What has ethics, legalities, culture, practicality and self-preservation stamped all over it? "Firing" a problem patient. It's a topic familiar to many NPs, although the preferred terminology may differ.
"There are times when the relationship with a patient needs to be terminated," said Deborah Kiley, DNP, FNP, FAANP, of Anchorage, Alaska, who specializes in pain management. "But 'firing' is a term that does not reflect the professional caring relationship that NPs have with their patients; discharge or transition to an appropriate care setting occurs when an existing relationship is not in the patient's best interest."
It may well be a matter of semantics. "I fire patients all the time," said Scharmaine Lawson-Baker, DNP, FNP-BC, owner of a house calls practice in New Orleans. "Every provider has a philosophy, mission or a certain culture to their practice. Whenever a patient doesn't fit into my philosophy, mission or culture, I fire them. It's that simple."
Making the Break
That doesn't mean the moment of separation is easy. There can be real angst for patients and providers alike. "It can be very difficult to tell a patient they will no longer be part of your practice," Kiley said. "They sometimes are angry, other times disappointed, and they may want to 'bargain.' In addition, the clinician may feel disappointment that she was not able to provide patients with the care that they needed."
However, Kiley also said there are times when an NP and patient simply must part ways. "If a patient is engaging in illegal behavior, such as selling controlled substances, or using illegal drugs such as cocaine or hallucinogens, or the relationship with a patient is a threat to the safety of the clinician or the staff she works with, it is part of a clinician's professional responsibility to terminate the relationship. This can happen in any clinical environment, but frequency can be higher depending on the practice setting."
Lawson-Baker noted that she most often dismisses patients when they harbor unrealistic expectations or insistence for services she cannot legally provide. "For instance, pain management can become an issue," she said. "The law in Louisiana does not allow NPs to prescribe for chronic pain; I can prescribe for an acute, emergent pain, but not an ongoing condition. Just last week a patient kept calling for pain meds. We've been back and forth about it. Although I repeatedly explained that I cannot treat for chronic pain, the patient kept asking ..."
When the patient finally threatened to call a lawyer, implying that care was not sufficient, ". it was time to pull the plug," Lawson-Baker said. "I finally had to say, 'I am not the right provider to meet your needs.' And that was that. She got a discharge letter, and I put a copy into her chart, and sent a copy to the associated home care agency."
An Eye for Ethics
Ethical and legal issues exist when discharging a patient. "While you cannot support illegal behavior, it is also inappropriate to abandon a patient," Kiley clarified. "Ethically, you do not want to place a patient in a situation where they don't have access to care, nor do you want to facilitate behavior that harms the community - such as drug diversion. There are times when you can work with a patient to give them opportunities to change behavior to meet practice standards, such as alcohol use or being nonadherent with agreed treatment plans. On the other hand, there are behaviors that may result in immediate discharge - such as stealing prescription pads or altering prescriptions."
Lawson-Baker takes a proactive approach during new patient intake in hopes of avoiding down-the-road dismissals. "I have what I call a 'come to Jesus meeting,'" she said with a chuckle. "I talk to new patients about all their comorbidities. I let them know that we are entering a contract to work together to get their issue under control. Once we have that initial talk, I start setting them up to see specialists and start making referrals; they know they'd better actually go or we are going to have a problem."
The problem of nonadherence must be addressed, because it eventually comes to bear on the provider. "For example, I've read that if a patient ends up having a leg amputated because he was not monitoring his blood sugar level, that sort of thing could come back on the provider if the patient were to claim inadequate care, medication or whatever," Lawson-Baker said. "At my practice we stay on top of each patient, we take notes and document that appropriate tests have been ordered and appointments have been made. We only refer to certain doctors, so at the end of the month we call them to make sure referred patients actually showed up. Certainly, if there is a viable reason for missing appointments, we understand. But after a few misses, we don't make any more appointments. If patients continue to be noncompliant, we do discharge them - in a heartbeat."
Proceed with Caution
Carolyn Buppert is an attorney who has written eight books on NP legal and business issues. These include the popular Nurse Practitioner's Business Practice and Legal Guide now in its 5th edition (Jones and Bartlett). Buppert has developed a tip sheet (www.buppert.com/articles/fire-patient.php) that suggests a legal strategy for firing patients, including five bases NPs needs to cover. The following is from her tip sheet, with her permission:
How to Fire a Patient
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 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 website to ascertain that the NP is not "abandoning" the patient under any definition or rules of the board.
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 discrimination lawsuit.
5. Do not terminate a relationship with a patient who is in an acute episode of illness. For example, if a patient is hospitalized, do not fire him or her. And, emergency departments are restricted by federal law from refusing to treat patients.
When Neil Sedaka warbled "Breaking Up Is Hard to Do," he didn't really have NPs and patients in mind. But his time-worn sentiment holds true: Parting ways is never easy. Yet understanding the issues at hand and the right ways to make a clean break can ease the experience.
Valerie Neff Newitt is on staff at Nurse Practitioner Perspective. Contact: firstname.lastname@example.org.