Medical Council of Hong Kong ruling on the ‘Use of Restrainers Form’ in residential care homes for the elderly
Many private practising doctors in Hong Kong provide healthcare services to residential care homes for the elderly (RCHEs) in addition to their daily clinical practices. Other than providing regular on-site medical examination and treatment to elderly residents, very often, doctors are asked by the RCHEs to assess whether restrainers ought to be used on certain elderly residents and to give written consent to the RCHEs to apply suitable restrainers. Restrainers are devices used for restricting a patient’s free movement in order to prevent physical harm to the patient or others. The purpose of using restrainers is to minimise harm to one-self (such as pulling off feeding tube) and/or other residents (such as fighting or throwing objects).
The Medical Council of Hong Kong (MCHK) has recently handed down a decision in relation to completion of the form that medical practitioners are required to complete prior to and in order to authorise, the use of restrainers in RCHEs. The decision serves as an important reminder to medical practitioners that they should always be diligent in maintaining true, adequate and clear contemporaneous medical records, including outside of the usual clinical and hospital settings. This includes documentation made in relation to use of restrainers at RCHEs. The Code of Professional Conduct for Guidance of Registered Medical Practitioners issued by the Medical Council as well as the Code of Practice for Residential Care Homes (Elderly Persons) (the Code for RCHEs) issued by the Social Welfare Department should always be complied with.
In accordance with the Code for RCHEs, restrainers should only be used in RCHEs with prior written consent obtained from a registered medical practitioner, the resident and/or his/her guardian/guarantor/family member/relatives. The Code for RCHEs requires RCHEs to use a standardised assessment record/consent form provided in the Code for RCHEs i.e. the Use of Restrainers Form. The signature of a medical practitioner is required, confirming his/her endorsement of the contents of the Use of Restrainers Form, before restrainers can be applied on an elderly resident by the RCHE. From time to time, inspectors of the Licensing Office of Residential Care Homes for the Elderly would conduct inspections at RCHEs to check if the Code for RCHEs is complied with.
In or about 2016, upon inspection at a number of RCHEs, inspectors of the Licensing Office found some Use of Restrainers Forms signed by the six different defendant doctors that lacked sufficient details of assessment records. Concerned that such practice might pose the risk of the forms being used by the RCHEs improperly without arranging the residents to undergo medical assessments, which would greatly hamper the welfare of elderly residents, the Director of Social Welfare referred the matter to the MCHK for investigation of the conduct of the six defendant doctors.
The charges and findings of the MCHK
There were variations to the charges laid against each of the six defendant doctors as the factual circumstances of their individual cases were different. However, the following two main charges were laid against all the defendants:
- “Signed on Use of Restrainers Forms in residential care homes for elderly without proper assessment records made”; and
- “Failed to take adequate steps to ensure information in the Use of Restrainers Forms were properly filled in”.
Amongst the six defendant doctors, five of them had signed some Use of Restrainers Forms that were completely blank with nothing filled in except they bore their signatures and name chops confirming their agreement to the RCHEs’ use of restrainers. There was no assessment record and patient’s name. The forms were undated. As for the other defendant doctor, whose case was regarded by the MCHK as relatively minor, most parts of the Use of Restrainers Forms had been properly filled out and contained the names of the relevant patients. However, those parts which he had signed were undated.
Besides the Use of Restrainers Forms, three defendant doctors had signed Medical Examination Forms for Residents and Medical Examination Forms for Staff at RCHEs without proper assessment records being made. Remarks were made by the doctors on the relevant forms and/or boxes confirming the patient’s history of major illness, functional assessment. However, all of those Medical Examination Forms did not show any patient’s name.
All defendants did not contest the charges against them. Most accepted the facts of their respective charges. In view of the lack of proper documentation on the signed Use of Restrainers Forms (and Medical Examination Forms), and the admissions made by the defendant doctors, the MCHK was satisfied that the facts of the charges were proved. The MCHK found all six defendants guilty of professional misconduct. Having considered the defendants’ frank admission and cooperation, taking into account the remedial measures adopted by each defendant and individual circumstances, the sentences imposed by the MCHK range from a warning letter to removal of a doctor’s name from the General Register for one month without suspension.
Medical practitioners must ensure they maintain the same standards of care and practice when providing medical services outside of the usual clinical settings. It must be remembered that Use of Restrainers Forms and Medical Examination Forms used in RCHEs are medical reports in specified forms. Documentation in these forms has to be contemporaneous as required under paragraph 1.1.3 of the Code of Professional Conduct for Guidance of Registered Medical Practitioners, whereby it is stated that “all doctors have the responsibility to maintain systematic, true, adequate, clear and contemporaneous medical records”.
This MCHK decision reiterates the importance of keeping true, complete and contemporaneous medical records and their role in supporting and facilitating subsequent patient care. In this context, they help to prevent improper restrainer use, which can cause serious psychological impact, morbidity and mortality. As the medical practitioner is the final adjudicator on if, what and how restrainers should be applied, medical practitioners should ensure the satisfactory completion of the Use of Restrainers Forms before endorsing their contents and giving their written consent.
The MCHK acknowledged that many doctors involved in this case might have been under pressure due to the lack of resources of RCHEs at the material time. The MCHK made further remarks that if there were sufficient resources to ensure frequent attendance of doctors to RCHEs to assess patients before deciding on the use of restrainers, that would have avoided the improper practice by some doctors in signing blank forms. The relevant authority was urged to look seriously into the matter.