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 noncompliance—The patient does not or will not follow the treatment plan.
- Follow-up noncompliance—The patient repeatedly cancels follow-up visits or is a “no-show.”
- Office policy noncompliance—The patient uses weekend on-call physicians or multiple health care providers to obtain refill prescriptions when office policy is for 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 made no effort to arrange a payment plan.
These examples are only a few of the situations that physicians encounter. If you experience these or different situations that are of concern, please contact your risk manager or the Department of Patient Safety.
Terminating Patient Relationships and Minimizing Liability
It is acceptable practice to end a patient relationship under most conditions. There are a few situations, however, which may require additional steps or a delay in 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 physician is the only source of medical care within a reasonable driving distance, he or she may need to continue care until other arrangements can be made.
- When the physician is the only source of a particular type of specialized medical care, he or she is obliged to continue this care until the patient can be safely transferred to another provider 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 physician has communicated with the third-party payor to request a transfer of the patient to another physician.
- A patient may not be terminated solely because he or she is diagnosed with AIDS/HIV.
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 formally completed. The patient should be put on written notice that he or she must find another health care provider. The written notice should be mailed to the patient by regular and certified mail, return receipt requested. Keep a copy in the patient’s medical record 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).
Elements of the Written Notice:
- Reason for termination—A specified reason for termination is not required. Under certain circumstances, it is acceptable to utilize the catchall phrase “inability to achieve or maintain rapport,” or “the therapeutic physician/patient relationship no longer exists.”
- Effective date—The effective date of termination should provide the patient with a reasonable period of time to establish a relationship with another provider. Usually, 30 working days from the date of the letter is considered adequate time. 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 physician 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 societies, nearby hospital medical staffs, or community resources. Do not recommend another health care provider by name.
- Request for medical record copies—Offer to provide a copy of the medical record to the new provider by enclosing an authorization document (to be returned to the office with the patient’s signature) with your letter. 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 care are now the patient’s responsibility and that both should be pursued.
Special Circumstances
- Pregnant patient—Termination can be safely accomplished during the first trimester with uncomplicated pregnancies and with adequate time for the patient to find another provider. Termination in the second trimester should occur only for uncomplicated pregnancies and with transfer of the patient to another obstetrical provider prior to actual cessation of services. Termination during the last trimester should occur only under extreme circumstances (such as illness of the provider, etc.).
- Physician groups—Groups with more than one physician may want to consider termination of a patient to include termination from the entire practice. This will avoid the possibility that the patient might be treated by the terminating physician during an on-call situation.
- Disabled patients—The presence of a 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 physician. Transferring care to a specialist who provides the particular care is a better approach.
Case Examples
The following scenarios illustrate some of the issues involved in patient termination:
Case 1
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 noncompliance, and you have rescued the patient on many occasions with emergent medications, usually in the local ED over a weekend. You are convinced that the patient understands but stubbornly refuses to comply.
Should This Patient Be Terminated from Your Practice?
Documenting your recommendations, the patient’s continued noncompliance, and that the patient understands the risks of noncompliance are essential with any noncompliant patient. Terminate the relationship if the patient and physician agree that the patient would achieve better compliance with another provider. The written notice terminating the relationship with this patient should be explicit in stating the reason you are no longer willing to provide care—that because of the patient’s noncompliance with recommended treatment plans, the patient’s outcome is predestined to be unfavorable. You should suggest that the patient would benefit from a relationship with another physician and that continued medical care is an absolute requirement.
Case 2
A new patient has made an appointment with your office for a full and complete physical examination. The patient experienced an unusually long wait before the appointment as a result of an urgent situation with an infant.
Your office personnel have explained the delay to those in the waiting room and this new patient has 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 Physician
In the examination room, 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 he will be seeking care with another physician, document that conversation and consider sending the patient a letter reiterating his decision to seek care elsewhere.
Assistance Is Available
The final decision of whether or not to terminate a patient is the physician’s. As always, The Doctors Company’s Department of Patient Safety is ready to assist you. We will be happy to discuss termination issues with you, send you sample letters, or help you develop special letters. When in doubt, feel free to call on your risk manager at (800) 421-2368, extension 1243.
Note: The state medical boards in many states have established guidelines or policies for discharging a patient, and it is always advisable that physicians familiarize themselves with and follow these guidelines or policies. It is also important that the practice knows the requirements of its managed care contracts.
By Laura A. Dixon, BS, JD, RN, CPHRM, Director, Department of Patient Safety, Western Region.
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 health care 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.