Dismissing a Problem Patient in 10 Safe Steps
- 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.
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