Physicians Can Be at Risk When Homebound Patients Refuse Help

Richard F. Cahill, JD, Vice President and Associate General Counsel

More than ever, physicians are focusing on treatment plans that include care that patients need at home. Physicians, however, face potential liability when patients refuse help that is offered or neglect to follow up as instructed. If a patient sues, even a verdict in favor of the physician does not negate the time, expense, damage to reputation, adverse social media publicity, or emotional impact of a lawsuit.

Case Example

A 67-year-old male with a history of obesity, hypertension, hypercholesterolemia, atrial fibrillation, and cardiovascular disease saw the same physician for 20 years. During one hospitalization, the patient was put on the anticoagulant Coumadin. The physician and the discharge nurse both educated the patient and his wife about the risks of Coumadin use and the importance of having blood work done every month. The conversations were appropriately documented in the medical record.

Nevertheless, the patient did not keep his first monthly appointment to check his international normalized ratio (INR). The physician’s staff called to schedule a follow-up visit, but the patient did not return the call. Two days following the call, the patient fell at home. His wife took him to the emergency department, where she told the staff that she had been unable to drive him to his appointment for blood work, but she had made sure he took his Coumadin as prescribed. The patient’s INR was 8.8—an extremely elevated reading (the therapeutic range for individuals on Coumadin is generally 2 to 3). The patient was diagnosed with a bilateral subdural hematoma and underwent a bilateral craniotomy. He was discharged home. Secondary to problems with coordination and confusion, he presented to the emergency department several more times over the next few months.

The patient sued for medical malpractice, claiming that the physician failed to properly manage his medication regimen and monitor his blood levels, resulting in the fall, subsequent injury, and poor recovery. He also claimed that the physician neglected to warn him of the risk of bleeding when taking Coumadin.

The case went to trial after extensive discovery had been conducted. Because of the thorough documentation, the jury agreed that the physician had properly educated the patient and made the appropriate resources available to monitor the effects of the Coumadin. The jury also found that the patient’s failure to schedule necessary lab appointments and then follow up with an in-office visit to discuss his medical condition as instructed was the cause of the injury. Accordingly, a defense verdict was rendered in favor of the physician.

Case Discussion

While this patient neglected to follow physician instructions, other homebound patients simply decline any help. A recent study found that between 6 percent and 28 percent of patients eligible for home healthcare refuse these services. Unfortunately, similar trends have been identified with other types of assistance for patients confined at home. Patients often say that they are managing just fine and don’t need help. Some individuals report that they do not want strangers in their homes due to fear of harm or infectious disease or that they worry about the cost of co-pays for home care. That means many patients are not getting the necessary follow-up and support that the physician outlined in the treatment plan. When a patient declines follow-up as instructed—for whatever reason—the clinician can be at increased risk for professional liability exposure.

Patient Safety Strategies

Consider the following strategies to help reduce potential patient safety and malpractice risks when treating homebound patients:

• Conduct a risk analysis to determine how likely the patient is to comply with medical instructions. Take into account the patient’s age, mental capacity, ability to drive, independent living status, whether the patient provides self-care or requires a caretaker, and any prior history of failing to comply with appointments, medication instructions, or orders for specialty referrals, diagnostic studies, therapeutic interventions, or other treatment regimens.
• Schedule the follow-up appointment before the patient leaves the office, and provide written documentation to the patient to reinforce all verbal instructions.
• Use the “Teach-Back” method to confirm patient understanding of home care and follow-up instructions.
• Provide telehealth services, if possible, if patients are unable to keep scheduled appointments or refuse home health provider visits. 
• Provide the patient and family with contact information for community home health resources. 
• Educate the patient about why community resources are provided, and draw a distinction between what is and is not offered. 
• Document the following actions:
• The patient received and understood verbal and written instructions.
• Resources were made available to overcome compliance challenges.
• The physician or practice made a good-faith effort to follow up and intervene if the patient was not in compliance. 

Patient reluctance to follow a treatment plan is often caused by a lack of understanding about what type of follow-up care is needed. Taking the time to document patient discussions gives home care providers valuable information to ensure that patients are following the plan—and it will also demonstrate, in the event of a lawsuit, the high quality of care that was provided.