Terminating the Pain Physician- or Anesthesiologist-Patient Relationship

It is rare that a patient’s conduct drives his or her physician to terminate the relationship, but it does happen—not necessarily in anesthesiology care, where ongoing patient relationships are the exception, but certainly in chronic pain practices.  Such an ending is uncomfortable for all the parties involved.  There are ways, however, to make the process smoother and less fraught with risk for the practice.

First, what is the risk?  Medical ethics and the medico-legal theory of abandonment establish the principle that once a patient engages a physician, that physician is under an obligation to provide the patient with continuous care and attention until the relationship is properly terminated.  The patient may terminate at any time, for any reason.  At least in those states that do not have legislation limiting the circumstances in which the physician may discharge a patient unilaterally, the physician may terminate for any non-discriminatory reason as long as the patient’s immediate health is not jeopardized.  The physician must give the patient reasonable notice and a reasonable amount of time to establish a relationship with another physician before the termination becomes effective.

Even if no malpractice jury could possibly find abandonment, the risk that a disgruntled patient might file a lawsuit, or a complaint with the state medical board, makes it important to protect the physician and the practice.  In the initial instance, this means protecting the patient relationship itself, through a discussion about the behavior that is unacceptable.  If the issue is non-payment, for example, working out a payment plan may be the solution.

Where the relationship has failed, the best protection will come from having in place a good policy and protocol, and following them.

Preventive Care Before Terminating any Patients:  Adopt a Written Policy

In addition to state law, malpractice insurance and managed care contracts, and possibly even your hospital contract or bylaws, may impose specific requirements on the process of termination.  You should check all of these before developing your policy.

Many but not all states have statutes comparable to Section 4731-27-02 of the Ohio Revised Code, which requires, among other things, a statement that the physician will continue to provide emergency treatment and access to services for up to thirty days from the date the letter was mailed, to allow the patient to secure care from another physician, and an offer to transfer records to a new provider upon receipt of the patient's signed authorization.  Your state medical society should be able to direct you toward any applicable statute or state medical board rules such as those of the Texas Medical Board that provide that "termination of patient care without providing reasonable notice to the patient" violates the Texas Medical Practice Act, without defining “reasonable notice.”

Malpractice insurance carriers may require certain steps such as notification, or at least provide assistance.  The Doctor’s Company, for one, gives general guidance on the process, including a list of circumstances in which extra time may be necessary (patient is in an acute phase of treatment, or physician is the only source of medical or dental care within a reasonable driving distance, etc.)  and offers personalized help with drafting patient letters.  It would be a good idea to ask the carrier to inform you if it makes changes to its policy or to any sample letter.  If you write your own letter, you might ask the carrier for a review.

Some managed care contracts contain rules for discontinuing the care of an enrolled patient.  At a minimum, if there are such rules, they will likely include a provision for notification to the health plan.

Since many anesthesia groups are parties to a service contract with their hospital that requires them to provide care to all patients whom the hospital refers, practices that provide chronic pain services may want to review their hospital contracts for potential restrictions on their right to terminate patients.

Once you have checked the possible third-party requirements and any sample documents provided, you will be ready to write a patient-termination policy for your own practice.  This policy will be your guidepost when you are questioning whether and how to dismiss a particularly difficult patient (although it does not take the place of legal advice).  It will reflect choices you have made about the types of patient behavior that will result in dismissal.  The final document should contain the following:

