Regarding Terminating the Treatment Relationship

| May 19, 2010 | 0 Comments

Dear Editor:

I read with interest the Risk Management column “Terminating the treatment relationship,” in the January issue of Psychiatry 2010 [Psychiatry (Edgemont) 2010;7(1):40–42]. When it comes to terminating a treatment relationship, what would you do in an academic setting?

We are unable to know, in most circumstances, where a student will end up after graduation so we give them basic information about termination. We do not send a follow-up letter because we have no idea of the patient’s new address. The following is what I discuss with my patients upon termination:

1. Review/confirm the patient’s graduation date and reasons he or she should continue medication/care.
2. Inform the patient that he or she will still have access to the university health center through the semester after he or she graduates (usually during the summer), provide the patient with the last date he or she will be able to access the university clinic, and inform the patient that our patient/provider relationship will be dissolved at that last date (unless they are back in school).
3. Discuss with the patient that he or she should find a new provider in the town or city to which he or she moves and that he or she should initiate getting his or her medical records transferred to this new provider. I also inform the patient of the phone and fax number of our clinic for tranferring medical records.
4. Inform the patient that he or she can call me with any questions during this process of transfer of care.

I would love to have any additional information on what else we could do.

With regards
Japheth (Jay) Hessler, PMHNP-BC
Staff Psychiatric Nurse Practitioner, Colorado State University

Author Response:

We appreciate the opportunity to respond to this important question. Clinicians are frequently faced with situations where the standard risk management advice about the termination process does not quite match with their practice setting. In general, the termination process in an academic setting should be very similar to the process in a private, group or facility practice.

You have described important points to include in termination discussions. Of particular importance is educating patients about the nature of their condition and the importance of continuing in treatment. This issue was raised in a North Carolina case [Williamson v. Liptzin, 539 S.E.2d 313 (N.C.App. 2000)] involving a psychiatrist (Dr. Liptzin) who treated a student (Mr. Williamson) at a university health center. Dr. Liptzin retired shortly after Mr. Williamson presented for treatment. Dr. Liptzin had discussed his retirement with Mr. Williamson and suggested that he see someone regularly for therapy. Because the patient was undecided about his summer plans, Dr. Liptzin instructed that if he returned home, he was to receive care from the community health center or his family physician; if he remained at school, he was instructed to return to the campus health center to continue treatment with Dr. Liptzin’s replacement. Mr. Williamson did not continue in treatment, but did well over the summer and in the fall, passing all of his law school classes. Over the Christmas break Mr. Williamson began to decompensate, and in January 1995 he fatally shot two students and injured several others. After Mr. Williamson was found not guilty by reason of insanity at his criminal trial, he sued Dr. Liptzin for malpractice.

Among Mr. Williamson’s complaints was that Dr. Liptzin had not discussed the severity of his disease or the likely prognosis should he fail to continue in treatment. The jury found Dr. Liptzin liable, and awarded $500,000 to Mr. Williamson. Fortunately the appellate court, finding that the case should never have even gone to the jury, reversed the trial court. The appellate court focused primarily on the fact that Mr. Williamson had been stable for eight months after he stopped treatment and had successfully completed an entire semester of law school. The appellate court unanimously found that under these unique circumstances, Dr. Liptzin could not have foreseen the tragic events that unfolded.

Patients often do not remember all the important points discussed during the termination process. Having a copy of a letter covering the points you mentioned can be a great reference for the patient and may further encourage and enable him or her to continue in treatment. Ideally, clinicians and campus health administrations will work together to find a way to provide follow-up letters to all patients who are leaving treatment (for whatever reason). One potential solution where, as in your situation, mailing addresses are not known would be to provide the letter during the last treatment session. However, if this is not possible, the chart should include a note indicating what was discussed with the patient prior to termination of the treatment relationship, as well as why a copy of the follow-up letter could not be provided to the patient. Should there ever be a question, having a copy of such a letter in the patient record or documentation of the termination process and discussion provides very strong evidence that a thorough termination process took place.

With regards,
Jacqueline M. Melonas, RN, MS, JD
Senior Vice President, Risk Management, PRMS, Inc., Arlington, Virginia

Tags: , , ,

Category: Letters to the Editor, Past Articles, Psychiatry, Psychology

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.