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:
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.
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:
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.
A notice should include:
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.
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.
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.
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.
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.