How to fire a patient

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A nurse practitioner (NP) has two patients she would like to discharge from her practice.

Patient A came in for a refill for two controlled substances, a sedative and a sleeping pill. The NP refilled the prescriptions, but advised the patient to begin to wean herself from the sedative and switch to an antidepressant. The patient agreed. The NP ordered the antidepressant. The next day, the pharmacist called the NP to report that the patient also filled prescriptions from another clinician for the two controlled substances.

Patient B has no insurance, has run up a bill for $500 over the past six months, and has paid nothing, despite numerous notices.

The NP may terminate the clinician-patient relationship with both of these patients. However, there are five bases the NP needs to cover:

1. If the patient has been assigned to the NP or practice by a health plan or managed care organization, the plan or organization may require the clinician to go through a specific process in order to transfer the care of the patient. The NP should read the contract between the patient's health plan and the practice, to determine whether the NP may discharge a covered patient from the practice, and if so, what notice or other paper work needs to be filed.

2. Write the patient a letter, stating:

  • The NP is terminating the patient-provider relationship as of a stated date 30 days from the date of the letter.
  • The NP will provide services for an acute or chronic illness until the date stated.
  • The reasons for discharging the patient. See #4, below.
  • The patient's record will be sent to another clinician, on request.

File a copy of the letter in the patient's chart. Send the letter certified, return receipt requested. If the patient refuses the letter, file the unopened envelope in the patient's chart and send another letter via regular mail. Note in the patient's chart that a second letter was sent, the method of delivery and the name of the sender.

3. Search the state Board of Nursing web site to ascertain that the NP is not "abandoning" the patient under any definition or rules of the Board. (If the NP covers the bases listed in this newsletter, that should not be a problem.)

4. Do not discharge a patient because the patient has an unappealing disease, gender, age, race, disability or handicap, unless the NP's education and training clearly disqualify the NP from caring for such a patient. To terminate a patient for any of these reasons could be a basis for a civil rights lawsuit on the basis of discrimination.

5. Do not terminate a relationship with a patient who is in an acute episode of illness. For example, if a patient is hospitalized, it is not the time to fire the patient. And, hospital emergency departments are restricted by Federal law from refusing to treat patients.

What legal recourse does a patient have, if an NP fires the patient?

A fired patient has a choice of three possible legal actions -- file a lawsuit on the basis of negligence (malpractice) or discrimination or report the NP to the Board of Nursing for patient abandonment. If an NP covers the bases stated in this newsletter, the patient will have no basis for any of these actions.

Negligence

The elements which a patient must prove, in order to mount a successful case against a clinician on the basis of negligence, are:

  • Duty of care (a patient-clinician relationship was established)
  • Breach by the clinician of the standard of care
  • Injury to patient
  • Causal relationship between the injury and the breach of the standard of care.

A clinician who starts seeing a patient has a duty to attend to the patient's needs until the patient terminates the relationship, the clinician terminates the relationship, the clinician transfers the care to another clinician (because, for example, the patient needs a specialist), or the patient is healthy (no further care is medically necessary), unless the clinician initially agreed to care only for a specific episode or aspect of the patient's illness, such as an emergency department NP who sees the patient for a specific emergency.

If a clinician stops seeing a patient without giving the appropriate notice, the patient can sue the clinician for negligence, if the patient suffers a preventable injury due to lack of medical attention. For example, reconsider the NP who no longer wants to treat Patient A (the patient who got multiple prescriptions for controlled substances from multiple providers). If, rather than officially terminating the patient-clinician relationship, the NP just refuses to take the patient's calls and instructs the receptionist to say the NP is "out" if the patient comes to the office, and if the patient has an adverse reaction to one of her medications and it continues for so long that the patient suffers an injury attributable to the reaction, the patient could sue the NP for negligence, saying a) the NP owed the patient a duty of care, b) the NP breached the standard of care (did not return telephone calls), c) the patient suffered an injury and d) the injury was related to the NP's inattention to the patient's telephone calls.

By firing a patient, the NP is terminating his or her duty to the patient. Terminating an NP's duty to a patient can be a risk-avoidance measure in itself. For example, if the NP who wanted to fire Patient A changed her mind and continued to see the patient and continued to prescribe narcotics, Patient A may later sue the NP, claiming that the NP negligently prescribed the controlled substances and contributed to the patient's addiction. The NP would need to mount a defense and prove that the NP followed the standard of care. However, if the NP appropriately fired Patient A, the NP could prove that she had no long-term duty to the patient (by producing the letter of termination). By terminating the patient, the NP avoids the risk of a lawsuit for negligent prescribing.

Patient abandonment

An example of a Board of Nursing statement on patient abandonment is: "For patient abandonment to occur:

  • the nurse must have first accepted a patient assignment, thus establishing a nurse-patient relationship
  • the nurse must have severed the nurse-patient relationship without giving reasonable notice to the appropriate person so that arrangements were made for continuing of nursing care
  • the patient must be in need of immediate professional care or circumstances must exist which would seriously impair the delivery of professional care to patients." (New York)

Frequently asked questions

  1. Do I have to find another provider who will take care of the patient? No, if the bases listed above have been covered.
  2. If the appointment scheduler does not realize I have terminated the patient and schedules an appointment, do I need to see the patient? Yes. Then fire the patient again.
  3. If a patient has not paid his or her bills, can I refuse to send the patient's record to another provider? No.

Copyright 2006, Carolyn Buppert
This article is taken from The Green Sheet, published monthly from the Law Office of Carolyn Buppert. To order, click here. For more detail on avoiding malpractice, see "Avoiding Malpractice: 20 cases, 10 rules, 5 systems." To order, click here.

 

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