PRACTICE MASTERY QUESTION #27

QUESTION:  What are the circumstances under which a DC can decline to accept or terminate care for a patient?

ANSWER:  There are a wide variety of situations in which it is appropriate to decline to care for a patient or to terminate care, and other situations in which it is important not to accept a patient for reasons of ethical or personal conflicts.

Declining to accept a case can and should be based on clear criteria, anchored in the specific laws of your jurisdiction and the ethical standards of the chiropractic profession.  ICA's official Code of Ethics provides the following guidelines: 

TERMINATION OF PATIENTS:

Since patients have the right to dismiss providers at will for reasons satisfactory to themselves, likewise, a doctor of chiropractic may decline to attend a patient if professional ethics and personal self-respect and dignity are compromised. The doctor of chiropractic is encouraged to terminate a doctor-patient relationship when it becomes reasonably clear that the patient is not benefiting from chiropractic care.

Having accepted a patient, a doctor of chiropractic shall give the patient the best chiropractic care possible within the confines of his or her expertise. If a doctor of chiropractic decides to withdraw from a particular case, the patient or the patient's legal representative shall be given sufficient notice to enable him/her to obtain another health care provider.

A health care provider may decide or be forced to terminate services to a patient for any one of a variety of reasons. This article will discuss the steps a health care provider should take to terminate services to a patient without committing patient abandonment.

Although terminating services to a patient is certainly a significant and undesirable event, it is legally permissible if the doctor carefully follows certain steps before discontinuing services. If the you fail to follow appropriate steps, you may open yourself and your practice up to potential liability under "patient abandonment" provisions that may apply in your jurisdiction.  This occurs when a patient alleges that they have suffered injury because the provider terminated services without sufficient notice.

Here are some matters to consider:

• If the initial clinical encounter reveals conditions or findings that clearly indicate that chiropractic care is inappropriate, or that the care of another provider is urgently needed and concurrent care is not practical, a doctor of chiropractic may decline to accept a case.
• If there are personal, family or other relationships involved in a potential patient that might be called into question, a DC may wish to decline to accept a case.   The issue of personal boundaries is a very difficult one and ICA strongly encourages all doctors of practice to maintain strict policies regarding even the appearance of an unethical or otherwise compromising situation.
• Patients who are disruptive to the practice, uncooperative, under the influence of any drug or alcohol or psychologically disturbed, potentially violent or otherwise of unusual concern may be discharged.  Such actions may need to be accompanied with a referral for other types of care, with such recommendation included in writing in the patient's record.
• Refusal to pay the bill for services rendered is recognized in all jurisdictions as sufficient reason to terminate care, provided the record shows reasonable efforts to accommodate and that the patient is clearly informed of their responsibility.
• What a provider must not do, however, is "abandon" a patient. Abandonment generally means a unilateral severance of the professional relationship between a health care provider and a patient without reasonable notice at a time when there is still a need for continuing health care.
• Three elements must exist for patient abandonment to occur:  (1) The termination of services must be unilateral, i.e., not by mutual agreement. (2) The termination must occur without reasonable notice, meaning notice adequate to give the patient a sufficient opportunity to secure alternative care; and, (3) The termination must occur when there is still the necessity of continuing care.
• Because the issue of patient abandonment arises in a situation in which it is the health care provider who acts to unilaterally terminate services at a time when there is a need for continuing care, the key to avoiding patient abandonment is to give reasonable notice of the termination of services. By taking this defensive step, you afford the patient time to secure alternate care and the patient therefore is not "abandoned." If reasonable notice is given, that critical second element for patient abandonment does not exist. 
• There are some specific steps that should be taken when the doctor determines that they must discontinue services to a patient:

(1) Review the Patient's Records

The patient's full record should be carefully examined to determine the degree of need, if any, for continuing care and the availability of other sources of care, i.e., other providers. If a patient is in the midst of ongoing care by the provider and is unable to find comparable care or has not been given adequate notice of the provider's intention to discontinue services, then the provider should not discontinue services without pursuing the remainder of these steps.

(2) Give Reasonable Notice to the Patient

The patient, or the patient's parent, guardian or trustee, should be notified in writing well in advance as to the date at which the relationship will end.  This notification should state in detail the reason or reasons for the doctor's decision to terminate care and state the ways in which the provider will assist the patient in securing appropriate services elsewhere.  This communication should be in writing and such a letter should advise the patient that the provider will make available to the patient, and other providers subsequently engaged by the patient, copies of all medical records and other information relating to the patient. This helps in maintaining continuity of care for the patient.  You may also want to offer to consult with any new provider regarding the details of the case.

It also could be useful for the letter to give the names, addresses and telephone numbers of other providers in the area that would be available to provide services to the patient. Generally, the letter should be sent by certified mail, return receipt requested, so the doctor can document that the patient or the responsible party received the letter.  A copy of the letter and the return receipt should be kept in the patient's records.

This notice must be received by the patient far enough in advance of the date services will terminate to give the patient sufficient time to secure alternate care, i.e. it must be "reasonable". How far in advance will be held to be reasonable will depend upon the facts of each case including the patient's condition, the availability of other providers, the ramifications if alternate care is not secured, and the reason for termination of services.

 

These basic steps are essential in any action to discontinue care. The vital step, however, is certainly the provision to the patient of reasonable notice of the doctor's decision to terminate care and documented assistance to the patient in obtaining an alternative source of care.  Each situation is different and requires careful evaluation and execution, with full documentation of every aspect of the situation.  It is also advisable to seek the advice of your own attorney and to access any and all regulatory and/or statutory guidelines or requirements for such actions.  It is also advisable to develop in advance, an office policy that outlines the steps that will be taken when care needs to be terminated. Establishing procedures and a chain of decision-making criteria in advance, you can minimize your exposure to patient abandonment charges, minimize difficulties in your communications with the patient and establish a non-discriminatory basis, anchored in your criteria, for the action(s) you take.

Your malpractice company may also serve as a good resource for advice in such situations.  ICA's exclusive malpractice program, ChiroSecure, assisted in the preparation of this release and routinely provides consultation services to policyholders.  You may wish to explore ChiroSecure's services and rates at www.chirosecure.com, or by calling toll-free at 866-802-4476.