12. Module 11 · Avoiding FEM, law & ethics

12.3. Case, consolidation & transfer

Case, consolidation and transfer

Two cases and what to take away

Case study

Safety without restraint

Mr D. (dementia) often gets up at night and is at risk of falling – the team considers a bed rail/physical restraint ‘for safety’. Instead of FEM, alternatives are chosen: understanding the cause (Mr D. needs to go to the toilet at night), a low-floor bed with a floor mat, a sensor mat (which alerts staff when he gets up), accompanying him to the toilet at night, and fall prevention. Mr D. can move safely, does not fall (or does so without serious consequences), and remains free and dignified. He might well have climbed over a bed rail (serious fall) – the alternatives are safer and more dignified. The case shows: real safety is achieved without FEM.

Second case

Mrs Hoffmann and the chair with a tray

Mrs Hoffmann (fictitious), 81, has dementia and a tendency to slide down in her chair. In the afternoons the team often puts her in a deep armchair with a fixed tray table “so that she is safe”. She cannot lift the tray and cries out when she tries to stand. The care assistant Tobias (fictitious) says: “She is trying to get up, and we do not let her.” The team leader asks for a short review with the physiotherapist. They find that the armchair is too soft and too low for Mrs Hoffmann to rise, and that she is in pain because she sits in the same position for long. The team replaces it with a firmer chair of the right height with arms, removes the tray, adds a cushion and offers a short walk every hour. They note which times she wants to move. Her calls stop within a week, she eats more at the table and she no longer slides down. The team leader records the change and the date for the next review.

Analysis. (1) A tray that cannot be removed limits free movement, so it is a measure that needs thought and, for a person who cannot agree, proper authorisation (Figure 11.1). (2) The behaviour had causes: pain, a chair that was too low, and the urge to move (Figure 11.2). (3) The team involved the right professional (physiotherapist) and looked at the setting. (4) The alternative was simple: a different chair and regular movement, recorded and reviewed (Figure 11.3). (5) “So that she is safe” described the aim but ignored the harm.

🗂️ Flashcards – think first, then open
Name the three groups of freedom-restricting measures.
Mechanical (bed rails, belts, fixed tray), medication to calm or immobilise, and other means (locked doors, aids taken away, chairs too low to rise from).
Why can bed rails make a fall worse?
A person who climbs over them falls from a greater height, and rails can cause entrapment and panic.
Who decides if a person cannot consent?
A person with a power of attorney or a legal custodian, and for longer or regular measures in a facility the custodianship court must approve (section 1831 BGB).
What question comes before any measure?
Why is the person doing this? Find the need behind the behaviour, then try alternatives.
When can a measure be taken without prior approval?
Only if waiting would create a danger, and then approval must follow at once. A recurring risk needs a plan, not repeated emergencies.
Why is a sensor mat not a solution by itself?
It is only a signal. Its value comes from a carer who comes at once and walks with the person.

Key messages

  • People with dementia keep their right to self-determination, dignity and liberty.
  • A FEM is judged by its effect on the person, not by the intention “for safety”.
  • Rails and restraints often make falls worse and cause decline, panic and loss of dignity.
  • Never decide alone: follow the legal path (consent, representative, court) and the organisation’s procedure.
  • Look for the need behind the behaviour, including pain, and try alternatives first.
  • Record, review and end any measure as soon as the reason has gone.
Reflection (for yourself, nothing is submitted).
  1. Which measures in your area could be described as FEM, and who decided on them?
  2. When did you last feel the “reflex to restrict”, and what was behind it?
  3. How could you answer a relative who asks for rails or restraints “for safety”?
  4. Which alternative from this module could you try this week?
For your everyday work – checklist
  • ☐ I ask why a person wants to get up or walk, and I look for pain, toilet needs and fear.
  • ☐ I try at least two alternatives before I suggest any restriction.
  • ☐ I do not decide on a restriction alone and I know who must be involved.
  • ☐ I check chairs, beds, doors and aids for restrictions the team no longer notices.
  • ☐ I record what I tried and I ask for regular review.
Transfer to practice

Exercise: Are FEM used in your area for people with dementia (bed rails, physical restraint, sedation, low armchairs)? Examine critically: are they truly necessary and legally sound? What alternatives would there be? How do you stand up for freedom and dignity?

Voluntary self-declaration – saved in your course account. Once all modules are marked as done, your confirmation of participation will be available.