'Firing' a Patient: May a Psychiatrist Unilaterally Terminate Care?

Article excerpt

Dear Dr. Mossman:

One of my patients, Ms. A, keeps calling in to refill her prescription, but will not come in for an appointment; she needs the medication, but I really shouldn't keep prescribing it without seeing her. Another patient, Mr. B, has an open chart, but he stopped seeing me last year after I treated him for an acute depressive episode. May I "fire" these patients? If so, what should I do?

[ILLUSTRATION OMITTED]

Submitted by "Dr. C"

All physicians occasionally encounter patients whom we'd like to stop treating, but because we feel devoted to those we treat, the idea of "firing" a patient makes us uncomfortable. Sometimes, however, ending a treatment relationship is the right choice for the doctor and patient. (1)

To know why, how, and when you may terminate your professional relationship with a patient, you need to:

* understand the legal and ethical status of a doctor-patient relationship

* know the proper way to end treatment relationships

* decide whether ending your care of the patient is the right medical and ethical choice.

After exploring these points, we'll return to the cases of Ms. A and Mr. B and consider what Dr. C might do.

Doctor-patient relationships

Legal and medical authorities characterize the treatment relationship as an implicit contract that imposes certain obligations on the doctor and the patient. (2), (3) Doctors are compelled to conduct themselves in accordance with the prevailing "standard of care." Patients' obligations include being honest and cooperating with care once they have agreed to a treatment plan (Table 1, page 20) (3).

Table 1

A patient's responsibilities

Being truthful

Providing a complete medical history

Cooperating with agreed-upon treatment and keeping appointments

Meeting financial obligations for medical care

Health-enhancing behavior

Not participating in fraudulent health care

Source: Reference 3

Patients may stop seeing their doctors at any time, but a physician usually must continue to provide all necessary medical attention until either the treatment episode has concluded or both parties agree to end the doctor-patient relationship. (2) If a physician wishes to withdraw from a case before the need for services has ended, the physician must either make arrangements for another competent physician to assume care or give the patient ample notice and opportunity to obtain treatment elsewhere. (2) If a doctor fails to do this and harm to the patient results, the doctor is guilty of "abandonment," legally defined as termination of the physician-patient relationship "at an unreasonable time or without affording the patient the opportunity to procure an equally qualified replacement." (2) Physician abandonment can lead to malpractice liability, (4) complaints to state licensing authorities, (5) and ethical condemnation. (6)

Terminating without abandoning

Doctors commonly terminate care of their patients when they decide to move or close their practices. Accusations of abandonment may arise if such career decisions are executed improperly, but these matters are not as emotionally troubling for physicians as a decision to "fire" a patient because of the patient's behavior. Common, legitimate reasons a doctor may consider unilateral termination appear in Table 2. (7), (8)

Table 2

Common reasons to consider terminating a patient's care

Failing to pay bills

Repeatedly cancelling or missing appointments

Repeatedly failing to follow the agreed-upon treatment plan

Overly demanding, rude, disruptive, threatening, or violent behavior toward staff or other patients

Patient is very dissatisfied with care

Needing specialized services that the physician cannot provide

Filing a complaint or legal action against the physician

Dishonesty that compromises safety or legality of treatment

Physician feels treatment is ineffective

Conflict of interest (eg, physician's religious beliefs preclude providing certain treatments that might be indicated)

Developing and acting upon an inappropriate personal interest in the physician

Inappropriate response by physician to feelings about the patient (eg, physician feels tempted to act upon an attraction)

Source: References 7, 8

Certain circumstances are not valid grounds for terminating a doctor-patient relationship. …