October 21, 2011
Question:
Hi Jennifer,
My question is at what point is it the patients full responsibility to follow through on the advice of their treating physician? I have a few patients who have come to my office with no insurance and can barely pay for their office visit. When I advise them that they need a specialist the openly tell me they are not going to go because of their lack of funds.
Besides documenting their intent to not comply with my recommendations and that the risks have been explained to them is there anything else I should take into consideration.
I am afraid that these patients are resulting in increased liability to myself. Can I dismiss them from my practice of course without “abandoning” them?
Thank you,
Dr. R
Answer:
Very tough question from an ethical standpoint and also a legal standpoint as there really is no bright-line rule as to when your responsibility ceases. However, at the end of the day you do reach a point where a patient's health is their own responsibility, and once you have provided guidance regarding the benefits, risks and costs of treatment alternatives, and documented same, you have arguably fulfilled your obligation to your patient, as evidenced in the AMA Code of Medical Ethics that states:
“The patient has the right to make decisions regarding the health care that is recommended by his or her physician. Accordingly, patients may accept or refuse any recommended medical treatment.” AMA Opinion 10.01.
Clearly, your patients are free to choose their course of action – and it follows that their decision to refuse further treatment reasonably shouldn’t result in increased exposure to you. With our litigious society, this is not always the case. Should a patient have an adverse result, there is always a chance that the treating provider will be named in a subsequent litigation to recover - whether by the patient or the patient's family/representative. The way to protect yourself from having liability is to document everything - any diagnosis and recommendations - in the patient record. Remember, your patient record is potentially a legal document that may be used to your benefit or detriment. The thought/threat of potential litigation aside, I do recommend not thinking yourself into the type of box that has you practicing defensive medicine to the extent that you are afraid of making decisions for care and follow-up for your patients that work for you and your practice. If you are feeling a captive of your patients, there are policies you can implement that may let you sleep sounder at night with regards to follow-up care. Other than documenting, the next step you should consider is clearly setting forth your follow-up responsibilities to your patients. Let them know through your written policy that your office will follow-up via phone ___ days/weeks later - and then be sure to abide by that follow-up policy. By creating expectations and abiding by them, you will be heading off the possibility of creating implied expectation or obligation, where in fact, none existed.
Should you have a patient that you really do not want to see any more, you are entitled to terminate patient care at any time so long as you do not "abandon" that patient, which constitutes misconduct under the New York State Education law, section 6530(30).
To effectively terminate a patient appropriately: (1) you must provide proper and adequate notice to the patient (make sure to document this!); and (2) the patient must be able to secure another doctor to replace you (the latter requirement may be difficult to fulfill if your practice is located in a rural area or your specialty is unique to an area, in which case you may be forced to continue treatment). In addition the AMA recommends other steps be taken when necessary in order to ensure continuity of care, such as: providing the patient with a brief explanation for the termination, agreeing to provide treatment for a reasonable period of time to allow the patient to secure care from an alternate physician, and helping the patient find an alternate physician.
For more guidance on this topic see the AMA article, ending the patient-physician relationship.
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