Terminating the Treatment Relationship

| January 15, 2010 | 0 Comments

Psychiatry (Edgemont) 2010;7(1):40–42

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 onsite risk management audits, and other resources to healthcare 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 may 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.

QUESTION: I recently tried to end my treatment relationship with a patient who needs more specialized care than I can provide in my practice setting. The patient said I was abandoning him—is he right?

Answer: Psychiatrists who do not properly end the physician-patient relationship expose themselves to allegations of abandonment. However, there is a difference between a patient who feels abandoned and one who has been abandoned legally or ethically speaking. There are generally two well-established and well-accepted methods of ending a treatment relationship ethically and legally—termination and transfer of care.

Whether care is being terminated or transferred, a therapeutic alliance is ending. Therefore, the advice given here should be considered in addition to considering the clinical implications of ending the treatment relationship.

Termination of the Treatment Relationship
Termination of the treatment relationship is appropriate for any number of reasons, including when there is a lack of agreement on a treatment plan, the patient no longer requires treatment, the psychiatrist is closing his or her practice, or the psychiatrist or the patient is moving away. Whatever the reason, there is a generally accepted process for ending the treatment relationship in a manner designed to protect the interests and well being of both the patient and the psychiatrist.
Termination and the termination process should be discussed in person with the patient if possible. The discussion should be followed by providing the pertinent information discussed in written form. Proper termination requires the following points:

1. Reasonable notice. The length of appropriate notice may depend on the patient’s condition and available psychiatric resources in the community. Generally, 30-days notice is considered reasonable; however, psychiatrists should check with their state medical boards and insurance provider contracts (if any) to see if more notice is required. The psychiatrist should provide the patient with a specific calendar date after which the psychiatrist will no longer be available for clinical issues.

2. Treatment recommendations and education. The psychiatrist should make clear to the patient what the psychiatrist’s recommendations are for treatment going forward. The psychiatrist should also discuss why he does or does not believe it is important for the patient to continue in treatment, and the potential risks of not continuing in treatment. This is particularly important when discussing continuing medications: for example, abruptly stopping some psychiatric medications can carry significant medical risks. The psychiatrist should be wary of prescribing large amounts of medications around the time of termination. If the patient experiences an adverse reaction to the medication but is not yet under the care of another psychiatrist, the original psychiatrist may be found liable even if the proper termination process was followed. This is because prescribing or refilling a medication is generally considered de-facto evidence that a treatment relationship has been established. Therefore, the most conservative approach is not to prescribe beyond the termination date. It is important to remember, however, that this process must be tailored to the needs of the individual patient. So, in a case where the psychiatrist makes a medical decision to prescribe or refill after termination, the implications for the termination process should be clear to the psychiatrist and communicated to the patient. The termination date may need to be extended or, possibly, the entire termination process begun again.

3. Resources for treatment. The psychiatrist should assist the patient in finding another source of treatment, but it is not necessary to find multiple individual providers who are willing and ready to accept the patient. Rather, the psychiatrist can point the patient toward resources for finding care, such as the patient’s insurance panel, local community mental health services, other physician referral services, and a reminder that hospital emergency departments are available in the event of an emergency.

4. Records and information. The patient should understand how to request that a copy of his or her record be released, and be informed that a copy will be sent to his or her new provider upon receipt of a proper written authorization signed by the patient.

5. Follow-up letter. After discussing these points, the pertinent information should be provided to the patient in writing so that the patient can reference instructions, recommendations, and resources later. A copy of the letter should be filed in the patient’s record. To best protect both the psychiatrist’s and patient’s interests, the letter should be sent in a manner that provides proof that it was sent, has the best chance of actually reaching the patient, and appropriately maintains confidentiality. Mailing one copy by certified mail and another by regular mail often accomplishes these goals. Some state medical boards have specific requirements about this and other elements in the termination process. Be sure you know the requirements in your state.

Termination by the patient
Sometimes a patient will terminate the treatment relationship. The risk management advice here is the same as when the psychiatrist terminates the relationship, but without the notice requirement. The psychiatrist should still communicate recommendations about continuing care, resources for finding care elsewhere, and how the patient can request a copy or summary of the record. This information should then be sent in a follow-up letter as well.

