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    As healthcare workers, we have certain legal, ethical and human responsibilities that can be neglected when dealing with challenging patients. “Contracting” with patients has been practiced for a number of years as a way to attempt to change or control non-adherent and disruptive behaviors. The involvement of corporate legal departments in the creation of these documents, has led to the inclusion of legal and punitive jargon that ultimately renders an ultimatum to the patient. Should we be surprised when patients who are asked to sign these contracts become defensive or refuse to sign? Are we not potentially provoking the patient and inviting an escalation of angry/aggressive behavior?

    Network 5 occasionally receives requests for behavior contract templates. Because of concern that these documents may be misused, the Network has not created templates. In certain settings the use of these documents are viewed by the Network as more appropriate, such as when attempting to impact adherence. If a facility is determined to implement such a document, the following guidelines are recommended.

    The word "contract" has a negative connotation. In recent years, the recommended approach has changed to the use of “behavior agreements” where two or more parties outline the expectations of all parties involved to reach the agreement goal. The agreement is two-way in that all parties involved agree to the changes to be made by each participating party. The document should be as brief and to the point as possible. It is important to ensure that the patient is able to accomplish the expectation of the agreement. It should be written in positive, expected terms such as, “Patient will ask for requests in a conversational tone and respectful manner.” The document should be drawn up with success in mind as the objective, not punitiveness. Goals should be reachable and concrete (measurable, if possible). Be clear -- if it is decided that the patient gets one warning if he/she becomes verbally abusive and if it happens again is taken off for the day, then state it. And then reinforce it consistently over time and across staff. Additionally, a balance should be maintained so that for each responsibility the patient is deemed to have, the next item should be a responsibility of the facility staff. For example, if the patient is agreeing to express his/her concerns by speaking directly with the social worker or the facility administrator (vs. yelling at the PCT or nurses on the floor), then that should be put as an item; the next item would say that the social worker and the facility administrator agree to check in with the patient at least once per week on different days to hear any concerns the patient might have.

    Agreements should be time limited; no more than six months for a behavioral agreement is recommended. Agreements should be reviewed on a scheduled basis (at least monthly up to 3 months and then quarterly) to determine progress or barriers. This keeps it fresh and at the top of the patient's mind and the teams’ collective mind instead of the agreement being stashed in the medical chart somewhere and then pulled out a year later when the patient has long passed pushed the limits and surpassed what was agreed upon. Once goals are met, the agreement can be retired. Renegotiations should occur when expectations or goals are not being met to explore ways to resolve this and to identify the changes that all parties need to make to accomplish the goal of the agreement. Thorough documentation of all steps taken to resolve the situation must be completed.

    AN AGREEMENT SHOULD NEVER BE USED FOR THE PURPOSE OF TERMINATING A PATIENT. Keep in mind that termination of dialysis services should be the last resort in resolving a situation. It is imperative that all possible interventions be explored before the facility takes steps towards discharging the patient. The Network collaborates with state survey agencies on facility decisions to involuntarily discharge patients and facilities should be prepared to share documentation demonstrating a good faith effort to resolve problematic issues with patients.

    Managing difficult patient behaviors is a team effort. Staff should be instructed regarding best practices for interacting with particularly disruptive individuals and empowered with information that reinforces the value of communicating with administration and one another when managing challenging patient situations. Education should be provided about boundaries, professionalism and skill building (teaching empathic responding and active listening vs. reactive responding such as challenging, arguing, inciting, and provoking).

    Visit http://esrdnet5.org/resources.asp for staff training resources and involuntary discharge guidelines. Network staff is available to provide resources and feedback regarding the management of difficult patient situations. Call Renée Bova-Collis at 804-794-3757 or email rbovacollis@nw5.esrd.net.