Terminating Patients for Disruptive Behavior
Dennis Boyle, M.D.
COPIC Department of Patient Safety and Risk Management
CASE STUDY 1
A 35-year-old patient “no showed” for her appointment the third time in a year. Your office has a firm policy of termination after three missed appointments (without proper notification to office staff). You have clearly discussed this policy with the patient at two previous visits with no apparent change or good explanation for her nonadherence. You decide to discharge her…
CASE STUDY 2
A 60-year-old patient is openly frustrated in the office waiting area. Previously, he was involved in a couple of incidents where he was abusive and threatening to the front desk staff. During this latest encounter, he loudly muttered that he is going to bring a gun to his next visit. You decide to discharge him….
These two case studies provide examples of situations where there is a question about how to terminate the provider-patient relationship. In the practice of medicine, there are several situations where the patient relationship has deteriorated to the point where terminating the relationship is a relevant option.
In these cases, it is vital to end the relationship in an appropriate manner. The relationship itself is voluntary, so ending it may be appropriate, but it is necessary to proceed properly to avoid a claim of abandonment. Ending the provider-patient relationship typically revolves around situations that include:
Patient nonadherence
No shows to appointments
Bill nonpayment
Abuse and/or threatening behavior
Before getting to the point of termination, providers should make an effort to repair the relationship, particularly when it involves nonadherent conduct or financial issues. Other more extreme situations, such as threats of violence, may call for quicker action in terminating the relationship.
Things to Consider Before Termination
When you decide to discharge the patient there are a number of issues to consider:
Abandonment—Allegations of abandonment are the most serious consideration and the one most likely to be considered by your state medical licensing board. The patient must be in a stable condition. You must give adequate notice and be available for emergency care, generally for 30 days. Records should not be withheld and should be expeditiously provided to the next clinician, even if there are monies owed. Examples of situations that may require longer times before termination include a hospitalized patient, a patient in late pregnancy, an immediate post-op patient or someone receiving chemotherapy. In these situations, it may be necessary to arrange for further care.
Discrimination—Termination may not be based upon gender, race, religion, disability, ethnic origin, national origin, or age. Disability status can be complex and contentious.
Contract issues—Be cautious when terminating patients who are members of managed care plans. Your contracts with health plans might specify the manner of termination with a member patient. This is especially true if the method of payment is capitation. Plans might need notification of the reason for termination to prevent allegations of dismissing a patient because he or she is “too expensive to treat.” The patient might also have different time constraints for the health plan to complete reassignment to a new physician. Medicaid has a specific process for termination of Medicaid patients, and health care professionals need to consult their provider participation agreement for details.