by Ann L. McNary, JD
Ms. McNary is a Senior Risk Manager at PRMS, Inc.
FUNDING: No funding was provided for the preparation of this article.
DISCLOSURES: The author is an employee of PRMS Inc., a risk-management consulting company for health care providers.
This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS, Inc. (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation, education and on-site risk management audits, and other resources offered to health care providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers might provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other health care professionals so “clinician” is used to indicate all treatment team members.
Innov Clin Neurosci. 2021;18(1–3):
Question
When I speak to my colleagues about terminating treatment with patients, I get a lot of different answers. Some have been in practice for many years and have never “fired” a patient. Others say they do it routinely. I’ve been told I can’t terminate with someone for non-payment but that I can withhold treatment until a patient pays me. I’ve heard that if I establish certain conditions for treatment in my policies and procedures, I can automatically terminate treatment if those conditions aren’t met but otherwise, I need to give notice. I’ve heard that if a patient stops showing up for six months, I can just close their file. I’m more than a little confused. Under what circumstances may treatment be terminated and how do I do it?
Answer
We frequently receive calls about termination of treatment on our Risk management Consultation Services helpline. Many of the calls we receive reflect misconceptions about how and when treatment may be terminated so you are not alone in your confusion. I’ll address some of the common misconceptions and then go over the generally accepted process for terminating treatment relationships. Please remember that your own state licensing board may have very specific requirements regarding termination the violation of which could result in allegations of patient abandonment.
Myths and Misconceptions
Terminating treatment is an acknowledgment that you have failed your patient. When speaking to psychiatrists about the issue of termination, I like to use the analogy of a teacher in a classroom. Throughout your academic career, you no doubt had a few teachers who really stood out and were able to inspire you in ways others could not. This does not mean your other teachers were not knowledgeable and were not also good teachers. It just means there were some who were able to communicate in ways that made the material resonate with you. Other students might have had different experiences with the same teachers. And so it is with doctors and patients. Even if you feel you have the necessary training and experience to treat a particular patient’s condition, if treatment is not progressing as you would like, particularly if the patient is not adhering to your recommendations, it might be time to ask whether the patient might do better with another psychiatrist. This is not you failing at treatment, this is you putting the needs of your patient above your own ego.
Do not forget to consider your own mental health. If one patient is using up all your energy and creating additional stress in your life, not only is this damaging to you personally, but it also detracts from your ability to care for other patients who very much want to work with you and whom you are able to help.
You cannot terminate treatment for non-payment, but you can refuse to see/prescribe for the patient until he pays what you are owed. First of all, you are entitled to be paid for services rendered. Before you enter into a treatment relationship with a patient, they should be made aware of your fees. If they agree to those fees, you have a right to expect they will be paid. You are no less worthy of being paid than a plumber, or auto mechanic, or anyone else from whom a patient may request services. This means that you can terminate treatment with patients who will not pay your agreed upon fees.
However, termination should not be the first response to an outstanding balance. If a patient is delinquent in meeting payment requirements, it is best to discuss the issue with the patient and address the problem clinically before the amount owed becomes substantial. An excessive outstanding balance can interfere with the therapeutic relationship, making it impossible for you to effectively treat the patient. You cannot, however, deny needed care due solely to an outstanding balance; you must remain available to meet the patient’s needs until proper termination has been effectuated.
If a patient becomes unable to pay for necessary (not optimal) treatment, then you must either find a way to accommodate the patient’s limited resources or terminate treatment appropriately. The care provided must be based upon the patient’s clinical needs and not solely on what services the patient can afford. If, for example, you agree to see a patient far less frequently than is appropriate while on certain medications, you risk liability exposure if your monitoring of the patient falls below the standard of care simply because the patient is unable or unwilling to pay for what is needed.
If your office policies and procedures clearly outline circumstances that will be ground for termination, you can immediately terminate with a patient who violates those policies. Written office policies and procedures are an excellent way to manage patient expectations and reinforce what is expected of them in upholding their end of the treatment relationship. However, they are not contracts; if a patient violates your policies and procedures that does not give you an automatic out. A violation of your office policies (particularly repeated violations) certainly can provide grounds for terminating the treatment relationship, but it will not in and of itself effectuate a termination. Appropriate steps (including notice of intent to terminate treatment) must still be taken to avoid allegations of abandonment.
That said, there could be times when immediate termination might be appropriate, such as when a patient behaves in a physically threatening or violent manner with you or one of your staff. Should you encounter such a situation, it is recommended that you contact your malpractice carrier or attorney for advice on how to terminate treatment.
If you do not hear from a patient for six months, they are no longer your patient. Over the years, we have heard from many psychiatrists after they received frantic calls from patients (or the family members of patients) with whom they thought treatment had ended, asking what their obligations were to respond. While it might seem logical to conclude that a patient who suddenly stops treatment does not plan on coming back, it is never safe to just assume that treatment is over and you have no further responsibility for the patient. In some states, a patient who was seen as long ago as two years may still be considered an active patient unless treatment was formally terminated.
It is a good idea to follow up with patients who have fallen out of treatment to determine their intentions. If they do not respond to your attempts at contact, consider writing a letter letting them know when they were last seen, that you have been unsuccessful in reaching them, that you are assuming they do not wish to continue treatment, and you will be closing their file. If this is a patient you would not mind continuing to treat, you might want to give them a certain period of time in which to respond before you close their file.
