Patient Abandonment and “The Difficult Patient”

Describe the fundamentals of the patient-physician relationship.

Describe the types of “Difficult Patients”

Define indications for terminating the patient relationship.

List the steps that should be taken in terminating a patient relationship.

The relationship is usually established when a physician conducts some form of history or physical examination. It may begin earlier, such as when a physician talks to the patient by phone and agrees to see them.

Once a physician-patient relationship is established, the physician has a responsibility until the relationship is terminated.

The obligation includes providing coverage when the physician is away or treating other patients.

• Multiple symptoms involving multiple body systems

• Vague and shifting complaints• Dependent, clinging behavior• Undue concern about minor

symptoms• Excessive preoccupation with

physical disease• Poor response to usual methods of

treatment• Difficult to communicate with

• Hostile, demanding, dissatisfied• High utilization of health care services• Manipulative, exploitative, controlling• Seductive• Unrealistic expectations of care• Raises new problems as visit ends• Resistant to physician’s

recommendations• Noncompliant with treatment program• Rambling, unfocused• Self-destructive

The “Angry” PatientThe “Manipulative” PatientSomatoform Disorder (“Frequent

Flyers”)Notorious Non-CompliantThe “Seductive” Patient

Pay attention to pre-visit signs: long waits and staff cues.

Is it true anger, or just pain and frustration?

Anticipation of Bad News?DO NOT GET DRAWN INTO THE

CONFLICTKNOW YOUR TRIGGERS!

1. Allow the patient to vent their anger. 2. Acknowledge the anger “I can see you

are really angry about this.” 3. Validate the anger “understandably you

are very angry as this is a very frustrating situation you are in.”

4. Offer to explore the situation in more depth – it is often found that there are many layers to the anger and frustration the patient is experiencing.

5. During the interchange keep calm6. Use a neutral tone of voice, adopt an

open body posture7. Move back from the patient so there is

plenty of space for the patient8. Do not become defensive (do not take

it personally)9. Be aware of the position of the door or

any emergency button should you require it.

Play on the GUILT of others. Impulsive behavior to get what they

want. High % of Borderline Personality

Disorder Be aware of your own EMOTIONAL

triggers Manage expectations and sometimes

just say “no”.

Doctor Shoppers Multiple tests, diagnoses, medications

and “medication allergies”, and ER visits

Physical manifestation of psychic distress

Symptoms are real, just as your moods and emotions are.

Rx: Regularly scheduled brief office visits, but avoid tests and polypharmacy

1. Conduct a straight-forward clinical investigation

2. Avoid elaborate follow-up and do not repeat tests without a compelling reason

3. Do not assume that a symptom is produced intentionally just because its psychological function is obvious to you

4. Many somatizing patients are alexothymic (without words for feelings)

5. If uncertain whether a symptom is produced intentionally, consult a psychiatrist

6. Treat the underlying psychological disturbance, not the physical symptom

1. Brief regular appointments (4-6 wks. Max.)

2. Relapsing course and low morbidity/mortality associated with somatization

3. Brief physical at each appointment focused on area of patient concern

4. Avoid hospitalization, diagnostic procedures, surgery and excessive lab

5. Respect the unconscious processes that give rise to the symptoms and do not tell the patient it is “all in your head” or other variants

1. The patient's medical problem is potentially serious and poses a clinically significant risk to length or quality of life

2. At least one treatment exists that if followed correctly, will markedly reduce this risk

3. The patient has easy access to the treatment or treatments

4. The patient deviates significantly from most patients (with similar medical problems) in degree of compliance with medical advice, treatment, or follow-up in a way that directly or potentially jeopardizes the patient's health or quality of life.