• Statement of purpose/policy
  • Example:  “It is the policy of this practice to maintain a trust-based, cooperative relationship with our patients.  When such a physician-patient relationship cannot be established or is no longer proceeding on the basis of mutual trust, it is the policy of this practice to terminate the physician-patient relationship consistent with applicable state and federal laws, rules and regulations and American Medical Association guidelines so that the patient may develop the type of trusting relationship with another physician that is essential to successful continued care and treatment.”
• Types of behavior that demonstrate breakdown of the relationship; examples only:
  • Noncompliance with treatments recommended
  • Patient’s medical problems are outside the physician’s scope
  • Failure to make payment for services, consistent with the payment policies of this practice
  • Repeated failure to keep appointments
  • Threatening or abusive behavior directed at physicians, other healthcare providers, office staff or patients
  • Patient abuses or appears to be diverting medication
  • Violation of narcotics contract
  • Patient initiates a malpractice lawsuit
• Procedures to be followed
  • The physician or practice manager drafts a letter to the patient. This letter will:
    • Inform the patient of the discharge from the practice
    • Explain to the patient that the practice values a mutually cooperative and trusting physician-patient relationship, which clearly does not exist
    • Give reasons for the termination [this is optional.  Some practices state the reason in general terms but the patient may ask for an explanation.]
    • Inform the patient that the practice will provide emergency care up to but no more than a certain number of days from the date of the letter. [Depending on the availability of other physicians in the relevant specialty and on the patient’s ability to obtain care elsewhere, the termination window is typically 15 to 30 days.]
    • Provide the patient with resources for choosing another competent physician to continue with his or her care [referral to local medical society, nearby hospital medical staffs, or community resources. Most experts recommend against identifying another health care practitioner by name.]
    • Attach a valid medical records release form and offer to send records to the patient’s new physician without charge
    • Identify any medical condition that requires immediate or continued care
  • Staff sends the letter by certified mail, return receipt requested and also sends a copy by regular mail [state law or rules may specify other methods.] If the certified letter is returned to the practice, it should be placed in the patient’s file unopened.
  • A copy of the letter is placed directly into the patient’s medical chart.
  • Record in the patient’s medical record that the practice sent the patient a letter.
  • When appropriate, send a copy of the letter to the health or insurance carrier or to any other appropriate entities or individuals.
  • Flag the patient discharge in the patient’s medical chart, as well as in the scheduling system.

Put your policy into practice.  Make sure your staff members understand what constitutes a reason for dismissal and that you apply your own rules with consistency so no legal difficulties result.

When a Patient Termination Looms

If the relationship with a challenging patient looks as though it is going to break down and you are going to need to terminate, you should take care to document in the patient’s chart the events leading to your decision.  In the event that the patient files a complaint, complete and objective documentation will help to establish that you had cause for the dismissal, that the reason was not discriminatory and that it did not violate any applicable laws.

Notify staff of the final decision to dismiss the patient from your practice and instruct them on how to handle any contact initiated by the patient.  One way to handle such contact is to designate a specific staff member to whom all questions or other communications from the patient will be referred.

The letter itself should be polite and should convey your professionalism and compassion.  Below is a sample, which, like the policy points above, should not be considered legal advice.

Dear {patient name},

As you know, a good relationship between a physician and his or her patient is essential for quality medical care. There are times when this relationship is no longer productive and the physician finds it necessary to ask the patient to select another physician.

This letter is to inform you that I will no longer be able to serve as your physician. The reason for this decision is [indicate an objective reason, e.g., failure to keep last three appointments, or omit this sentence.]

As you [may] require medical attention in the future, I recommend you promptly find another physician to care for you. [You require ongoing medical attention for the following:] Your insurance plan or the local medical society or General Hospital [insert contact information] will be able to assist you in identifying physicians who are accepting new patients.

I will be available to treat you on an emergency basis only until [insert date, 15-30 days after the letter is mailed].  Until {date}, our office may also renew prescriptions for any medications that are medically necessary.  This will give you time to find a new physician. 

Enclosed is an authorization form that permits me to send your new physician a copy of your medical records.  Please complete the form and return it to me.

Sincerely yours,

__________________________,M.D.

Sent by registered mail, return receipt requested, on {date}.

We hope that it will never be necessary for you to send such a letter or to worry about the consequences.  As Susan Keane Baker, a consultant in risk management and patient relations based in New Canaan, CT stated in an article for Physicians Practice (Patient Dismissal:  The When, Why and How), "It's not the patient who's terminated that keeps the doctor up at night.  It's the one who should have been terminated but wasn’t."  Following a policy as described here may help you with difficult but necessary terminations.