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>The behavioral contract should be discussed in a meeting with the patient and members of the dialysis facility staff, i.e., administrator, primary nurse, social worker, nephrologist, and/or technician. It is important to schedule such meetings during non-dialysis times when the patient will not be distracted. Family members and/or the patient's representatives should be encouraged to attend the meeting.<
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>The behavioral contract should be signed by all involved. If the patient refuses to sign, this should be noted on the document, along with the patient's reason for not signing. Likewise, all proceedings involved in instituting the behavioral contract should be documented and kept as a part of the patient's medical record. <
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>LEGAL ISSUES: Physicians have a responsibility to direct and support the steps leading to termination of services. It is not the responsibility of the dialysis staff to terminate the relationship of a physician with the patient. That is within the purview of the managing physician, and the circumstances leading to the severing of the physician/patient relationship must be clearly documented. Once the decision has been made to terminate services, the patient must be given adequate notice and help in locating a new physician and dialysis facility. Generally, a minimum of 30 days is considered to be adequate notice.<
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>The Federal ESRD regulations (Section 45.2138(2)) state that patients are transferred for medical reasons or for the patient's welfare or that of other patients, or for non-payment of fees, and are given advance notice to ensure orderly transfer or discharge. Appropriate state laws should also be examined by the dialysis facility.<
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>Nephrologists and facility managers should still be concerned about the possibility of litigation. The Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA), protect the disabled from discrimination. By law, all ESRD patients are disabled. When the decision is made to terminate a patient for disruptive and/or abusive behavior, it is critical that the decision and the actions leading up to the decision are thoroughly documented and dated separately. This documentation should show that the patient was not discriminated against due to disability, but due to his or her own disruptive and/or abusive behavior.<
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>The major court cases (Payton v. Weaver, Brown V. Bower) regarding termination of dialysis services to extremely difficult or dangerous patients have found physicians are not liable when all reasonable attempts have been made to ameliorate the situation.<
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>The courts do not believe that such problems should be resolved in the legal arena, however, but that the renal community has a responsibility to resolve the problem within its own resources. Along the same lines, the Network cannot undertake the placement of a patient, but can provide information and act as a resource.<
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>THE PATIENT'S BEHAVIOR: Facility staff should be able to describe, in writing, the specific behaviors or actions that support the claim that a patient is disruptive, abusive, and/or dangerous. Documentation should describe specific incidents or episodes, and be meticulously dated. These are some common examples:<
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>Abusive Behavior: verbal actions include using obscenities, shouting, screaming, name-calling. Physical actions include actual or perceived violent/threatening behavior, throwing of objects, hitting staff, yanking out needles, blood spray, spitting, abuse of drugs and/or alcohol.<
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>Threats: Written or verbal; display or threats about weapons.<
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>Interference With Facility Operations: Too many or intrusive visitors, manipulation of dialysis machines, slanderous and/or libelous statements regarding staff members of the facility, the operation of the facility, or other patients at the facility, destruction of equipment, trespassing into unauthorized areas.<
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>Law enforcement should be contacted when physical aggression occurs or is threatened. Dialysis patients are subject to the same criminal justice system as other citizens. Serious episodes where a patient behaves in a blatantly violent manner should not be tolerated; it is critical to ensure the safety of the facility staff and patients. Police reports of such incidents should be added to the patient's medical record to substantiate the claim of abusive behavior.<
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>MEDICAL AND PSYCHO-SOCIAL MANAGEMENT. When making the decision to terminate dialysis services, the staff should always attempt to take into consideration the underlying reasons for the behavioral problems. All attempts to determine and treat such problems should be documented in the patient's record. Here is a sample listing of things to be considered:<
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