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Gabriela, an 81-year-old-woman, showed some resistance in the dimly lit room of the dilapidated long-term care facility. Amidst peeling walls, and an air saturated with neglect, nurse Luz struggled to pin Gabriela’s arms to the bed rail, trying to restrain her movements so she could administer her medications without interruption. With inadequate resources and no affordable harnesses available, Luz resorted to using cloth rags. Gabriela’s Alzheimer’s did not prevent her from complaining of pain.
Like many other residents facing cognitive decline or dementia, Gabriela—arms and legs restrained to her ramshackle bed— spent her days and nights with no choice but to stare into the void or at the dirty, peeling wall in front of her, which years ago had been shiny white. Such were the days at the La Merced shelter, a decrepit care institution administered by the Benevolent Society and the Municipality of Lima, Peru. While offering a roof and food to men and women who would otherwise perish on the streets, the care La Merced provided to its residents seemed to those who received it as poor, often precarious, and, in some cases, even neglectful and indolent. This was certainly the case when staff at the institution performed practices of physical restraint against the residents, many of whom had taken to calling this deployment of force amarrarlos (from the Spanish amarrar, “to tie down”).
June 2022. It was a damp winter morning. I had decided to spend the hours before lunch with a resident called Miguel in Ward 4. Sitting by his bedside, our conversation was suddenly interrupted by the desperate crying of a woman whose face I was unable to see from Miguel’s room. I exited his bedroom, seeking the anxious woman in one of the ward’s many bedrooms. In the common area, I witnessed a heartbreaking scene. Amid the nurse aides’ hands and arms that were trying to apprehend her, an old resident woman was crying for a reason that neither I nor the nurse aides were able to decipher. The screaming woman was Olivia, whom I always saw in her wheelchair due to Parkinson’s disease. Olivia’s vivid crying was a shout for help in a voice that exploded in pounding frustration. She was seized by hands and arms and coarsely pushed back into her room in the midst of tears, anguish, and desperation. I noticed that the nurse aide abruptly placed her on a chair. There, caught in overwhelming weeping, staff tied her down to the chair with a cloth rope. Olivia vividly exclaimed: “¡No! ¡Amarrar no! ¡No, por favor! ¡Me duele, me duele!” (No, please, don’t tie me down, no, please! It hurts, it hurts!). Nurse aides entered and exited her room, demanding that she calm down. But bewildered and exhausted, Olivia continued to cry inconsolably. The nurse aides were obviously annoyed, and one of them, exasperated, wondered how to placate Olivia’s despair. Her crying, nevertheless, permeated every single corner of the ward. It was a hoarse, desolate cry—a cry beyond words. Without a solution, one of the nurse aides slammed the room’s door and left Olivia in her room, crying and physically restrained. Those imponderable tears would vanish in the loneliness of silence, with no witnesses. Invisible in a corner of her dilapidated bedroom, lacking any empathy, comfort, affection, or freedom of movement, Olivia cried, heartbroken. Outside the room, however, the problem had been solved.
Understanding Amarrar as Humiliation and Security
As I observed this scene silently in the middle of the ward, I kept asking myself why care at this facility was being provided through a profound lack of compassion and empathy. I later learned from my months at the institution that care at La Merced was inconsistent and contradictory, always fraught on the grounds of the quotidian and dependent upon several variables—the availability of resources, the staff’s preparedness, staff’s satisfaction with their remuneration, the institution’s infrastructure, etc.— mainly because the place was pierced by a daunting precarity. Living within—or surviving—this condition led to a structuring of the forms of care that was as unpredictable as it was fraught in the face of unstable supply chains, staff exhaustion, and the pressures of limited time.
During one afternoon when I was helping the technicians in Ward 10 feed the residents, I saw how the physical restraint procedure was used on older adults. Anabel, the attendant on duty, ensured that all the residents were securely placed in their wheelchairs after dinner. It was vital to make sure that those who suffered from anxiety or were “problematic”—according to the staff—were well restrained or “amarrados.” It was Pelayo’s turn. Anabel realized that the scarves keeping his hands immobile were slightly loose and, to avoid mishaps—such as fumbling with his diaper and playing with his feces—she secured his hands more tightly. While Anabel was doing this, I could not help being surprised by Pelayo’s calmness, as if he understood there was no alternative. Perhaps he had internalized that the only thing he had left was to resign himself to being restrained in that way. The routine was, by default, unalterable.
Anabel finished and continued the process with other residents. When she was far enough away not to have him under her gaze, Pelayo—who no longer had the use of his hands—began to desperately loosen the ties with his mouth and teeth, his face filled with fury as he sat in his wheelchair. But luck was not on his side; Anabel saw him and tied his hands even tighter to the chair. I witnessed all of this. When the technician was finally far enough from Pelayo, I was subjected to his withering gaze. “Get me out of here,” he yelled at me. “I want to leave!” All I could do was give the inevitable answer: “I can’t do that. I don’t have the authority.” I would have liked to have been able to take him for a walk through the withered gardens of La Merced, but going against the staff could lead to problems with them, and, thus, complications that could revoke my permission to be in Ward 10.
