Findng Information
Joined: 19 Jul 2003
Posts: 1
Posted: Sat Jul 19, 2003 4:57 am Post subject: I found this
--------------------------------------------------------------------------------
on the Renal Network Website. Prior to a few days ago, when I accessed this site, I was taken to the National Site, now I am limited to my region. I thought this might interest everyone. It concerns the policies and procedures on how you can be dismissed from a Unit:<
><
> <
> Printer Friendly Version ESRD Network 9/10 Privacy Policy <
> <
> Home <
> About Us <
> Nephrology Conference <
> Data <
> Quality Improvement <
> Patient Services <
> Network Policies & <
> Guidelines <
> Renal Links <
> Community News <
> <
> <
> <
> Home -> Network Policies -> Recommendations for Termination of Dialysis Services <
> <
> <
> Recommendations for Termination of Dialysis Services <
> <
><
><
><
>THE RENAL NETWORK, INC.? <
>Legal Review Complete 2/99<
>MRB Approved 2/10/99<
>Board of Trustees Approved 3/23/99<
>Recommendations<
>For Termination of Dialysis Services <
><
>INTRODUCTION: Terminating services to a chronic dialysis patient is a serious step which should not be undertaken lightly, and only when all other steps have failed. There are legal, medical, and ethical considerations to be explored.<
><
>Dialysis professionals, along with others in health care, are responsible for taking care of all patients in their charge, some of whom may be unusual, difficult, unpleasant, or even dangerous. By the same token, facility managers and medical directors have a responsibility to protect their staff and patients, and assure their safety.<
><
>Dialysis staff should be trained to deal with difficult patients, and how to defuse potentially explosive situations. Training should be available to staff members by experts in the field.<
><
>Psychiatrists, psychologists, mediators, law enforcement, legal counsel, and clinical social workers are just some of the resources that might be utilized. Dialysis staff must act in a consistent manner and support each other to carry out the decisions taken. Problem patients can exploit or manipulate inconsistent behaviors.<
><
>BEHAVIORAL CONTRACTS: Prior to the decision to terminate services, steps should be taken to counsel the patient on his or her unacceptable behavior. Behavioral contracts can be used to define problems and state expected solutions, for both the patient and the facility staff. The behavioral contract should be a written document containing the following:<
><
> A clear definition of the problem behavior and why it is unacceptable.<
><
> The expectation for improvement of the patient's behavior.<
><
> Responsibilities of the dialysis staff to the patient.<
><
> Timelines for improvement.<
><
> Actions which will be taken if the timelines are not met.<
><
> A statement that the patient's continued negative behavior will cause the dialysis facility to begin termination of treatment process against him or her, and at what time this process will begin.<
><
>When setting out timelines, a minimum of 30 days should be allowed for the behavior to improve, separate from any notice of termination of services.<
><
>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.<
><
>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. <
><
>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.<
><
>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.<
><
>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.<
><
>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.<
><
>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.<
><
>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:<
><
>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.<
><
>Threats: Written or verbal; display or threats about weapons.<
><
>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.<
><
>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.<
><
>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:<
><
>