However, if a patient decides to terminate treatment while in crisis, the psychiatrist should not automatically accept the decision and assume that he or she is free of any obligation or duty to the patient. If a psychiatrist is “fired” by a patient, it is important to consider the patient’s state of mind and understanding. If the psychiatrist thinks the patient is unable to make an informed decision, the psychiatrist may need to attempt to follow up with the patient or involve members of the patient’s support network to ensure the patient’s safety.

Transfer of Care
A transfer of care is similar to termination in many ways, but is effected when the responsibility for a patient’s care is smoothly handed from one physician directly to another, with no gap in treatment. For those who have worked in a hospital or other facility, shift-change hand-offs are one example of a transfer of care, where the departing clinician gives the incoming clinician the information needed to continue evaluating and caring for the patient. In any event, the transfer should be to a clinician who is able to meet the patient’s clinical needs.

There are two common types of transfers of care when outpatient psychiatrists are treating a patient: to another outpatient psychiatrist and to a facility. The risk management considerations are similar in both cases and revolve around communicating.

Outpatient to outpatient. A psychiatrist may transfer a patient’s care to another psychiatrist for a variety of reasons, such as when a patient moves away, develops new symptoms that require the services of a sub-specialist, or no longer requires the specialized care being provided by the current psychiatrist. In any event, the primary goal of a transfer of care is to ensure that the patient receives appropriate continuing psychiatric evaluation and treatment.

When a receiving psychiatrist or other physician has agreed to take on the care of a patient and the patient has assented to the transfer, the receiving physician should be given all information needed to continue to provide treatment to the patient per the patient’s consent. The patient should understand when to begin contacting the new provider for any clinical issues, and it is best to also provide this information in writing.

Outpatient to facility. Transfers to a facility in psychiatric practice often occur in an emergency, or during crisis. As with transfers to another outpatient provider, the facility should be given all the information they need to provide appropriate clinical care to the patient.

Psychiatrists are generally familiar with the risk management principle that one should not terminate the treatment relationship during a crisis, but this can cause some confusion in the context of hospitalization. The difference between hospitalizing a patient and terminating during a crisis is that care has been transferred, not terminated, and so the patient is not left in crisis without treatment.

It may also be appropriate for the outpatient psychiatrist to consider whether he or she can continue to meet the patient’s clinical needs after the hospitalization. It is well known that the period of time immediately postdischarge is a high-risk time for patients. Providing appropriate clinical care is always the most important goal, and if the psychiatrist determines he or she cannot provide that in his or her practice setting, he or she should notify the patient and the facility that he or she will not be available to the patient on discharge.

The psychiatrist should use his or her clinical judgment in determining whether that information is best communicated to the patient by the psychiatrist him or herself or relayed through the hospital’s attending psychiatrist. Either way, a follow-up letter should be sent to the patient explaining that the psychiatrist will no longer be providing treatment on discharge and referring the patient to the facility discharge instructions for continuing care.

Whether the psychiatrist will continue treating the patient after discharge or not, she should communicate with the hospital during the discharge planning process to ensure that the psychiatrist’s availability is appropriately incorporated into the discharge plans. Further, communicating with the facility during discharge planning may help the outpatient psychiatrist determine whether he or she can meet the patient’s clinical needs at that point in time.

The bottom line is that psychiatrists must exercise their professional judgment when ending the treatment relationship. There are proper ways to end a treatment relationship that, when followed, will reduce the psychiatrist’s risk of a claim of legal or ethical abandonment.

Submit your own question
To submit a question, e-mail Elizabeth Klumpp, Executive Editor, eklumpp [at] matrixmedcom.com. Include “Risk Management Column” in the subject line of your e-mail. All chosen questions will be published anonymously. All questions are reviewed by the editors and are selected based upon interest, timeliness, and pertinence, as determined by the editors. There is no guarantee a submitted question will be published or answered. Questions that are not intended for publication by the authors should state this in the e-mail. Published questions are edited and may be shortened.

Category: Past Articles, Psychiatry, Psychology, Risk Management

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