All concepts, explanations, trials, and studies have been re-written in plain English and may contain errors. I am not a doctor ----------------------------------------------------------- A contract is a binding agreement between 2 or more persons. Compliance in medicine means getting patients to do what their doctors want them to do - take all their meds in the right doses at the right times, lose weight, exercise, follow the special diet, etc,... Contracting has been used to increase compliance in patients with diabetes; obesity; smoking, drinking, and drug addiction; and cancer. Psycho-social factors are important in heart transplant evaluation. Given the small number of donor organs, transplant teams screen potential recipients very carefully. Factors such as alcohol or drug abuse and smoking are considered barriers to transplant. Behavior contracting has been used with transplant patients to reduce such high-risk behaviors. A behavior contract is a formal, written, signed agreement between the patient and healthcare team that clearly states the behaviors to be changed, the methods that will be used to make sure the changes are made, and the consequences of making or not making the changes as agreed. The healthcare team gains advantages from such a contract. The contract gives the patient specific expectations from the team, eliminating miscommunication. It also tells the patient that his healthcare team is serious about him changing behaviors. We believe 4 factors influence a person's compliance: 1) his perceptions about the impact of the disease, effectiveness of treatment, self-confidence and ability to manage the disease, and understanding of the treatment plan. 2) factors such as age, sex and education. 3) disease and treatment factors such as length and severity of the illness and complexity of the treatment. 4) degree of social support available from family members, friends, and healthcare professionals. Making a contract gives the healthcare team some opportunities: 1) the team can clarify a patient's perceptions about the transplant team's expectations regarding behavior modification. 2) how well a patient can change his own behavior is seen. 3) a program can be custom-made that takes into consideration the stage and severity of the patient's disease. 4) doctors get a public commitment from the patient about his intent to change. 5) doctors can set extremely specific goals and use definite means to measure whether the goals are really met - set in advance. Starting a heart transplant behavior contract at the Washington Hospital Center was prompted by 2 factors. Both the transplant team and nursing staff became concerned when several hospitalized (status 1) candidates refused to do specific, agreed-upon self-care routines like daily monitoring and recording of blood pressure. Although expectations about things like substance abuse and not taking meds are verbally agreed on with all transplant candidates when they go on the list, it was clear this "agreement" was not taken seriously. Written - as opposed to verbal - contracts give positive proof that an agreement really exists. A written contract specifically assigns responsibilities, and holds patients accountable for their actions. Both parties must agree on the expected behavior changes. In heart transplant, behavior goals are not usually negotiated. For example, abstinence must be the goal, not limited smoking. The patient makes the decision about whether getting a transplant makes changing worthwhile. This is as far as mutual agreement goes. The transplant team sets the requirements and the patient either accepts them or doesn't get a chance at a donor heart. The only area of negotiation between patient and team is in deciding on strategies to achieve the behavior goals. For example, kicking the smoking habit can be done in different ways, including "cold turkey," support groups, hypnosis, acupuncture, and nicotine therapy. Based on the patient's current level of cigarette use, history of trying to quit, level of motivation, and preferences, a plan is designed. This plan is then written into the contract. A critical part of the process is to review together with the patient - in detail - the behaviors agreed upon. For instance, one patient interpreted the phrase "no smoking" to mean "not smoking regularly." After a period of abstinence that was verified by negative results on cotinine screen, the patient continued to smoke once in awhile. When family members became concerned, they alerted the transplant team and results from a repeat cotinine screen were positive. After discussions with the patient, the wording of his contract was changed and he began to work toward the required 6-month period of abstinence before being listed. The patient later had successful heart transplant. It is critical to use objective measurements of behaviors and to document this in the medical record. Random drug or cotinine screens give objective results about substance abuse and smoking. For our nicotine tests, we require that patients come in for a blood draw within 4 hours of being notified. We based this on the half-life of nicotine. For patients who have questionable social support, telephone contact can be made with identified support persons to make sure they are willing to help, and to make clear their responsibilities. During a trial period, support persons can bring the patient to doctor's appointments