How long you wait to send the letter will depend upon the frequency with which the patient was typically seen. You might have patients you see weekly and others just every few months. Some you might have seen for years but are inconsistent about following up and only contact you when they feel the need to be seen again. You might be aware of one patient’s absence in a week or two, but for another, it might be months.
If a patient terminates treatment with you but changes their mind later, you must take them back. Raise your hand if you have had the patient who leaves you a horrible scathing message in the middle of the night, telling you they are finding another psychiatrist and never coming back, only to call a day or two later to apologize or make an appointment. If a patient fires you and they are not in crisis, you are free to accept their decision to end treatment and do not have to agree to continue treating should they change their mind. If you believe they would benefit from further treatment, you should, however, provide general resources for finding ongoing care, and warn about any risks of stopping medications abruptly. You should send the patient a letter acknowledging their decision to end treatment that includes this information.
If a patient moves out of the area, you must continue to prescribe medication until the patient establishes care with a new psychiatrist. When a patient informs you that they are moving from your local area, you must decide whether continuing the treatment relationship is feasible. There are many issues to consider, including licensure and whether you are comfortable trying to manage the patient at a distance. Oftentimes, the decision is made that the patient will find a new psychiatrist in their new location. What is not always decided, is when the current treatment relationship will end. This often results in the psychiatrist doing something they intended to avoid, managing the patient at a distance, perhaps even in a state where they are not licensed.
The best practice is to have a clear end date to the treatment relationship and memorialize this in a letter to the patient. If you are comfortable doing so, you might want to provide your patient with medication for an additional month or two to allow them time to get into see another doctor. However, it is not your obligation to keep prescribing if this process takes longer than expected.
Termination of Treatment
There are many valid reasons for terminating a professional treatment relationship. The optimal reason, of course, is that the patient no longer needs treatment. You might also find that a patient could benefit from the care of another psychiatrist who specializes in treating your patient’s particular disorder or you might be moving or retiring from practice. Your patient might be non-adherent to the point where you have concerns that you might be found liable when they suffer from their own neglect; you might have a patient who is overly demanding of your time and that of your staff; or the patient might be unwilling to pay your fee despite numerous attempts to work out a payment plan. All of these are perfectly acceptable reasons for ending care as is anything else that damages the efficacy of the treatment relationship.
Whatever the reason, the relationship must be terminated properly. It is important to remember that this process, like every aspect of treatment, must be continually tailored to the needs of the individual patient. Remember to also consult your state licensing boards for specific regulations regarding termination of treatment and to be familiar with referral and termination provisions in all provider contracts.
The Termination Process
In a non-crisis situation, you can properly terminate the treatment relationship by doing the following: 1) giving the patient reasonable notice and time to find alternative treatment; 2) educating the patient about treatment recommendations; 3) assisting the patient with finding resources for treatment; 4) providing records and information, as requested; and 5) sending a letter to the patient. Ideally, the patient will learn of your need to terminate treatment during a conversation as opposed to reading it in a letter; however, this might not be feasible.
1. Reasonable Notice. The length of the notice may depend upon the patient’s condition and available psychiatric resources in the community. Usually, thirty days’ notice of termination is considered adequate. In areas where it could be difficult to find another psychiatrist, it might be appropriate to give longer notice. You should always provide the patient with a specific termination date after which you will no longer be available to provide treatment.
2. Treatment Recommendations and Education. It is important to give explicit treatment recommendations to the patient and to educate them about the need for continued psychiatric care and the potential risks of not obtaining recommended treatment. If the patient is high-risk and does not understand the need for care or how to find that care, you might want to consider whether the risk is such that you should involve the patient’s family members or significant others or take a more active role than is customary in transferring care.
Make sure the patient has detailed instructions regarding medications. Include the name and dosage for each medication, as well as any other important information. For example, if stopping a medication abruptly could cause injury to the patient, this should be explained.
You should not prescribe large amounts of medications around the time of termination. Additionally, prescribing or re-filling a prescription for a patient after termination has been effectuated re-establishes the psychiatrist-patient relationship, requiring you to extend the termination time period or, possibly, begin the termination process over from the beginning.
3. Resources for Treatment. When assisting the patient with finding alternative treatment, it is not necessary to provide names of psychiatrists who have agreed to accept the patient. Resources could include local community mental health services, a find a psychiatrist site (such as that available in the patient and family section of the APA’s website, finder.psychiatry.org), or the patient’s insurance panel. You are not required to come up with specific names. The patient should be reminded that hospital emergency departments are available in the event of an emergency. For high-risk patients and for patients who have impaired judgment and no appropriate support system, you may choose to provide additional assistance.
4. Records and Information. The patient should be informed that a copy or summary of their record will be forwarded to their new psychiatrist upon receipt of proper written authorization.
5. Follow-up Letter. The follow-up letter is intended to summarize your conversation with the patient, and, thus, should contain all of the information discussed above.
If you are a member of a group practice, consider whether the termination will apply to all members of the group. This could be important if you might be called upon to treat the patient while covering for one of the other psychiatrists.
A copy of the letter should be filed in the patient’s record. Your state might have specific requirements regarding how the letter is sent, e.g., via certified mail. Bear in mind, however, that some patients, particularly those who owe money, might avoid signing for a certified letter. It might be beneficial then to send another letter with delivery confirmation that does not require a signature.
Remember that if at any time during the termination period the patient goes into crisis (imminently suicidal / imminently homicidal), and the patient is hospitalized, you can transfer care directly to the hospital, and then no notice is required. We suggest you confirm your transfer of care in writing (such as a fax) after letting the attending psychiatrist know that you are not available to the patient upon discharge.
