Dismiss a problem
 patient in 10 safe steps

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Dismiss a problem
 patient in 10 safe steps
Dismiss a problem
 patient in 10 safe steps

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At a glance

  • Providers may become concerned about being blamed for a poor outcome when a patient is continually noncompliant with prescribed interventions.
  • Discontinuing patient-provider relationships should be undertaken only after a serious attempt has been made to clarify and understand the expectations and concerns of all involved parties.
  • Having a guided pathway available to protect oneself and staff from unfortunate patient situations will result in better patient outcomes, better delivery of care, and better business overall.

''Firing a patient" has become common in the modern health-care environment. The phrase can be seen in print or heard uttered by exasperated providers in reference to individuals who have become "problem patients."1,2 These are patients who fail to complete indicated tests, refuse necessary treatments, miss appointments, do not pay bills, are rude, unreasonably demanding, dissatisfied, dishonest, threatening, violent, or litigious.3

When the relationship is unable to continue towards a therapeutic goal, termination may become an attractive option for both parties.2,4 A provider may become concerned about being blamed for a poor outcome when a patient is continually noncompliant with prescribed interventions.5

A conflict of interest may arise between the provider and the patient (e.g., a financial investment or familial relation) that makes termination of the relationship an ethical and legal necessity. Termination of the relationship may even be necessary for such benign reasons as the patient changing insurance carriers or the relocation or retirement of the clinician.6

This discussion will focus on the nurse practitioner or physician assistant as a primary provider of outpatient services and the patient as an established recipient of the provider's care.



Protecting yourself


Although there are no formal laws against a provider terminating a patient relationship for nondiscriminatory reasons,1,7 certainly ethical concerns exist, but these are beyond the scope of this article. However, such valuable resources as time, money and manpower can be diverted away from one's profession when terminating a patient becomes a legal issue in defense against litigation arising from accusations of abandonment.8

Practitioners may feel compelled to continue a relationship that they would prefer to terminate, out of fear of legal reprisal or simply not being aware of alternatives.9 Knowing how to protect oneself, one's business, and one's profession from nontherapeutic relationships can result in a safe and productive practice environment.


The American Medical Association (AMA) has formally addressed this issue by outlining legitimate reasons for dismissing a patient and offering a protocol for dismissal that advocates safety in patient care as well as legal protection for the provider.6 The American Academy of Physician Assistants (AAPA) offers general guidance, but no specific protocol. The AAPA guide states, "A PA...may discontinue their professional relationship with an established patient as long as proper procedures are followed. The PA...should provide the patient with adequate notice, offer to transfer records, and arrange for continuity of care if the patient has an ongoing medical condition. Discontinuation of the professional relationship should be undertaken only after a serious attempt has been made to clarify and understand the expectations and concerns of all involved parties."10

Having studied in Texas, I am familiar with the state's regulations. The Texas Administrative Code, which defines the scope of practice and rules of NPs, is silent on the issue of terminating the clinician-patient relationship.11 The Texas Board of Nursing addresses patient abandonment from employment and licensure perspectives but with verbiage more suited to bedside or inpatient nursing care. The board does not speak to dismissing a patient as a primary provider in the advanced practice role.12

If a relationship has never been established, abandonment cannot be construed.13 The AMA defines abandonment of an established patient as, "the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement."6 To prove abandonment, three items must be demonstrated: (1) termination must not have been mutual; (2) termination transpired without reasonable notice; and (3) the need for care remained.8 The AMA suggests that 30 days' time is a "reasonable notice."6 Thirty days' notice was also cited as good risk management by a malpractice insurer.14

In the absence of an official guideline for the termination of the NP/PA-patient relationship, I propose the following 10-point plan:


  1. Develop a policy for provider-patient termination that is made available to patients at the initiation of service.14
  2. Keep accurate and detailed documentation.6,7
  3. Speak with the patient prior to making a final decision regarding the relationship termination, and consider sending a “pre-withdrawal letter” that gently expresses your concern over his or her noncompliance.5
  4. Discuss the situation with a colleague, risk-management professional, or legal advisor.9
  5. Explain to the patient that he or she is being terminated from care, and provide an explicit reason. Do not delegate this task; speak directly with the patient.4,15,16
  6. Inform clinic staff of the termination.14
  7. Send a certified letter with return receipt17 to the patient and the insurance carrier16 stating the termination, and that care will be discontinued in thirty days' time, noting the specific date.18
  8. Offer the patient interim care.6
  9. Provide names and contact information for suggested potential alternate providers.19
  10. Offer to transfer records when given written permission.6