or support group meetings. This lets the transplant team see for sure the patient's level of social support. If patients are getting mental health services, the transplant team can request that the patient sign a release permitting the therapist to share information about attendance at sessions, compliance with meds, and other information. In addition to periodic weigh-ins, patients in a weight loss effort might have to keep daily diaries detailing food intake, calorie counts, and family feedback. Figuring out how to give positive reinforcement that works for each individual patient is essential. Obviously, being listed for heart transplant is the ultimate reinforcement but most people need more immediate reinforcement. This can be positive attention from team members or family. Such reinforcement may be phone contact, face to face meetings, or special attention in support group meetings. A patient's need for reinforcement may fluctuate during the contract period. The contract must clearly state the consequences if the patient does not successfully reach his goals. The main consequence is not being listing for transplant until goals are met. Including some other consequences if a patient fails to take any action toward a goal in a certain time is also a good idea. Specific time frames need to be set for everything. All parties involved must sign the contract. This may include the patient, family members, support persons, and transplant team members. A copy of the signed contract is given to all parties. The transplant team keeps the original document in the patient's medical record. As changes are made to the plan and noted on the original contract, copies of the revised contract must be issued. We believe that a person's refusal to sign such a contract justifies not accepting the patient for transplant, in order to maximize positive outcomes for other patients. At the first transplant evaluation appointment, our team meets patients and families as a group. One advantage is that patients and families understand from this that we are a team of professionals who work together. During this meeting behaviors are identified that may need contracting, and the idea of contracting is first presented. Follow-up meetings may be scheduled to complete the contract plan. Once the contract is complete, the patient should take it home and think about it for at least 24 hours before signing it. This delay reinforces the importance of the agreement. Patients then mail back the signed contract and representatives from the transplant team sign the contract. Copies are then returned to the patient. Patients who choose not to begin a behavior changing process will not be considered for transplant. Patients are encouraged to stay in touch anyway and tell us if they ever change their minds. Either the social worker or transplant coordinator will have responsibility for managing the contract process. Identifying a primary contract manager is important. The patient begins to develop a sustained relationship with a team member who gives positive reinforcement at each step in the behavior changing process. The contract manager must obtain the necessary information. For example, random blood or urine tests must be done if a patient has been a substance abuser. Our team makes a special effort to surprise patients in order to accurately test their progress. We call patients in for drug screening on weekends or on 2 days in a row. We rarely test patients during scheduled appointments or on days when the patient's support group meets. Failure to appear for a drug test is considered the same as testing positive. Such patients are dropped from consideration. If such patients already listed, they are inactivated until they again reach the desired behavior change for the specified amount of time. Such patients who have already had a heart transplant continue to receive care but they must get counseling. Patients in a contract who volunteer to us that they are still engaging in the undesired behavior but want to change may recontract, with new interventions created. Educating persons outside the transplant team about the significance of behavior contracting is important. This includes primary care physicians, inpatient nurses, home care personnel, mental health specialists, addiction counselors, and Alcoholics Anonymous sponsors. Contracting may be viewed with skepticism or resistance. ADVANTAGES: 1) Encourages a positive rather than negative approach to "problem" behavior. 2) Defines the problem in terms of the patient's behavior rather than in terms of the patient. 3) Enables the patient to focus on making needed changes rather than maintaining defensive attitudes. 4) Makes patients assume responsibility for their own behaviors. 5) Provides an opportunity for patients to make a public commitment. 6) Identifies specific expectations. ------------------------------------------------------------ A SAMPLE CONTRACT: You are being considered/have been accepted for heart transplantation at the Washington Hospital Center. To help determine whether this is the best option for you, there needs to be agreement about what is required of you both before and after transplantation. The success of the transplant procedure depends on your following a medical program that includes clinic visits, an exercise program, dietary guidelines, and taking prescription medicine every day for the rest of your life. I, ___________, make a commitment to myself, my family, and the transplant team to take care of myself in the following ways: 1. I will participate in the exercise plan as recommended by my cardiologist and/or the cardiac rehabilitation team. I understand that the rehabilitation team may recommend a formal outpatient program or may recommend general exercise guidelines for home, whichever is best for my well-being. 