The complexities of firing a patient, according to experts
Naveed Saleh, MD, MS|July 23, 2021
Physicians cherish caring for patients. The drive to help others is woven into the very fabric of medicine, as demonstrated by lines from the modern version of the Hippocratic Oath:
It doesn’t happen often, but occasionally it is necessary for a doctor to terminate a relationship with a difficult patient.
“I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug. … I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”
Physicians can help the vast majority of patients—even those who may appear to be challenging. Very rarely, however, terminating a patient relationship may be necessary. Let’s take a closer look at the issues surrounding this stark option.
The clinical encounter represents the culmination of the practice of medicine. It is more than a quotidian event, it is a moral activity that stems from an obligation to care for patients and alleviate suffering.
According to the AMA, “The relationship between a patient and a physician is based on trust, which gives rise to physicians’ ethical responsibility to place patients’ welfare above the physician’s own self-interest or obligations to others, to use sound medical judgment on patients’ behalf, and to advocate for their patients’ welfare. A patient-physician relationship exists when a physician serves a patient’s medical needs.”
Reasons to terminate care
Many physicians align their professional calling with their foundational beliefs and worldviews. Occasionally, the expectation to put a patient’s needs first may run counter to a physician’s moral code and disrupt his or her personal and professional life. In these cases, it may be necessary to terminate care.
“Preserving opportunity for physicians to act (or to refrain from acting) in accordance with the dictates of conscience in their professional practice is important for preserving the integrity of the medical profession as well as the integrity of the individual physician, on which patients and the public rely. Thus physicians should have considerable latitude to practice in accord with well-considered, deeply held beliefs that are central to their self-identities,” advised the AMA.
One reason to terminate care is when a patient expresses considerable disrespect to the physician and healthcare staff. For instance, the habitual hurling of invective, threats, and blame can undermine the clinic dynamic and upset providers and patients.
However, reasons to terminate care need not be so dramatic. Under “futility of care,” physicians can refuse care requests that are unsubstantiated by evidence-based medical judgment. Another futility of care example is continued nonadherence to treatment plans. If such issues become overbearing and unreasonable despite best efforts to resolve them, a physician can consider terminating care.
Before you decide to end the relationship, however, it’s important to try to work things out, according to a classic article on the topic from the AAFP.
“The first step to take when evaluating a potentially broken relationship with a patient may be a step backwards,” the authors wrote. “Unless the patient’s misconduct is severe, it is often productive to step back and consider whether you have done everything you reasonably can to salvage the relationship. Investing this extra effort has transformed some of our most challenging relationships into ones where the patients are engaged and invested partners in their healthcare and appreciative of the work of our staff and physicians.”
Patients may escalate their behavior when they feel they aren’t getting the services they expect or feel their needs aren’t being met, they added. It’s important to sit down with the patient with the intention of gaining a deeper understanding of the underlying expectations that are driving the behavior. “Some patients have unreasonable expectations, but for others, understanding the point they’re trying to make can go a long way in repairing the relationship,” they added.
While working things out with a patient, it may help to bring in an outside resource, such as an office manager, to facilitate communication. Moreover, another person may also add perspective and make constructive recommendations not immediately apparent to the provider.
How to terminate care
Unlike the excruciating calculus of deciding to terminate care, the termination process itself is relatively straightforward. The key is not to “abandon” the patient and his or her needs, as well as obviating any risk of litigation.
According to the California Medical Board, “In general, the physician-patient relationship can be terminated in two ways without creating liability for abandonment: 1) the physician ends the relationship after giving the patient notice, a reasonable opportunity to find substitute care and the information necessary to obtain the patient’s medical records, or 2) the patient ends the relationship.”
Physicians must send written notice to a patient via certified mail, with a return receipt requested. It’s imperative that the physician continues to care for the patient until an alternative source of care is found. The duration of continued care depends on the severity of the patient’s medical conditions, access to suitable alternative care, and the patient’s ability to afford this care.
Since the United States is a highly litigious country, it may be worth consulting a lawyer before terminating a patient relationship. Employed physicians should contact the legal team representing your institution.
On a final note, hopefully, most doctors will never have to terminate a relationship with a patient. Building a trusting and open relationship with patients to begin with can go a long way when trying to de-escalate conflicts that may arise down the road. And, as it turns out, it’s also key to avoiding litigation.