Clearly angered, he berated me: “What am I? An animal? A prisoner? Where is my dignity? This is an arrest that they have subjected me to. Tying me down like this is merciless. There is no compassion for us here. Animals, that’s what staff think we are!” Naturally, his words made me feel completely useless and overwhelmed by the situation. In that moment, there was no satisfactory answer that I could give Pelayo. Saddened, I left the ward and went to get some air. A moment later I returned to find that Anabel was less busy, and I was able to ask her some questions about why they restrained residents. She responded:
We restrain the patients who can no longer be managed. It is for their own good. We want to prevent them from being injured. It’s for security. They can bump into things; they can fall out of their bed or chair. Some are also badly behaved, because they play with their feces or remove their nasogastric tubes. So, we restrain them. They are our responsibility and right now there are not enough staff for each resident. We cannot watch over everyone, that’s why we tie them up, because there aren’t staff members for each one and their health must be protected.
Physical restraint has been defined in different ways, but the general consensus is that it implies a restriction in movement and freedom for the person being taken care of. It has long been debated in bioethics and nursing literature and, while today there are some claims that it must only be used under strict and specific circumstances, the use of this procedure when working with older adults and patients suffering from dementia and impairment remains highly controversial. Justification for the method lies in the fact that patients can be a danger to themselves and to others. In order to prevent injury, aggression, and wandering, as well as to allow for medical treatment without disruption and resistance, some health providers see physical restraint as the most viable option to manage peoples’ bodies and lives. When I asked in La Merced why people were tied down (amarrados), I was specifically told that it was the most effective security measure in a context of deep material scarcity. Precariousness and a lack of resources were key factors in understanding how relations of assistance and aid were shaped at this institution. Furthermore, at La Merced, restraint was care.
Anabel’s words illustrate it clearly: the justification for physically restraining elderly people was that staff had to “care” for them responsibly. In this context, the meaning of “caring” was, undoubtedly, protecting them from hurting themselves by removing their own feeding tubes or intravenous therapy and doing what was “best” for the residents, such as keeping them clean by not allowing them to play with their food or to remove their diapers. Thus, it is, above all, about having the capacity to exercise control over these bodies. An institutionalized method for controlling those people’s biological existence: this was what physical restraint meant.
When I visited Miguel the next day, he agreed with the nurse aides that tying up residents was the best security measure. However, for Miguel, the crux of the matter was who was the subject of these “supposed” security measures. He told me:
Of course it’s the best security measure but not for us, for them. They see us as beasts, as senile, as degenerate. We don’t speak anymore; we only babble, and when we do speak, they think we speak nonsense. So all that makes us look like monsters that have to be tied and locked down. That’s the only way for them to be safe. But tying us down strips our humanity away. They tie us down because they don’t understand us, they don’t understand old age, our needs, they don’t know what to do with us. For them, it’s safety, sure, but for us, it’s humiliating.
Concluding Thoughts: Towards a Culture of Care
Law 30490—the Law of the Elderly—in Peru stipulates that the country’s long-term care facilities should provide their residents with comprehensive care depending on their needs. Furthermore, Article 28 of the law states that violence against older adults is considered to be any single or repeated conduct, whether by action or omission, that causes harm of any nature or that violates the enjoyment or exercise of their human rights and fundamental freedoms, precisely as physical restraint does. What happens, then, when, instead of being spaces of protection, long-term care institutions are geographies where the socially vulnerable feel unsafe, are frequently trespassed, and physically abused? How are the lives of those vulnerable and marginalized impacted when the care they are administered to functions as a tactic of severe body control?
Physically restraining residents is an act that can be seen and understood from many angles. For residents and for me, it meant a coercive use of force; it implied abuse and the subjugation of bodies to an institutional order/power that wanted to control them no matter what. But, for the institution, this is actually a practice of care, as it allows residents to be safe in their space by not suffering any falls, not hitting themselves, not breaking any limbs, or not tearing off their fluid therapy. Of course, care implies social and human relations between staff and residents. Staff believe they are doing what is best for older residents with the resources they have, and, in this exercise, they conceive of themselves as moral subjects. The reality is that, in this particular context, those in charge of providing care and assistance are trampling over the desires and life expectations of those persons deemed by the system as incapable of looking after themselves. Such transgressions occur in response to the institutional imperative of enforcing life even at the expense of poor personal treatment. This enforcement of life—this so called care—is not only biopolitical. It is necropolitical by default.
My research at La Merced allowed me to witness the bioethical dilemmas this population faced, as residents suffering from dementia and those who were bedridden had no option but to endure their last days tied to their bed rails with rags lacerating their wrists and ankles. Many people growing old under these precarious circumstances today are divested of social and political recognition and often excluded from their rights to citizenship and a good life (and death). We need to guarantee and provide adequate conditions in order for the most vulnerable to live in full freedom of their rights and maintain a life purpose that encourages them to find value and meaning in their existence. Care facilities, hospitals, governmental spaces, and the state itself must guarantee older adults’ dignity above anything else. This presupposes that these institutions never see the residents’ lives as expired and worthless. I believe that physical restraint does precisely this, which is detrimental for older adults’ health and even personal dignity. Restraint is a poignant example of when care turns to dehumanization or neglect.La Merced highlights the need for more than public policies to improve older adults’ living conditions and wellbeing. As a society—local and global—we must urge on the development of political, economic, legal, social, and moral frameworks that allow us to move towards a culture of care. Only by instituting solidarity mechanisms supported by both family and social networks, as well as by our political systems, can we build a culture of care where older adults are not left behind and do not undergo the dramatic process of physical restraint. Rather, the goal is that institutions where older adults without family support and economic means live can assure them a decent and dignified quality of life and death.