While a last resort, termination of a patient is sometimes required. Termination must be done carefully in order to avoiding worsening a patience physical condition and to avoid lawsuits.
The following is a partial list of situations in which termination is appropriate and acceptable:
•Treatment nonadherence – The patient does not or will not follow the treatment plan.
•Follow-up nonadherence – The patient repeatedly cancels follow-up visits or is a no show.
•Office policy nonadherence – The patient uses weekend on-call physicians or multiple physicians to obtain refill prescriptions when office policy specifies a certain number of refills between visits.
•Verbal abuse—The patient or a family member is rude and uses improper language with office personnel, exhibits violent behavior, makes threats of physical harm, or uses anger to jeopardize the safety and well-being of office personnel or other patients with threats of violent actions.
•Nonpayment—The patient owes a backlog of bills and has declined to work with the office to establish a payment plan.
The following circumstances require additional steps or a delay of the termination:
•If the patient is in an acute phase of treatment, termination must be delayed until the acute phase has passed. For example, if the patient is in the immediate postoperative stage or is in the process of medical workup for diagnosis, it is not recommended to end the relationship.
•If the physician is the only source of medical or dental care within a reasonable driving distance, he or she may need to continue care until other arrangements can be made.
•When the physician is the only source of a particular type of specialized medical or dental care, he or she is obliged to continue this care until the patient can be safely transferred to another physician who is able to provide treatment and follow-up.
•If the patient is a member of a prepaid health plan, the patient cannot be discharged until the physician has communicated with the third-party payer to request a transfer of the patient to another physician.
•A patient may not be terminated solely because he or she is diagnosed with AIDS/HIV or for any reason if the patient is in a protected class.
•If a patient is pregnant, termination can be safely accomplished during the first trimester with uncomplicated pregnancies and with adequate time for the patient to find another physician. Termination in the second trimester should occur only for uncomplicated pregnancies and with transfer of the patient to another obstetrical physician prior to actual cessation of services. Termination during the last trimester should occur only under extreme circumstances, such as illness of the physician.
•The presence of a patient’s disability cannot be the reason for termination unless the patient requires care or treatment for the particular disability that is outside the expertise of the physician. Transferring care to a specialist who provides the particular care is a better approach.
Physician or dental groups with more than one physician may want to consider terminating a patient from the entire practice. This will avoid the possibility of the patient being treated by the terminating physician during an on-call situation.
To terminate the physician-patient relationship:
1. Put the patient on written notice that he or she must find another physician. The notice should include:
•Reason for termination—A specific reason for termination is not required. Under certain circumstances, it is acceptable to use the phrase “inability to achieve or maintain rapport” or to state “The therapeutic physician-patient relationship no longer exists.”
•Effective date—The effective date of termination should provide the patient with a reasonable time period to establish a relationship with another physician. Usually, 30 days from the date of the letter is considered adequate, but be sure to follow state regulations. The relationship can be terminated immediately under the following circumstances:
•The patient has terminated the relationship.
•The patient or a family member has threatened the physician or staff with violence or has exhibited threatening behavior.
•Interim care provisions—Offer interim care. However, true emergency situations should be referred to an emergency department.
•Continued care provisions—Offer suggestions for continued care through local referral services such as medical or dental societies, nearby hospital medical staffs, or community resources. Do not recommend another physician by name.
•Request for medical or dental record copies—In your written notice, offer to provide a copy of the medical or dental record to the new physician by enclosing an authorization document, which must be returned to the office with the patient’s signature. One exception to this element is the psychiatric record, which may be offered as a summary in lieu of the full copy of the medical record.
•Patient responsibility—Remind the patient that follow-up and continued medical or dental care are now the patient’s responsibility and that both should be pursued.
•Medication refills—Explain that medications and refills will only be provided up to the effective date of termination.
2. Mail the written notice to the patient by regular and certified mail, return receipt requested.
3. Keep copies of the letter, the original certified mail receipt, and the original certified mail return receipt (even if the patient refuses to sign for the certified letter) in the patient’s medical record.
For questions, contact your local medical association or liability insurance provider.