Failure of Communication and Lack of Comprehension

Cultural Issues Psychological Issues Secondary Gain Psychosocial Stress Substance Dependency

“The most helpful things I have ever done with noncompliant patients have been to ask questions, not to lecture, and to be willing to listen to what patients say. These activities are often very difficult to do within the time constraints of clinical practice. Sometimes I have to "suspend" the clock and my usual clinical approach and just tell the patient that I'm frustrated and concerned and that I need to know what he or she understands about the disease process and problems being faced. And then I'll just be quiet and listen as nonjudgmentally as possible. “

Quoted from Fred Kleinsinger, MD, Understanding Noncompliant Behavior: Definitions and Causes |

Even non-psychiatric care involves “transference” phenomenon

Caring and compassion misinterpreted as sexual suggestion

Innocent flirtations NEVER appropriate Emphasize that this is a strictly

professional relationship  Utilize chaperone throughout interactions Obtain consultation/referral if needed Institute and enforce written office

guidelines

Patient abandonment occurs when a physician fails to provide necessary medical care to a current patient without justification.

The physician duty: an obligation is created when there is an established relationship.

The patient must have had a reasonable expectation that care would be provided.

The physician must have failed to carry out the obligation.

There must be injury or harm to the patient caused by the abandonment.

Proof of a physician-patient relationship is an essential element in determining abandonment.

Abandoning a patient under care without making reasonable arrangements for the continuation of care is unprofessional conduct.

If no relationship exists, there usually is no duty to treat.

Disciplinary action (licensing)MalpracticeCOBRA violationsPunitive damagesElder abuse (example: neglecting to

provide care for patients in SNF)

Doctors are subject to professional misconduct disciplinary action, including license suspension, for abandoning patients.

It is well established that a doctor who undertakes to examine a patient (thus creating a doctor-patient relationship) and then abandons the patient may be held liable for malpractice.

When a physician abandons a patient in need of medical attention, the conduct is egregious.

The common sense of laypersons may well be sufficient to suggest that such conduct by a doctor is not compatible with skillful or acceptable treatment.

The abandonment of a patient is something that all people can understand is wrong.

From: Moore, Thomas, et al. Abandonment of a Patient: A Physician's Liability. New York Law Journal, March 6, 2001.

Punitive damages = not to compensate the injured party, but to punish the wrongdoer for egregious conduct and to serve as a deterrent to others.

In contrast to cases with mistaken diagnosis or negligent treatment, abandonment involves acts with a bad motive or reckless indifference to a patient’s welfare.

Often punitive damages are not covered by malpractice insurance.

Violation of COBRA if emergency treatment and stabilization is not rendered when a patient seeks care.

COBRA was designed to prohibit physicians from limiting the care of emergency patients to only those with financial resources to pay.

KEY POINT = If a physician does not respond to a patient who seeks emergency care and the case has already been discussed w/ the physician (thus initiating a relationship), the physician may be accused of abandonment.

A physician may not decline to accept patients because of “sex, color, creed, race, religion, disability, ethnic origin, sexual orientation, age or any other basis that would constitute obvious willful discrimination.”

Physicians cannot refuse to see a patient who is protected by law against discrimination.

If patient is illegally turned away, malpractice insurance may not cover any resulting claims.

Examples that are on the rise include refusal to treat HIV-positive patients without credible medical reasons.

However, a physician is not required to perform a procedure that conflicts with his/her religious beliefs.

A physician may turn a patient away from the practice if the practice already has too many patients and is closed to new patients.

However, the physician must be consistent (that is, not accept some patients and turn others away).

Failure to transfer patient to appropriate care level.

Failing to respond to calls from hospital regarding inpatient.

Failing to respond to ER when on listed call panel.

Refusing to care for patient after arranging admission.

Anesthesiologist leaving a surgical case in progress without coverage.

Failing to continue to treat the patient until coverage or consulting physician is able to assume care.

Failure to make routine visits to a patient in a skilled nursing facility.

By the patient at any time.

By the physician for specific reasons AFTER providing formal notice AND a reasonable opportunity to find substitute care

Breakdown of rapport with patient/family that makes it medically impossible to treat patient

Threatening behavior, abusive behavior or violence

Sexual advances Repeated no-shows or non-compliance that

interferes or jeopardizes patient safety Refusal of treatment plan recommended by

provider after having opportunity to actively participate in decisions.

Failure to pay (consistent) *BEWARE*Patient misidentification of selfFraud or theft (but NOT for drug-

seeking behavior without first addressing problem)

Other reasons may exist per managed care organization contract

Adverse change in health statusCost of healthcare needsHigh utilizationDrug-seeking behavior that you

have not addressed

Some situations require extreme caution.

