Terminating Patient Relationships

Julie Brightwell, JD, RN, Director, Healthcare Systems Patient Safety, and Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company

A review of our call data shows that terminating patient relationships consistently appears as one of the top reasons that members request assistance from our Department of Patient Safety and Risk Management.

It may become necessary to end patient relationships that are no longer therapeutic or appropriate based on patient behaviors. It is critical, however, that the provider end the relationship in a manner that will not lead to claims of discrimination or abandonment.

Prior to terminating a patient relationship, consider addressing the underlying reasons for ending the relationship, including noncompliant/nonadherent conduct, mental competency, health literacy, language or cultural barriers, or financial restraints. (For strategies to address patient relations—the most common reason that members request assistance—read our articles “Nonadherent and Noncompliant Patients: Overcoming Barriers” and “Patient Relations: Anticipate and Address Challenging Situations.”)

If efforts to rehabilitate the relationship are not appropriate or unsuccessful, the criteria for terminating a provider-patient relationship require careful documentation in the patient’s record. Although the following list is not exhaustive, it is generally appropriate to end a relationship under the following circumstances:

Treatment nonadherence: The patient does not or will not follow the treatment plan or the terms of a pain management contract or discontinues medication or therapy regimens prior to completion.

Follow-up noncompliance: The patient repeatedly cancels follow-up visits or fails to keep scheduled appointments with providers or consultants.

Office policy nonadherence: The patient fails to observe office policies, such as those implemented for prescription refills or appointment cancellations, or refuses to adhere to mandated infection-control precautions.

Verbal abuse or violence: The patient, a family member, or a third-party caregiver is rude, uses disparaging or demeaning language, or sexually harasses office personnel or other patients, visitors, or vendors; exhibits violent or irrational behavior; makes threats of physical harm; or uses anger to jeopardize the safety and well-being of anyone present in the office.

Display of firearms or weapons: The patient, a family member, or a third-party caregiver wields a firearm or weapon on the premises.

Inappropriate or criminal conduct: The patient exhibits inappropriate sexual behavior toward providers or staff or participates in drug diversion, theft, or other criminal conduct involving the practice.

Nonpayment: The patient owes a backlog of bills and has declined to work with the office to establish a payment plan or has discontinued making payments that had been agreed on previously.

Exceptions and Special Circumstances

A number of situations may require additional steps or a delay before ending the patient relationship. Examples include the following situations:

• 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 diagnostic workup, it is not advisable to terminate the relationship.
• If the provider is the only source of medical or dental care within a reasonable driving distance, care may need to continue until other arrangements can be made.
• When the provider is the only source of specialized medical or dental care, treatment may need to continue until the patient can be safely transferred to another provider who is able to provide appropriate care and follow-up.
• If the patient is a member of a prepaid health plan, the practitioner must communicate with the third-party payer to request the patient’s transfer to another provider or otherwise comply with the specific terms of the payer-provider agreement.
• If a patient is pregnant. During the first trimester: End the relationship only if it is an uncomplicated pregnancy and the patient has time to find another practitioner. During the second trimester: only for uncomplicated pregnancies and only if the patient transfers to another practitioner prior to cessation of services. During the third trimester: only under extreme circumstances, such as illness of the provider. Effect a safe transition by working with the risk manager of the facility where delivery is scheduled.

Certain situations prohibit patient dismissal:

• Patients may not be dismissed or discriminated against based on limited English proficiency or status within a protected category under federal or state legislation, including race, color, national origin, sex, disability, and age. Examples of laws prohibiting discrimination—which carry significant civil and administrative penalties for violations—include the Americans with Disabilities Act (ADA), the Civil Rights Act, and the Affordable Care Act. (The Department of Health and Human Services outlines requirements for providers regarding nondiscrimination policies and notices.)

• A patient’s disability cannot be the reason 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 and safer approach.

Steps for Withdrawing Care

Establish a written policy and procedure with a standardized process that addresses interventions prior to ending the relationship and the steps to take if it becomes necessary to dismiss the patient. Ensure that approvals for any patient dismissal go through practice leadership and the assigned provider. Medical or dental groups may consider dismissing a patient from the entire practice. This avoids an on-call situation that might require the practitioner who ended the relationship to treat the patient.

When the situation for dismissing the patient is appropriate, provide a formal written notice stating that you are withdrawing care and requiring the patient to find another practitioner. Mail the written notice to the patient by both first-class and certified mail with a return receipt requested. (Both types of mailing are required in some states.)

Keep copies in the patient’s medical or dental record of all the materials: the letter, the original certified mail receipt (showing that 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

Include the following information in the written notice:

Reason: Although stating a specific reason for ending the relationship is not required, it is acceptable to use the catchall phrase “inability to achieve or maintain rapport,” state that “the therapeutic provider-patient relationship no longer exists,” or assert that “the trust necessary to support the relationship no longer exists.” If the reason for ending the relationship is patient noncompliance/nonadherence, that may be stated as well, along with your attempts to obtain patient compliance.

Effective date: The effective date for ending the relationship 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 written notice is usually considered adequate, follow your state regulations. The relationship may be ended immediately under the following circumstances:

• The patient has ended the relationship. (Acknowledge this in writing with a letter from the practice.)
• The patient or a family member has threatened the provider or staff with violence or has exhibited threatening behavior.
• The patient participates in drug diversion, theft, or other criminal activity involving the practice.
• The patient exhibits inappropriate behavior or sexual misconduct toward the provider or staff.

Interim care provisions: Offer interim emergency care prior to the effective date. For emergency situations that cannot be handled in the office, refer the patient to an emergency department or instruct the patient to call 911.

Continued care provisions: Offer referral suggestions for continued care through medical or dental societies, nearby hospital referral services, community resources, or the patient’s health plan network. Do not recommend another healthcare provider specifically by name.

Patient records: Offer to provide a copy of the office record to the new practitioner by enclosing a HIPAA-compliant authorization (to be returned to the office with the name and address of the new practitioner and the patient’s signature). One exception is a psychiatric record, which may be offered as a summary in many jurisdictions in lieu of a full copy of the medical record.

Transition of care: Indicate your willingness to speak with the patient’s new provider to help ensure a smooth transition.

Patient responsibility: Specify that the patient is personally responsible for all follow-up and for continued medical or dental care.

Medication refills: Explain that medications will be provided only up to the effective date that the relationship ends.

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 and 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 noncompliance, your attempts to address the patient’s reasons for noncompliance, your efforts to help the patient understand the risks of nonadherence, and the patient’s persistent failure to follow the treatment plan and advice.

Terminate the relationship if the patient and provider agree that the patient would achieve better conformity 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 the willful nonadherence with recommended treatment plans. Suggest that the patient would benefit from a relationship with another provider, and state that continued care is an absolute requirement.

Case Two

A new patient has made an appointment with your office for a complete 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. 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 provider.

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 condoned in the future. After you have completed his examination, suggest that he seek care elsewhere if he is reluctant to observe office decorum. If the patient indicates a refusal to comply, consider preparing and sending a letter terminating the relationship. If the patient fails to keep subsequent appointments or has notified your office that he will be seeking treatment with another provider, document the conversation and send the patient a letter confirming his decision to seek care elsewhere.

Assistance Is Available

The final decision about ending a patient relationship belongs to the practitioner. The Doctors Company’s Department of Patient Safety and Risk Management is ready to assist you. We can discuss patient dismissal issues, send you sample correspondence, or help you develop special letters for an individual situation. Contact your patient safety risk manager at (800) 421-2368 or by email.