Terminating Patient Relationships
Just as it is an acceptable and reasonable practice to screen incoming patients, it is acceptable and reasonable to know when to end relationships.
Termination criteria are numerous and varied. Although not exhaustive, the following are situations in which termination is appropriate and acceptable:
- 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 uses weekend on-call physicians or multiple healthcare practitioners to obtain refill prescriptions when office policy specifies a certain number of refills between visits.
- Verbal abuse—The patient or a family member is rude and uses improper language with office personnel, exhibits violent behavior, makes threats of physical harm, or uses anger to jeopardize the safety and well-being of office personnel with threats of violent actions.
- Nonpayment—The patient owes a backlog of bills and has declined to work with the office to establish a payment plan.
These examples are only a few of the situations that practitioners encounter. If you experience these or different situations that cause concern, please contact your patient safety risk manager or the Department of Patient Safety and Risk Management.
Terminating Patient Relationships and Minimizing Liability
It is an acceptable practice to end a patient relationship under most conditions. A few situations, however, may require additional steps or a delay of the termination. The following circumstances fall into this category:
- If the patient is in an acute phase of treatment, termination must be delayed until the acute phase has passed. For example, if the patient is in the immediate postoperative stage or is in the process of medical workup for 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 a particular type of specialized medical or dental care, he or she is obliged to continue this 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 a transfer of the patient to another practitioner.
- A patient may not be terminated solely because he or she is diagnosed with AIDS/HIV or for any reason if the patient is in a protected class.
- If a patient is pregnant, termination can be safely accomplished during the first trimester with uncomplicated pregnancies and with adequate time for the patient to find another practitioner. Termination in the second trimester should occur only for uncomplicated pregnancies and with transfer of the patient to another obstetrical practitioner prior to actual cessation of services. Termination during the last trimester should occur only under extreme circumstances (such as illness of the practitioner, etc.).
- Physician or dental groups with more than one practitioner may want to consider terminating a patient from the entire practice. This will avoid the possibility that the patient might be treated by the terminating practitioner during an on-call situation.
- The presence of a patient’s disability cannot be the reason(s) for termination 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.
Recommended Steps for Patient Termination
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. The patient should be put on written notice that he or she must find another healthcare practitioner. The written notice should be mailed to the patient by regular and certified mail, return receipt requested. Keep copies of the letter, the original certified mail receipt, and the original certified mail return receipt (even if the patient refuses to sign for the certified letter) in the patient’s medical record.
Elements of the Written Notice
A notice should include:
- Reason for termination—A specific reason for termination is not required. Under certain circumstances, it is acceptable to use the catchall phrase “inability to achieve or maintain rapport” or to state “The therapeutic practitioner-patient relationship no longer exists.”
- Effective date—The effective date of termination should provide the patient with a reasonable time period to establish a relationship with another practitioner. Usually, 30 days from the date of the letter is considered adequate, however, you should follow your state regulations. The relationship can be terminated immediately under the following circumstances:
- The patient has terminated the relationship.
- The patient or a family member has threatened the practitioner or staff with violence or has exhibited threatening behavior.
- Interim care provisions—Offer interim care. True emergency situations, however, should be referred to an emergency department.
- Continued care provisions—Offer suggestions for continued care through local referral services such as 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 to this element is the psychiatric record, which may be offered as a summary in lieu of the full copy of the medical record.
- Patient responsibility—Remind the patient that follow-up and continued medical or dental care are now the patient’s responsibility and that both should be pursued.
- Medication refills—Explain that medications will only be provided up to the effective date of termination.
The following scenarios illustrate some of the issues involved in patient termination:
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 issues of nonadherence, and you have rescued the patient on many occasions with emergent medications, usually in the local emergency room over a weekend. You are convinced that the patient understands but stubbornly refuses to comply.
Should This Patient Be Terminated from Your Practice?
With any nonadherent patient, it is essential to document your recommendations, the patient’s continued nonadherence, your efforts to help the patient understand the risk of nonadherence and his or her inability 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 the relationship with such a patient 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. You should suggest that the patient would benefit from a relationship with another physician and that continued medical care is an absolute requirement.
A new patient has made an appointment with your office for a full and complete physical examination. The patient experienced an unusually long wait in your office before the appointment as a result of your need to deal with 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, shouting that his time is as valuable as that of the doctor, and making a general nuisance of himself.
Options for the Practitioner
In the examination area, address your concerns about his behavior and state that this type of reaction will not be tolerated in the future. After you have completed his physical examination, you might 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 consider sending the patient a letter reiterating his decision to seek care elsewhere.
Assistance Is Available
The final decision about terminating a patient is the practitioner’s. The Doctors Company’s Department of Patient Safety and Risk Management is ready to assist you. We can discuss termination issues with you, send you sample letters, or help you develop special letters. Feel free to contact your patient safety risk manager at (800) 421-2368, extension 1243, or firstname.lastname@example.org.
Note: The medical/dental boards in many states have established guidelines or policies for discharging a patient. Make sure you review your state-specific guidelines as well as your managed care contracts.
By Susan Shepard, MSN, RN, Director, Patient Safety and Risk Management Education, and Richard Cahill, Esq., Vice President and Associate General Counsel, The Doctors Company.
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 in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.