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Terminating a Patient Relationship
| Response from Carolyn Buppert, MSN, JD
Occasionally, a patient can be a liability. That is, a patient's behavior can put a clinician at a disadvantage. For example, some people are unreliable about returning for follow-up, some fail to get diagnostic tests or consultations that the clinician believes are necessary, and some don't follow instructions or recommendations. Yet the individual keeps returning, although maybe not on schedule.
And then there is the patient who is on a controlled drug for chronic pain, has signed a contract in which he has agreed to give 72-hour notice when needing refills, to keep logs of daily functional status, and to use only one pharmacy and only one prescriber. The clinician finds out that the patient has been getting prescriptions for controlled drugs from another provider. The clinician is worried that the patient will overdose. If that happens, the prosecutorial spotlight will turn onto the clinician. That patient has become a liability, not only to himself but also to the clinician and the clinician's employer.
To reduce this risk, the clinician's best choice, at times, is to fire the patient. How can a clinician terminate a professional relationship with a patient?
There are several steps to follow.
1. Write the patient a letter, stating:
The practice is terminating the patient/provider relationship as of a stated date 30 days from the date of the letter.
The practice will provide services until the date stated.
The patient's record will be sent to another clinician, on request.
This information may be communicated orally, but even if terminating the patient relationship face-to-face, follow up with a letter. File a copy of the letter in the patient's chart. Send the letter certified, return-receipt requested. If the patient refuses the letter, file the unopened envelope in the patient's chart and send another letter via regular mail. Note in the patient's chart that a second letter was sent, the method of delivery, and the name of the sender.
As of the date of termination, stop seeing and talking with the patient, except as necessary to provide medical records. If a scheduler doesn't realize that the patient has been terminated and books an appointment, then the clinician must see the patient, and can then reterminate the relationship.
The clinician need not state the reasons for discharging the patient but may want to.
The clinician is not required, generally, to set the patient up with another clinician. Note, however, that state medical/nursing boards may have policies on this. For example, the California Board of Medicine says that the terminating physician should notify the patient of "alternative sources of medical care" (ie, refer the patient to other physicians, by name, or to the local medical society's referral service.) Practically, referring the patient to the local medical society's referral services might be best, because fellow clinicians may not be happy to be the alternative source, if the patient is being terminated for being a liability. On the other hand, if the terminating clinician can find another appropriate provider who is willing to take on the patient, then the terminating provider may send the patient to the new provider right away and need not provide 30 days' notice. The point is that the patient needs to be given reasonable notice and/or contacts and should not be left high and dry.
If the patient owes money to the practice, collections efforts may continue. However, the practice cannot use lack of payment as a reason to withhold the patient's chart from the patient or the patient's next provider.
2. Do not discharge a patient because the patient has an unappealing disease, or because of race, national origin, disability, or handicap. If the patient is outside the clinician's scope of practice, then the discharge from care is not only appropriate but necessary. However, civil rights laws prohibit discrimination against patients on the basis of certain Constitutionally protected attributes.
3. Do not terminate a relationship with a patient who is in an acute episode of illness or in the third trimester of pregnancy. If the patient is an outpatient in the midst of a flare-up of heart failure, wait until the episode has stabilized before terminating the professional relationship. It is inappropriate and against federal law for clinicians to refuse to treat patients who present themselves at an emergency department.
What legal recourse does a patient have if a clinician fires the patient?
A fired patient has a choice of three possible legal actions: (1) file a lawsuit on the basis of negligence (malpractice); (2) file a complaint under the Americans With Disabilities Act on the basis of discrimination; or (3) report the clinician to the licensing board for patient abandonment. If a clinician covers the bases stated earlier, the patient will have no basis for any of these actions.
The elements that a patient must prove to mount a successful case against a clinician on the basis of negligence are:
Duty of care (a patient-clinician relationship was established);
Breach by the clinician of the standard of care;
Injury to the patient; and
Causal relationship between the injury and the breach of the standard of care.
A clinician who starts seeing a patient has a duty to attend to the patient's needs until the patient terminates the relationship, the clinician terminates the relationship, the clinician transfers the care to another clinician (because, for example, the patient needs a specialist), or the patient is healthy (no further care is medically necessary). For patients and clinicians in emergency departments or urgent care clinics, the duty of care ends when the patient leaves. But in office practice, once a clinician takes on a patient's care, the clinician has a duty to respond to the patient's needs and act within the standard of care.
If a clinician stops seeing a patient without giving the appropriate notice, the patient can sue the clinician for negligence if the patient suffers a preventable injury due to lack of medical attention. For example, let's say a clinician no longer wants to treat a patient who has been getting multiple prescriptions for controlled substances from multiple providers. Rather than officially terminating the patient-clinician relationship, the clinician just refuses to take the patient's calls and instructs the receptionist to say that the clinician is "out." If the patient has an adverse reaction to one of her medications and suffers an injury that is attributable to the reaction, the patient may have just cause for suing the clinician. The patient's attorney would argue that the clinician was negligent, saying (1) the clinician owed the patient a duty of care, (2) the clinician breached the standard of care (which calls for returning patients' telephone calls), (3) the patient suffered an injury, and (4) the injury was related to the clinician's inattention to the patient's telephone calls.
By firing a patient, the clinician is terminating his or her duty to the patient.
The Americans With Disabilities Act (ADA) gives federal civil rights protections to individuals with disabilities. It guarantees equal opportunity for individuals with disabilities in public accommodations, employment, transportation, state and local government services, and telecommunications. A public accommodation is facility, whether public or private, used by the public. Places of public accommodation include doctors' offices, dentists' offices, and hospitals.
Under the ADA, it is discrimination to fail to give a person with a disability the equal opportunity to use or enjoy the public accommodation's goods, services, or facilities. An example of an ADA violation would include a clinician who categorically refused to treat all persons with HIV/AIDS. More information on what the ADA covers can be found here.
The Civil Rights Act of 1964 prohibits discrimination by places of public accommodation on the basis of race, color, religion, or national origin. A practice may not discharge a patient because of race, color, religion, or national origin. For more discussion on this, see The Refusal of Care.
Licensing boards, medical societies, and malpractice cases focus on the need for patients to have reasonable notice or access to an alternative provider when a clinician wants out. If the clinician provides the patient with reasonable notice of termination and does not terminate the relationship at a time when the patient is in need of care, then there is no patient abandonment. Although a patient who is terminated might report the terminating clinician to the licensing board, if the clinician provides documentation of adequate notice, the licensing board should dismiss the complaint.
Obviously, it makes no sense for clinicians to fire patients frequently and without giving the matter serious consideration. It can be bad for business and create wear and tear on the psyche, for both clinician and patient. Clinicians should spend time trying to discover why a patient is noncompliant and address these hurdles before terminating the relationship. However, in some cases, firing a patient is a positive step, in that it terminates a duty to a patient who is exceptionally risky, stops the flow of uncompensated care, or cuts off a patient who is abusing drugs.
Medscape Internal Medicine © 2018 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: How to 'Fire' a Patient - Medscape - Jul 17, 2018.