Continued treatment, at least temporarily, may be preferred. acute stage of chronic illness final stages of pregnancy or Situations that may appear to be

discrimination

Advise patient of potential consequences of behavior

Utilize patient care conference Contract with patient for behavioral

changes Utilize case manager or social worker For violent or abusive situations: may

require a show-of-force or security Appropriate use of other internal staff:

risk manager, psych consult, or medical director

Procedure should include:– Written notification – Reasonable notice and period of time for

patient to find another practitioner (usually 30 days)

– Adequate documentation of rationale for termination

– Remain available for E.R. consultation until transition completed

– Review managed care contracts

Focus the letter on the patient’s long-term benefits

State the reason objectively and briefly. Examples: persistent missed appointments, non-compliance with care

Do not be adversarial or accusatory. State exact date of termination: e.g., at

least 30 days from receipt of letter. Remain available for emergency care

during interim.

Give referral resources (e.g., local medical society, patient’s health plan). Do not give specific physician name(s).

Offer to transfer copy of records. Include authorization form for the

patient with the termination letter. Keep a copy of the letter in the

patient’s record.

Inform all staff when patents are terminated.

Continuing contact with any staff member may extend the physician-patient relationship. Examples: Rx Refills on day 28

“resets” the 30-day provision

For non-payment of bills: Go through formal process in writing. Provide adequate warning that

patient will be terminated. If managed care patient, check with

plan first. Do NOT refuse to copy medical

records for subsequent providers if patient does not pay bill.

No appointment for more than a year = does not necessarily terminate the relationship. Patient may be assuming that the physician is available to treat conditions that arise.

If a physician treats a patient who was previously terminated, a new patient-physician relationship is established. The physician has a duty not to abandon the patient until the relationship is again terminated.

Extra burden on physician may exist if there

are no other services in the area.

When a patient is non-compliant with treatment: State the behavior that illustrates non-

compliance. Labeling patient may give impression that you did not like the patient and therefore gave substandard care.

Document when and why specific treatment was not completed: i.e. “patient did not comply with instructions to take meds…”

If patient chooses to see another physician, send a note to the subsequent provider with detailed history.

If repeated non-compliance makes it impossible to continue to treat patient, formally terminate relationship via procedure with letter.

Keep a copy in patient’s record.

Missed visits are one example of non-compliance.

Document all no shows and ALL resulting attempts to contact patient.

If patient indicates that they do not plan to follow-up, educate them as to the consequences. Document it.

Do not white out the information on the day sheet; indicate “no show.” Keep sheets per record retention policy.

The physician may have some duty to try to contact the patient depending of the nature of the missed visit.

If, for example, vital lab test results have been obtained, it may be necessary to send a certified letter to the patient encouraging them to contact the office

A physician can be removed from a plan for financially discriminating against a patient.

The contract may have specific requirements for terminating a patient’s care. If done in a manner that is not in

accordance with plan’s requirements, physician could be in violation of the contract.

Some plans require that the plan be notified prior to terminating a patient.

Patient abandonment occurs when a physician fails to provide necessary medical care to a current patient without justification.

Once a physician-patient relationship is established, the physician has a responsibility until the relationship is terminated.

There are situations in which the physician can discontinue patient treatment. However, formal notice must be given and a reasonable opportunity to find substitute care must be provided.

Allow patients to vent their feelings. Strengthen your communication skills. Become a more effective history taker. Try not to judge. Remain calm and confident. Understand your own strengths and

vulnerabilities. Be patient. Be proactive. Avoid becoming an enabler. Respect your patients.

Hull S, Broquet K. How to Manage Difficult Patient Encounters.FPM. June 2007. http://www.aafp.org/fpm/20070600/30howt.pdf

Haas L, et al. Management of the Difficult Patient. AFP. November 2005. http://www.aafp.org/afp/20051115/2063.pdf

Kleinsinger F. Understanding Noncompliant Behavior: Definitions and Causes. The Permanente Journal. Fall 2003. http://xnet.kp.org/permanentejournal/fall03/behavior.pdf

Gillette R. ‘Problem Patients': A Fresh Look at an Old Vexation. FPM. August 2000. http://www.aafp.org/fpm/20000700/57prob.html