We recognize that where patient contracts are likely to be ineffective, or ethically and legally problematic, other tools and techniques are needed. A promising and often underused source of guidance can be found in the discipline of behavioural therapy. Behavioural therapy tools are designed to benefit patients by identifying and capitalizing on their existing strengths rather than by emphasizing their vulnerabilities. They provide alternatives that do not entail a reduction in the quality or availability of care provided to patients with serious psychological and physical illnesses. Below, we provide a brief glimpse of tools and strategies that we have found helpful in our rehabilitation setting. They doubtless are transferable to other contexts as well.
Behavioural tools come in many forms, and their implementation may begin even prior to a patient’s formal admission. For instance, we have found social scripts [22], which are similar to movie scripts in their attention to detail and ability to clarify roles, have been invaluable in preparing patients for a rehabilitation stay. They can be used to set facility expectations and goals, and to help patients and clinicians mitigate foreseeable concerns. Once patients have arrived at a facility, collaborative goal setting can be used to increase patients’ investments in their own care, investments that are positively correlated with better patient outcomes [23]. As one might expect, success in achieving such goals is more likely when care plans are rooted in patient values, as opposed to those of staff [24].
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Additional behavioural tools are well-suited to patients who exhibit challenging behaviours. These tools include those outlined by William R. Dubin, whose core clinical strategy for psychiatric patients consists of using verbal intervention techniques, as well as active clinician responses, such as direct eye contact and body language. Dubin emphasizes prevention in his non-pharmacological strategies, which include risk assessments and psychotherapeutic interventions when caring for patients who exhibit behavioural challenges or show warning signs of aggression. His observation that “implementing strategies that minimize humiliation and helplessness will almost always lead to a safer and more successful outcome”[25], is important because it shifts some of the onus for patient behaviours away from the patient and toward the professional(s). Another promising technique is motivational interviewing, which originated in efforts to address alcohol-dependence disorders [1]. At its core, this technique aims to return a sense of power and responsibility to the patient by inviting clinicians to focus on three skills (listening, asking, and informing) and four principles (resist the righting reflex, understand the patient’s motivation, listen to the patient, and empower the patient) [25]. This is a particularly appropriate approach in a rehabilitation context due to its compatibility with goal setting and a rehabilitation philosophy that aims to empower patients and foster independence. Finally, clinicians might employ “token economies” [27] to motivate patients to complete tasks and engage in their care. Successful implementation of this strategy requires a careful assessment of the rewards that are likely to motivate a specific patient.
Patient rewards should be designed to enrich the care experience and are not meant to serve as compensation for deprived environments. Although these methods differ from one another, and require different levels of expertise, the purpose is the same: to effectively and equitably mitigate the impact of variables that negatively influence a patient’s clinical care and subsequent health outcomes.
Conclusions
In conclusion, we suggest that the widespread use of patient contracts ought to be re-evaluated on practical and ethical grounds. Although contracts may have limited value in select circumstances, the evidence for their effectiveness is weak and their potential to undermine trust and exacerbate existing disparities makes them problematic. It is our view that rehabilitation (and other) professionals would benefit from access to a more comprehensive “toolkit” designed to help address challenges that arise in the care of patients who present with so-called “behavioural difficulties”. Behavioural therapists, and the strategies that are well-developed in their practices, have the potential to offer significant benefits to their colleagues in rehabilitation medicine and beyond. Equitable, accessible, and patient-centred care are goals that we believe all healthcare providers can embrace. In that case, it is worth further examining the ethical standing of contracts and exploring alternatives to “contracting compliance.”
Remerciements Acknowledgements
Nous aimerions remercier deux patients partenaires de l’UHN pour les commentaires dont ils nous ont fait part durant l’élaboration du présent document et pour leurs points de vue sur les contrats de patients. Ce travail a été appuyé en partie par une généreuse subvention du Fonds de recherche pour les étudiants de premier cycle en arts et en sciences de l’Université Queen’s.
We would like to thank two UHN patient partners for providing us with their feedback and perspectives on patient contracts during the development of this paper. This work was supported in part by a generous grant from the Queen’s University’s Arts and Science Undergraduate Research Fund.
Conflits d’intérêts Conflicts of Interest
Certains auteurs (Heesters, Bianchi, Rodrigues et Brown) travaillent comme employés salariés pour un réseau hospitalier financé par l’État qui comprend des établissements de réadaptation. Nos opinions ne reflètent pas nécessairement celles de notre employeur.
Some of the authors (Heesters, Bianchi, Rodrigues, and Brown) work as salaried employees for a publicly funded hospital network that includes rehabilitation facilities. Our opinions are not necessarily those of our employer.
Responsabilités des évaluateurs externes Peer-reviewer responsibilities Les recommandations des évaluateurs externes sont prises en
considération de façon sérieuse par les éditeurs et les auteurs dans la préparation des manuscrits pour publication. Toutefois, être nommé comme évaluateurs n’indique pas nécessairement l’approbation de ce manuscrit. Les éditeurs de la Revue canadienne de bioéthique assument la responsabilité entière de l’acceptation finale et de la publication d’un article.
Reviewer evaluations are given serious consideration by the editors and authors in the preparation of manuscripts for publication.
Nonetheless, being named as a reviewer does not necessarily denote approval of a manuscript; the editors of Canadian Journal of Bioethics take full responsibility for final acceptance and publication of an article.
Édition/Editors: Loubna Affdal, Zubin Master & Aliya Affdal Évaluation/Peer-Review: Catherine Régis
Affiliations
1 Department of Arts and Sciences, Queen’s University, Kingston, Canada
2 Bioethics Program, University Health Network, Toronto, Canada
3 Department of Bioethics, Harvard Medical School, Boston, United States of America
4 Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
5 Brain Program of Toronto Rehab, University Health Network, Toronto, Canada
6 Department of Education, Western University, London, Canada
Correspondance / Correspondence: Andria Bianchi, andria.bianchi@uhn.ca Reçu/Received: 4 Feb 2019 Publié/Published: 23 Oct 2019
Cooper et al. 2019
Les éditeurs suivent les recommandations et les procédures décrites dans le Code of Conduct and Best Practice Guidelines for Journal Editors de COPE. Plus précisément, ils travaillent pour s’assurer des plus hautes normes éthiques de la publication, y compris l’identification et la gestion des conflits d’intérêts (pour les éditeurs et pour les auteurs), la juste évaluation des manuscrits et la publication de manuscrits qui répondent aux normes d’excellence de la revue.
The editors follow the recommendations and procedures outlined in the COPE Code of Conduct and Best Practice Guidelines for Journal Editors. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal’s standards of excellence.
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S Hyett, C Gabel, S Marjerrison, L Schwartz. Can J Bioeth / Rev Can Bioeth. 2019;2(2):102-109. Canadian Journal of Bioethics Revue canadienne de bioéthique
2019 S Hyatt, C Gabel, S Marjerrson, L Schwartz. Creative Commons Attribution 4.0 International License ISSN 2561-4665
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