Fabi R, Johnson LSM.
JAMA. 2024;331(10):823–824.
doi:10.1001/jama.2024.0216
Here is an excerpt:
The epidemic of workplace violence has prompted the use of harsh responses that include “behavior contracts” (sometimes called “behavioral agreements”) that can undermine a hospital’s commitment to providing evidence-based, patient-centered care. There is no national repository of data on the use of behavior contracts, or on hospital policies, but in our experience as clinical ethics consultants, and through discussions with colleagues nationally, we have observed that hospitals increasingly try to manage so-called difficult patients and families through behavior contracts that impose paternalistic limits and punitive consequences on patients for a wide range of behaviors. Yet behavior contracts pose serious ethical challenges, especially when unilaterally imposed on patients whose behavior is upsetting and disrespectful but not unsafe. Moreover, the evidence supporting the efficacy of contracts is lacking.
Behavior contracts are used in a variety of health care contexts to promote patient adherence with treatment, including smoking cessation, weight loss, substance use disorder rehabilitation, and psychiatric treatment. A Cochrane systematic review found that evidence of their effectiveness at improving adherence is limited and mixed; it did not find evidence from randomized clinical trials outside of this context.1 Indeed, we could find no empirical evidence to support or challenge the effectiveness of behavior contracts as a tool for addressing the problems of undesirable patient or family behaviors, patient-staff conflicts, and workplace violence in health care. Absent such evidence, health care institutions committed to evidence-based medicine and workplace safety might hesitate before using these contracts. When viewed alongside the ethical considerations, which have been extensively explored in the bioethics literature, we argue that the lack of supportive evidence generates an ethical imperative to reconsider their use altogether. Such reconsideration should include internal audits of how and when they are used, address the lack of institutional transparency and accountability about their use, and impose consistency and ethical safeguards. Based on our own experience, and that of many colleagues, we suspect that institutions that engage in this kind of self-reflection will find worrisome disparities in their use of behavior contracts.
Quick summary:
The article discusses strategies for responding effectively to disruptive patient behaviors beyond behavior contracts. It emphasizes the importance of recognizing risks, de-escalating situations, and maintaining safety in healthcare settings. Key points include the impact of disruptive behavior on patient safety, the need for de-escalation techniques, and the significance of understanding triggers to prevent disruptive incidents. The article also highlights the role of training, policies, and protocols in managing disruptive behaviors successfully.
