fear?3TryTwo alternatives:care and equipment4InvolveTeam, doctor,relatives, custodian5ReviewAfter a few days:what worked? RecordThe example is fictitious. The steps are a cycle to repeat, not a protocol.
Figure 11.3: Five steps to avoid a restriction, using a fictitious example. Source: own illustration.

Return to Mr D. from the case study on page 4 and imagine the team working through Figure 11.3 in more detail. The case study gives the result. Here are the steps.

  1. Notice. For a week the night carer notes when Mr D. gets up: usually between 2 and 3 a.m., and he has twice stood unsteadily beside the bed. The risk is falling in the dark.
  2. Understand. The carer asks, “What does he do next?” He goes to the door on the left, where the toilet is. At night he cannot find the light switch. The team also asks the nurse in charge to check for pain and for a urinary problem, because this could be a medical matter.
  3. Try. The team tries two changes: a low-floor bed with a mat beside it, and a night light on the way to the toilet. A sensor mat tells the carer when he stands up, and the carer goes to him at once and walks with him.
  4. Involve. The team leader, the doctor and his daughter hear about the plan. The daughter first wants bed rails. The nurse explains why rails can make a fall worse and shows what the team does instead. Mr D. is asked too, and says he likes the night light.
  5. Review. After ten days the team meets. Mr D. has not fallen, he sleeps a little longer and the carers know his pattern. They record the plan, keep it and review it again in a month.

Notice that no measure here limits his freedom. The change is mostly one of attention, light and equipment. The sensor mat is only a signal: its value comes from the person who walks to him.

Phrases to adapt
SituationYou might say
To a person at night“Good evening, Mr D. I am here. Where would you like to go? I will come with you.”
To a relative asking for rails“I understand that you are afraid he will fall. Rails can make a fall worse. May I show you what we do instead?”
To a colleague“What do we think he is looking for? Let us try a night light and a walk before we decide anything.”
To the team leader“We have tried two alternatives for a week. Here is what we saw. Can we discuss next steps with the doctor?”
When you are unsure“I am not sure whether this limits her freedom. May I ask you to check with me?”
Exercise (voluntary self-check). Mrs Nowak (fictitious), 86, often tries to leave the unit in the afternoon, says she must “fetch the children from school”, and pulls at the door. The team considers locking the unit door and giving her a calming drug. A colleague argues that it is “only for a few hours”. Is this a FEM? Name two possible needs behind her behaviour, two alternatives, and say who must be involved if the team still thinks a measure is needed.
Hint 1
Use the three groups in the text: mechanical, medication, other. Then use Figure 11.1: does the measure limit her free movement, and can she agree?
Hint 2
Think of her life: she was a mother who collected children every afternoon. What need could this express? Look at Figure 11.2, the rows on disorientation and the urge to move.
Suggested answer
Yes: a locked door and a drug given to calm her are both ways of restricting movement (other means, medication). Needs: a lifelong role and routine (care for children), and an urge to move in the afternoon. Alternatives: a walk with a carer or volunteer at that time, a safe circular route or garden, a task that fits her role (folding laundry, a doll or photographs), a calm answer such as “The children are safe, let us have tea together” (Module 8). Who is involved: the team leader and the doctor, her relatives, and a person holding a power of attorney or a legal custodian, who may need court approval for a longer or regular measure (section 1831 BGB). Not for care staff alone to decide, and not “only for a few hours”.
In German practice you will hear …
  • FEM (freiheitsentziehende Maßnahmen) – freedom-restricting measures; also called “freiheitseinschränkende Maßnahmen”
  • Bettgitter / Bettseitenteile – bed rails
  • Fixierung – physical restraint with belts or straps
  • Niedrigflurbett / Sensormatte – low-floor bed / sensor mat
  • Betreuungsgericht – custodianship court that approves certain measures
  • rechtliche Betreuung / Betreuer:in – legal custodianship / legal custodian
  • Vorsorgevollmacht – lasting power of attorney (advance authorisation)