2. I will follow the nutritional guidelines and restrictions as prescribed by the clinical nutritionist. I understand that if I am placed on a weight loss regimen, I must demonstrate continued appropriate weight loss through compliance with the recommended diet. 3. I will follow the treatment plan as prescribed by my physicians. I will keep my clinic appointments and take my medicines as directed. I will read the pre-transplant educational materials provided to me by the transplant team and ask questions about any content I do not understand. I understand that a copy of these materials will be provided to me and my family. I will bring the materials to the hospital when requested. 4. I commit to attending the mandatory monthly support group meeting while waiting for transplantation. I understand that it is important for me to attend this group meeting so that my family and I can receive ongoing education and emotional support related to the transplant process. I understand that it is also an opportunity to meet others who are awaiting transplantation as well as transplant recipients. 5. If alcohol abuse or dependence has been identified as an issue for me, I commit to cease drinking alcohol. I must demonstrate 6 months of abstinence before being considered for listing. 6. I will not use any substance or drug not prescribed by my physicians and I will use prescription drugs as prescribed. I must demonstrate 6 months of abstinence from undesirable drugs before being considered for listing. 7. I will stop smoking all substances, including marijuana, cigarettes, pipes, and cigars. I must demonstrate 6 months of abstinence before being considered for listing. 8. I am willing to have random urine and/or blood tests for evidence of drugs, nicotine, and/or alcohol. I recognize that the transplant team may call me at any time and request that I appear for this testing. I commit to appearing within 4 hours of that call. If I fail to appear or if the tests reveal that I have been using any substance, I will agree to begin or continue with formal substance abuse treatment as deemed appropriate by myself and the transplant team. I will need to recontract and demonstrate 6 months of abstinence before I will be considered again for listing. 9. I commit to participating in any needed treatment programs to address substance abuse issues. I agree to sign a release of information document to allow the Washington Hospital Center transplant team to monitor my progress and attendance in the chosen treatment program. 10. I will adhere to safe sex guidelines in order to prevent AIDS and other sexually transmitted diseases. 11. I understand that I am responsible for the costs of transplantation, which include hospitalization, physician charges, outpatient and laboratory charges, and medication expenses. There are likely to be costs to me, as few insurance plans cover all these services fully. My insurer is: _______________ My coverage parameters are: _________________ My outpatient medication coverage is: ______________ 12. I understand that if I break this contract I will not be placed on the heart transplantation list, or I will be removed from the list. I understand that in changing and/or maintaining healthy behaviors, relapses can occur. I commit to learning my specific situations or triggers for a relapse and to seeking immediate assistance to bring this under control. I will be honest in my requests for support in difficult situations. If I feel like I am going to break this contract, I will call a member of the transplant team for assistance. 13. When I receive a transplant, I understand that these requirements continue as a lifetime commitment. 14. Other: ______________________________________________________ A SAMPLE WEIGHT LOSS CONTRACT ADDITION: I will follow the nutritional guidelines and restrictions as prescribed by the clinical nutritionist listed below. I understand that if I am placed on a weight loss regimen that I must demonstrate continued, appropriate weight loss. I also understand that these dietary changes, such as incorporation of a low-fat diet, will be crucial to my overall health after transplant. 1. I will complete daily food records that will include all food consumed during the day. 2. I will comply with the 2000-2200 calorie/low fat/low cholesterol diet regimen provided by the transplant nutritionist. 3. I will consume no more than 2000 mg of sodium per day. 4. If consuming no more than 2000-2200 calories does not produce weight loss, I will agree to an 1800 calorie/low fat/low cholesterol diet regimen provided by the transplant nutritionist. 5. I will meet with the transplant nutritionist once a month to review my diet record and nutritional needs. It will be my responsibility to schedule meetings with the nutritionist. 6. I will lose 15 pounds in the next 6 months. Title: Use of Behavior Contracting With Heart Transplant Candidates Authors: Sandra Cupples, Barbara Steslow Source: Progress in Transplantation 11(2):137-144, 2001