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By JULIE BRIGHTWELL, JD, RN and RICHARD CAHILL, JD
Just as it is an acceptable and reasonable practice to screen incoming patients, it is acceptable and reasonable to know when to end patient relationships that are no longer therapeutic. It is critical, however, that the physician end the patient relationship in a manner that will not lead to claims of discrimination or abandonment.
The criteria for terminating a physician-patient relationship are numerous and varied. Although the list is not exhaustive, it is appropriate and acceptable to terminate a relationship under the following circumstances:
- Treatment nonadherence--The patient does not or will not follow the treatment plan.
- Follow-up nonadherence--The patient repeatedly cancels follow-up visits or is a no-show.
- Office policy nonadherence--The patient fails to follow office policies, such as those for payment, prescription refills, or appointments. For example, the patient uses weekend on-call physicians or multiple healthcare practitioners to obtain refill prescriptions when office policy specifies how to obtain refills between visits.
- Verbal abuse--The patient or a family member is rude and uses improper language with office personnel or other patients, visitors, or vendors; exhibits violent behavior; makes threats of physical harm; or uses anger to jeopardize the safety and well-being of anyone present in the office.
- Nonpayment--The patient owes a backlog of bills and has declined to work with the office to establish a payment plan.
Exceptions and Special Circumstances
A few situations, however, may require additional steps or a delay or even prohibit patient dismissal. Examples of these circumstances include the following:
- If the patient is in an acute phase of treatment, delay ending the relationship until the acute phase has passed. For example, if the patient is in the immediate postoperative stage or is in the process of a medical workup for a diagnosis, it is not advisable to end the relationship.
- If the practitioner is the only source of medical or dental care within a reasonable driving distance, he or she may need to continue care until other arrangements can be made.
- When the practitioner is the only source of specialized medical or dental care, he or she is obliged to continue care until the patient can be safely transferred to another practitioner who is able to provide treatment and follow-up.
- If the patient is a member of a prepaid health plan, the patient cannot be discharged until the practitioner has communicated with the third-party payer to request that the patient be transferred to another practitioner or otherwise complies with the terms of the payer-provider agreement.
- A patient may not be dismissed or discriminated against based on limited English proficiency or because he or she falls within a protected category under federal or state legislation. Examples of civil rights laws include the Americans with Disabilities Act (ADA), the Civil Rights Act, and the Emergency Medical Treatment and Labor Act (EMTALA).
- If a patient is pregnant, the physician can safely end the relationship during the first trimester if the pregnancy is uncomplicated and there is adequate time for the patient to find another practitioner. During the second trimester, a relationship should be ended only when it is an uncomplicated pregnancy and the patient is transferred to another obstetrical practitioner prior to the cessation of services. During the third trimester, a relationship should end only under extreme circumstances (such as illness of the practitioner, etc.).
- Physician or dental groups with more than one practitioner may want to consider dismissing a patient from the entire practice. This will avoid the possibility that the patient might be treated during an on-call situation by the practitioner who ended the relationship.
- The presence of a patient's disability cannot be the reason(s) for terminating the relationship unless the patient requires care or treatment for the particular disability that is outside the expertise of the practitioner. Transferring care to a specialist who provides the particular care is a better approach.
Steps for Withdrawing Care
When the situation with the patient is such that terminating the relationship is appropriate and acceptable and none of the restrictions mentioned above are present, termination of the patient relationship should be completed formally. Put the patient on written notice that he or she must find another healthcare practitioner. The written notice should be mailed to the patient by both regular mail and certified mail with a return receipt requested. (Both types of mailing are required in some states.) Keep copies of all the materials in the patient's medical record: the letter, the original certified mail receipt (showing the letter was sent), and the original certified mail return receipt (even if the patient refuses to sign for the certified letter).
Elements of the Written Notice
The written notice terminating the relationship should include the following information:
- Reason for termination--Although a specific reason for termination is not required, it is acceptable to use the catchall phrase "inability to achieve or maintain rapport" or to state that "the therapeutic practitioner-patient relationship no longer exists."
- Effective date--The effective date of termination should provide the patient with a reasonable amount of time to establish a relationship with another practitioner. Although 30 days from the date of the letter is usually considered adequate, follow your state regulations. The relationship may be terminated immediately under the following circumstances:
- The patient has terminated the relationship. (Acknowledge this in writing with a letter from the practice.)
- The patient or a family member has threatened the practitioner or staff with violence or has exhibited threatening behavior.
- Interim care provisions--Offer interim emergency care. Refer true emergency situations to an emergency department or instruct the patient to call 911 as necessary.
- Continued care provisions--Offer referral suggestions for continued care through medical or dental societies, nearby hospital medical staffs, or community resources. Do not recommend another healthcare practitioner by name.
- Request for medical or dental record copies--In your written notice, offer to provide a copy of the medical or dental record to the new practitioner by enclosing an authorization document (to be returned to the office with the patient's signature). One exception is a psychiatric record, which may be offered as a summary in lieu of a full copy of the medical record.
- Patient responsibility--Include a reminder that the patient is responsible for all follow-up and continued medical or dental care.
- Medication refills--Explain that medications will be provided only up to the effective date of termination.
Case Examples
The following scenarios illustrate some of the issues involved in terminating a patient relationship.
Case One
A patient has been in your practice for about 10 years, has faithfully made regular visits, but has not been compliant with your medical regime for taking hypertension medications. You have repeatedly explained the risks of nonadherence, and you have rescued the patient on many occasions with emergent medications, usually in the local emergency department over a weekend. You are convinced that the patient understands but stubbornly refuses to comply.
Should This Patient Relationship Be Terminated?
With any nonadherent patient, it is essential to document your recommendations, the patient's continued nonadherence, your efforts to help the patient understand the risks of nonadherence, and his or her failure to follow the treatment plan and advice. Terminate the relationship if the patient and physician agree that the patient would achieve better compliance with another practitioner. The written notice terminating this relationship should be explicit in stating the reason you are no longer willing to provide care--that the patient's outcome is predestined to be unfavorable because of his or her nonadherence with recommended treatment plans. Suggest that the patient would benefit from a relationship with another physician, and state that continued medical care is an absolute requirement.
Case Two
A new patient has made an appointment with your office for a full and complete physical examination. Before the appointment, the patient experienced an unusually long wait in your office as a result of your need to address an urgent situation with an infant. Your office personnel explained the delay to those in the waiting room, and this new patient reacted by becoming loud and abusive, insulting the registration person, and shouting that his time is as valuable as that of the doctor.
Options for the Practitioner
In the privacy of an office or an examination area, address your concerns about his behavior by indicating that the practice maintains a zero-tolerance policy for loud, threatening, or abusive behavior, and state that this type of reaction will not be tolerated in the future. After you have completed his physical examination, suggest that he seek medical care elsewhere if he is reluctant to observe office decorum. If the patient indicates a refusal to comply, consider preparing and sending a termination letter. If the patient fails to keep subsequent appointments or has notified your office that he will be seeking care with another physician, document the conversation and send the patient a letter reiterating his decision to seek care elsewhere.
Julie Brightwell, JD, RN, is Director of Healthcare Systems Patient Safety, Department of Patient Safety and Risk Management for The Doctors Company, and Richard Cahill, JD, is Vice President and Associate General Counsel for The Doctors Company.
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The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.