Behavior contracts often are used for families labeled as “difficult,” but this raises some ethical concerns, says Aleksandra Olszewski, MD, lead author of a paper on this topic.1 “The contracts are applied in a unidirectional way, which assumes that the family’s at fault and that something punitive and restrictive is needed,” says Olszewski, a pediatric critical care fellow at Ann & Robert H. Lurie Children’s Hospital of Chicago.
Clinicians sometimes overlook the fact there are many contributing factors when a patient or family member displays “difficult” behavior. Ethicists can help clinicians parse those, recognize their own internal biases, and think about the family’s perspective. “The family may be going through the worst things they’ve ever gone through in their lives, and it’s not realistic to expect people to not get upset,” Olszewski says.
The family may have unmet needs that are causing the “difficult” behavior. “Ethicists can be on the lookout for conflict and call it out early on so the team can work through it,” Olszewski suggests.
Ethicists have received calls from clinicians who are frustrated because the family is “just not getting it” when the clinical team attempts to convey their understanding of the patient’s prognosis. In some of those cases, the family rarely is at the bedside. “Clinicians might frame that in a judgmental way,” Olszewski says.
Ethicists encourage clinicians to reflect on some of the barriers that prevent the family from staying at the hospital. Then, social workers or care coordinators can find ways to support the family. It will not solve the entire conflict. “But breaking things up like that is a way to improve things, to avoid having to resort to things like behavior contracts,” Olszewski says.
Once a family member is threatened with removal from the bedside if he or she breaks the contract, it can negatively affect the patient/physician relationship and the care the patient receives. “Risking worsening the conflict for the benefit of people’s safety is sometimes necessary,” Olszewski admits. “But clinicians overuse behavior contracts in general and use them in subjective and random ways.”
This also is true for restrictive and punitive approaches in healthcare generally. “A big reason for this is that such measures are applied in subjective ways, and thus prone to biases and environmental stressors,” Olszewski says.
Another concern is there can be disparities in how behavior contracts are used. “It could be that there are differences in how conflicts are perceived in different race and ethnicity groups,” Olszewski observes.
This points to the importance of the ethicists’ role in conflict mediation. “When something is going wrong, ethicists can serve as mediators,” Olszewski says.
Even if no one requests a formal consult, ethicists can debrief clinicians during morally distressing cases involving conflict. This includes consideration of social determinants of health. “The impact of social determinants of health on a conflict can be insidious, and then really spiral. Ethicists should have it on their radar on the checklist of things they are looking for during every consult,” Olszewski recommends.
Behavior contracts can provide a transparent statement of expectations on what is necessary for the patient’s time in the hospital to be effective. That can help clinicians to provide good care. “The concern is the weaponization of the contracts, and clinicians using them unevenly from patient to patient,” says Caroline Buchanan, PhD, assistant professor with the UK Program for Bioethics at the University of Kentucky College of Medicine.
Ethicists can help ensure that if clinicians are thinking about asking a patient to sign a contract that includes a threat of administrative discharge, it is either because that patient’s behavior is interfering with their own care, or because the patient is an acute threat to staff or other patients.
“That’s where an ethics consultant might be involved in a mediation role, to set the bar appropriately high,” Buchanan says.
Ethicists can suggest effective behavior modification approaches, especially if people are acting out because of grief or trying to cope with a terrible situation. “Ethicists can present a set of questions to make sure clinicians have considered all options on how to talk to this family member or patient, and try to get to the bottom of the underlying cause of the behavior,” Buchanan says.
Possibly, the patient clashed with a particular resident and never wants to see that resident again. Together, the ethicist and clinician could find a way to work around this personality issue, preventing future disruptive behavior and the introduction of a behavior contract. “If the patient is given a chance to say what they need, maybe the situation would fizzle out and de-escalate,” Buchanan says. If patients make staff or clinicians feel unsafe, it probably is time to call security right away; immediate intervention is warranted.
“But there is a whole other subset of patients who no one feels threatened by, but are annoying, rude, or angry, and are making care really difficult,” Buchanan says. In those cases, behavior contracts can set expectations on what needs to happen. The key is behavior contracts are “used as a piece of a larger conversation,” Buchanan stresses. “It’s a tool in our toolbox. But there is a very small subset of situations that they’re appropriate for.”
REFERENCE
1. Olszewski AE, Mendelsohn L, Paquette ET. Unique ethical and practical considerations in the use of behavior contracts for families of minors and minoritized populations in pediatric settings. Am J Bioeth 2023;23:82-85.
Clinicians sometimes overlook the fact there are many contributing factors when a patient or family member displays “difficult” behavior. Ethicists can help clinicians parse those, recognize their own internal biases, and think about the family’s perspective.
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