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Terminating patient relationships appropriately

By James W. Saxton, Esq

There is not a physician’s practice in existence that doesn’t have conflicts with patients from time to time, especially in contemporary times where patients’ expectations of what they deserve when visiting a physician’s practice have grown out of line with reality. Patients want their care quicker, quieter, more conveniently, without complication and, of course, inexpensively! Further, when patient’s expectations are not met, there is another profession ready to help them follow-up on their rights.

Practices are and should be doing more in an attempt to meet patients’ expectations or provide an environment where patients feel cared about and listened to. This in itself will reduce liability exposure and makes sense from a practice management point of view. This will be even more true in the future when market share may well be in part determined by patient satisfaction.

However, notwithstanding practices’ attempts to meet these expectations, sometimes serious conflicts with patients do arise and it becomes appropriate to discuss the issue of patient discharge.

Let’s consider both the risk management as well as legal implications of patient discharge. In other words, under what circumstances is a patient discharge appropriate and, when this circumstance arises, what legal concerns need to be addressed? It is important to save discharging the patient for extreme situations and when doing so following certain rules so you do not expose yourself to liability.

First, patients that are just difficult for the physician or the staff to handle are probably not appropriate candidates for discharge. These individuals will always be a certain percentage of your patient population. If anything, these are patients with whom you need to work hard to establish a relationship.

Trying to rehabilitate these patients if at all possible is the best policy. In fact, one of the major reason for professional liability lawsuits is because patients feel disconnected and do not truly understand their treatment course or the care which is being offered to them. Working hard to bring a disconnected patient back on board is worthwhile.

However, patients who are continually noncompliant or unwilling to follow the treatment path you have prescribed puts you and them at great risk and is an appropriate circumstance to consider discharge. Attempts should be made to let those patient know the consequences of their actions, both to their health and to your relationship with them. Often this will be effective, but if the behavior continues, discharge would be the next step.

Here lies an important risk management concept. When discharging a patient it ought to be done such that the reader of the discharge letter will feel that, to a great extent, the discharge is for the patient and not solely the practice. In essence you are saying to the patient that the physician-patient relationship is very important and that for reasons you will enumerate, you have been unable to effectively create this relationship, or something has happened which has so hampered the relationship it is now ineffective. Therefore, you are terminating it and asking the patient to attempt to find a physician with whom that all-important relationship can be created. This probably doesn’t feel as good as simply “firing” a patient, but in the end it provides you with the protection you may need to reduce the potential of a claim of unprofessional conduct or medical negligence with a claim of abandonment.

Other appropriate circumstances for discharge include: chronic missed appointments, sexual advances and even non-payment of a professional fee. The latter is perhaps the most difficult and should only be considered after all attempts at payment arrangements have been exhausted.

When discharging a patient, some general rules should be strictly followed. Write to the patient using certified mail. This is not required, but notice to the patient is, and certified mail enables you to have appropriate evidence of the notice. Let the patient know what has occurred that mandates the termination of the physician-patient relationship. Hopefully, you will have warned the patient in the past that the relationship termination could occur so as to provide yourself with a paper trail.

Be specific as to the reasons, whether they are missed appointments, advice not followed, medications not taken or non-participation in therapy. Encourage the patient to properly follow up and find another provider. Give the name of a hospital hotline that provides information about physicians or your local medical society’s phone number. Let the patient know that they need to continue to seek treatment for their underlying illness or follow up as necessitated by the circumstances. Offer to see the patient for the next 30 days for emergent conditions. Let the patient know that you will help with this new transition once an appropriately executed release is received.

After you send this letter, expect a phone call from the patient. Many will be angry and hurt, even if they have abused your practice for many years. Others will try to win themselves back into your practice. As a general rule it is best to resist those efforts. There is little doubt that you will end up with the same problem again in the future. There are, of course, exceptions. But if you have gotten to the point where you need to discharge a patient and have sent the letter described above, there is little hope for truly mending and continuing the relationship.

Further, you have not addressed the underlying issues that led to the problem in the first place. The patient needs to know that there are consequences for their actions. Often they will develop a better relationship with the next provider, which may mean that they become more compliant or cooperative. No patient wants to be discharged and need to relocate where their care is going to be provided. Stick to your guns for both them and yourself.

Patient discharge has serious implications. If done incorrectly, the patient can make a claim of abandonment. An abandonment claim means leaving a patient without appropriate care or guidance while the physician-patient relationship exists. An abandonment claim has serious implications since there could further be a claim of unprofessional conduct and the Bureau of Professional and Occupational Affairs could become involved. Further, a lawsuit could be instituted. The claim of abandonment could lead to a claim for punitive damages not insured in the Commonwealth of Pennsylvania. When a discharge occurs patients can also be bitter and consider other possible bases for a professional liability claim.

Good documentation reduces the potential of a malpractice claim more than we realize.

James W. Saxton, Esq., is chairman, Healthcare Litigation Group, Stevens & Lee.

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