It happens every now and then: A physician is providing care to a patient and things aren’t going as smoothly as they should. In fact, the situation is deteriorating. The reasons vary, but the end result is almost always the same, and necessary—the physician-patient relationship must be terminated. When, why, and how the relationship ends can make the difference between an amicable separation and years of litigation. Terminating a relationship with a patient, however, presents special challenges for a hospitalist.
Relationship to Nowhere
Certainly, some days are better than others in all relationships, and physician-patient relationships are no exception.
Hospitalists regularly talk to patients about unpleasant realities. Each patient responds to the information differently. More often than not, these difficult conversations lead to a focused plan for dealing with a patient’s health needs. Sometimes, however, a patient refuses to acknowledge the information provided, responds in an abusive manner to the physician or hospital staff, or is simply noncompliant.
An isolated incident is one thing; an ongoing pattern is another. One key consideration is deterioration of trust—for example, when a physician suspects a patient is malingering or seeking drugs, or the patient lacks confidence in the physician.
Another example is when the hospitalist determines that hospitalization is no longer necessary but the patient or their family does not want the patient discharged. In such cases, a hospitalist cannot continue to order care that is not medically necessary. Nonetheless, if the patient experiences a future adverse outcome, the fact that the patient opposed discharge increases the potential for a lawsuit.
This is particularly true when a patient must be forcibly removed from the hospital. In such cases, it is always best to get another hospitalist and the patient’s primary-care physician involved. Having two or three concurring opinions from outside physicians can help temper the liability risk.
Perhaps most difficult is assessing the impact of external factors on a physician’s ability to provide care. A hospitalist might have a difficult time providing objective care to a patient who is covered by the insurance carrier that is investigating him, the friend of a patient who is suing him, or a close friend or family member. Most state medical boards provide physicians with guidance on “boundary issues,” which boil down to a simple principle: If personal feelings have the appearance of interfering with objective assessment or treatment of the patient, the patient’s care is better left to another hospitalist.
Transitioning Care and Abandonment
Deciding that a physician-patient relationship is no longer productive is only the beginning of a termination. Prohibitions on patient “abandonment” restrict a physician’s ability to immediately terminate a relationship. Particularly when a patient objects to discharge, it is extremely important to have a comprehensive post-discharge plan. Such a plan must include ensuring that outpatient care providers are available and willing to see the patient.
Even transitioning care to another provider must be handled carefully. As a hospitalist, you first must ensure that another provider is able to promptly take responsibility. It is not enough to just call the service to assign a new hospitalist. Rather, your responsibilities end only when the new provider sees the patient. Moreover, there should be a “handoff” so you can pinpoint when your obligations to the patient officially end.
Physicians may not refuse to treat a patient for a discriminatory reason. For example, federal and state laws prohibit discrimination based on race, religion, sex, national origin, disability, or age. Additionally, some states prohibit discrimination based on sexual orientation. So while a physician can decide not to treat lawyers (not a protected class), they are not allowed to refuse to treat someone because they are Hispanic, Muslim, or homosexual.
The simple answer to the question of when to terminate a physician-patient relationship is: whenever a conflict arises that is likely to impact the provision of care. Terminating the relationship in a manner that protects both the patient and the physician is the key to reducing potential liability. TH
Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado, Denver.
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