Dismissing a Problem
 Patient in 10 Safe Steps

Having studied in Texas, I am familiar with the state’s regulations. The Texas Administrative Code, which defines the scope of practice and rules of NPs, is silent on the issue of terminating the clinician-patient relationship.¹¹ The Texas Board of Nursing addresses patient abandonment from employment and licensure perspectives but with verbiage more suited to bedside or inpatient nursing care. The board does not speak to dismissing a patient as a primary provider in the advanced practice role.¹²

If a relationship has never been established, abandonment cannot be construed.¹³ The AMA defines abandonment of an established patient as, “the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement.”⁶ To prove abandonment, three items must be demonstrated: (1) termination must not have been mutual; (2) termination transpired without reasonable notice; and (3) the need for care remained.⁸ The AMA suggests that 30 days’ time is a “reasonable notice.”⁶ Thirty days’ notice was also cited as good risk management by a malpractice insurer.¹⁴ 


In the absence of an official guideline for the termination of the NP/PA-patient relationship, I propose the following 10-point plan:


1. Develop a policy for provider-patient termination that is made available to patients at the initiation of service.¹⁴

2. Keep accurate and detailed documentation.^6,7
3. Speak with the patient prior to making a final decision regarding the relationship termination, and consider sending a “pre-withdrawal letter” that gently expresses your concern over his or her noncompliance.⁵
4. Discuss the situation with a colleague, risk-management professional, or legal advisor.⁹
5. Explain to the patient that he or she is being terminated from care, and provide an explicit reason. Do not delegate this task; speak directly with the patient.^4,15,16
6. Inform clinic staff of the termination.¹⁴
7. Send a certified letter with return receipt¹⁷ to the patient and the insurance carrier¹⁶ stating the termination, and that care will be discontinued in thirty days’ time, noting the specific date.¹⁸
8. Offer the patient interim care.⁶
9. Provide names and contact information for suggested potential alternate providers.¹⁹
10. Offer to transfer records when given written permission.⁶

Establishing National Guidelines

The American Nurses Association’s (ANA) Code of Ethics and Scope and Standards of Practice can certainly provide ethical guidance to the NP concerning the patient relationship.^20,21 The National Commission on Certification of Physician Assistants’ Code of Conduct for Certified and Certifying PAs²² and the AAPA’s Guidelines for Ethical Conduct for the Physician Assistant Profession¹⁰ can inform PAs regarding ethical conduct within the provider-patient relationship. Of course since there is no official legal guidance to NPs or PAs regarding termination of relationships, observing guidelines already established by the AMA is appropriate.⁷

HOW DID YOU HANDLE A PROBLEM PATIENT? SHARE YOUR EXPERIENCE 

Developing and incorporating guidelines similar to the AMA protocol into a national template for midlevel providers would involve input from the ANA and AAPA similar to the processes used in past revisions of their guidelines. Input would be needed from individual NPs and PAs, specialty organizations, major stakeholders and focus groups. The newly created standard would need to be reviewed and approved by the ANA Congress on Nursing Practice and the AAPA Board of Directors.


This article originally appeared on Clinical Advisor