National Alliance on Mental Illness
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Advocate Coalition For Appropriate Use Of Restraints

Chris Marshall
For Immediate Release
19 May 99

The following is a letter from NAMI on behalf of the Advocate Coalition for Appropriate Use of Restraints to the Secretary of the Department of Health and Human Services, Donna Shalala, regarding the Department's impending insufficient response to the tragedy of people with serious brain disorders and other disabilities dying or suffering serious injury from the use of restraints.


May 17, 1999

Honorable Donna E. Shalala
Department of Health and Human Services
615 F Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201

Dear Secretary Shalala:

We are a coalition of advocates alarmed by the deaths and serious injuries caused by the use of restraints in HCFA funded facilities for the purpose of the treatment of persons with psychiatric illnesses, mental retardation, and other disabilities.

For many months we have worked with U.S. Congressional offices, federal administrative agencies, professional societies, and provider associations. We are alarmed that given at least six deaths related to the use of restraints since the October 1998 Hartford Courant series which documented the deaths of 142 persons because of the use of restraint, the Department’s first public response apparently will be a Medicare hospital condition of participation announcement which emphasizes that restraints may be used for the treatment of medical symptoms. Given the gravity of this national crisis, if this is the extent of the response, this is completely inadequate.

We have shared many detailed comments with many federal officials over the past months, particularly with the Health Care Financing Administration (HCFA). These comments and papers are available to you upon request. Our comments consistently made four points:

1. The use of restraints in the treatment of psychiatric illness and for persons with mental retardation or other disabilities, is only appropriate for responding to emergency safety situations. The use of restraints in treatment facilities for persons with psychiatric illness and mental retardation is a reflection of a treatment failure. HCFA and Department arguments that restraints are appropriate for the treatment of medical symptoms have no scientific basis. No professional peer reviewed publication describes the therapeutic value of the use of restraints. The Department must acknowledge this lack of science base and restrict the use of restraint to emergency situations involving safety.

2. A Medicare hospital COP announcement is an inadequate response to this national crises of death and serious injuries. Five of the reported deaths since October 1998 have been children and adolescents and three of these deaths have been in Residential Treatment Centers. One involved a nine year old, 53 pound boy, crushed in restraint for reasons of discipline in a RTC specializing in the treatment of psychiatric illness which advertised itself as a medication free facility. How does this happen? Because there are no HCFA RTC rules. Here is a Medicaid benefit, established in 1972, expanded in 1990, with a proposed rule published in November 1994. In November 1998 HCFA published a partial final rule which merely said that Medicaid RTCs must meet whatever accreditation process the state determines.

When HCFA announces its Medicare hospital COP related to restraints, it must, in the same issue of the Federal Register on that same day, announce at minimum a notice of proposed rule making applying a single national restraint policy to all HCFA funded programs.

3. All deaths and serious injuries which potentially may be related to restraints must be reported to a third party, independent state-based authority which has the ability to investigate the circumstances behind such death and injury. To adequately respond to such national crises, HCFA must include this provision.

4. HCFA standards must be based on best practices throughout the nation. We have offered many citations about these practices. They are available to you upon request.

As more vulnerable persons with serious mental illness, mental retardation, and other disabilities die, are physically injured, and are psychologically scarred for life because of restraints applied for inappropriate reasons, the national government must make some affirmative statement in response. Such statement must acknowledge that: a single HCFA-wide standard is necessary, restraints are only appropriate for emergency safety reasons, all deaths and injuries must be reported to an entity which can investigate such deaths, and standards must be based on nationally documented best practice, not on the lowest common denominator of practice.

Thank you for giving this issue the national attention it requires.


E. Clarke Ross, D.P.A., National Alliance for the Mentally Ill, on behalf of:

Bazelon Center for Mental Health Law
National Association of Protection and Advocacy Systems
National Council for Community Behavioral Health
National Mental Health Association