Establishing national guidelines for NPs and PAs


The American Nurses Association's (ANA) Code of Ethics and Scope and Standards of Practice can certainly provide ethical guidance to the NP concerning the patient relationship.20,21 The National Commission on Certification of Physician Assistants' Code of Conduct for Certified and Certifying PAs22 and the AAPA's Guidelines for Ethical Conduct for the Physician Assistant Profession10 can inform PAs regarding ethical conduct within the provider-patient relationship. Of course since there is no official legal guidance to NPs or PAs regarding termination of relationships, observing guidelines already established by the AMA is appropriate.7

Developing and incorporating guidelines similar to the AMA protocol into a national template for midlevel providers would involve input from the ANA and AAPA similar to the processes used in past revisions of their guidelines. Input would be needed from individual NPs and PAs, specialty organizations, major stakeholders and focus groups. The newly created standard would need to be reviewed and approved by the ANA Congress on Nursing Practice and the AAPA Board of Directors.


Having a guided pathway available to protect oneself and staff from unfortunate patient situations will result in better patient outcomes, better delivery of care, and better business overall. Embracing established steps to terminate a patient relationship can help prevent vulnerability to claims of abandonment. Finally, being aware of an existing alternative to staying in a negative patient-provider relationship will offer the NP and PA increased autonomy in practice.

Roslyn Walden, MSN, FNP-BC, is a family nurse practitioner in Las Cruces, N.M.


References


  1. Kern SI. Discharging the problem patient. Med Econ. 2008;85:32.

  2. Parikh RK. Showing the patient the door, permanently. New York Times. June 10, 2008. Available at
  3. American Medical News. Take care when firing a patient.
  4. Gianola FJ. Terminating your professional relationship with a patient. JAMA. 2009;22:57-58. 

  5. Chiropractic Economics. How to fire a bad patient.
  6. American Medical Association. Ending the patient-physician relationship. 
  7. Smith JA. Terminating the provider-patient relationship. Nurse Pract. 2005;30:58-60.

  8. Fishbain DA, Lewis JE, Gao J, et al. Alleged medical abandonment in chronic opioid analgesic therapy: case report. Pain Med. 2009;10:722-729.

  9. Mossman D, Farrell HM, Gilday E: 'Firing' a patient: May a psychiatrist unilaterally terminate care? Curr Psychiatry. 2010;9:18-29.

  10. Nelson RL; AAPA. Guidelines for ethical conduct for the PA profession. JAAPA. 2001;14:10-2, 15-6, 19-20.

  11. Texas Administrative Code, 22 TX Sec of State § 11.
  12. Texas Board of Nursing Board Rules Associated with Alleged Patient "Abandonment."
  13. Buppert C. Nurse Practitioner's Business Practice and Legal Guide, 3rd ed. Sudbury, Mass.: Jones and Bartlett; 2007:479.

  14. Greenwald L. Terminating the physician-patient relationship. 
  15. NSIDE MD. Firing a patient: Recognizing the signs and symptoms and prescribing an effective treatment. 
  16. Willis DR, Zerr A. Terminating a patient: is it time to part ways? Fam Pract Manag. 2005;12:34-38. 
  17. O'Brien, L. When a patient refuses your dismissal letter. Med Econ. 2008;85:58. 

  18. Borglum K, Martin V, Kern SI. Liability issues after dismissing a patient. Med Econ. 2008;85:46.

  19. O'Brien, L. Defense against abandonment charges. Med Econ, 2005;82:116.

  20. American Nurses Association. Nursing: Scope and standards of practice.
  21. American Nurses Association. Code of ethics for nurses with interpretive statements.
  22. National Commission on Certification of Physician Assistants. Code of conduct for certified and certifying PAs. 

All electronic documents accessed May 15, 2012.


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