Ethical Concerns About Terminating a Provider–Patient Relationship During the Pandemic
Laura M. Cascella, MA, CPHRM
The outbreak of the coronavirus disease 2019 (COVID-19) has rocked the healthcare community, sending ripples of uncertainty in relation to patient and healthcare worker safety, financial security, ethical decision-making, standards of care, and beyond. Decisions, choices, and actions that were already difficult prior to COVID-19 — such as terminating a provider–patient relationship — have become even more complex in the face of the ongoing pandemic.
Yet, these situations will undoubtedly still arise, particularly as healthcare professionals resume services, triage patient care needs, and adapt to developing standards and practices precipitated by the evolution of the virus.
General risk management guidance historically has stated that healthcare providers have the right to treat the patients they wish to treat and the right to terminate relationships with patients for various reasons as long as the practitioners are not violating federal and state laws — e.g., in relation to discrimination or patient abandonment. However, the pandemic has sowed seeds of doubt and hesitation in various facets of healthcare, including patient relations. As a result, many decisions are not clear cut, and providers might be concerned about how COVID-19 affects their typical protocols.
When deciding whether and how to terminate a provider–patient relationship in the era of COVID-19, taking into account some additional factors is prudent. First and foremost, providers should consider the reason for wanting to dismiss the patient from the practice. Often, providers seek to terminate relationships with patients due to behavioral issues or nonadherence, such as unsuccessful communication attempts, missed or cancelled appointments, refusal to obtain needed tests or treatments, rude or demeaning behavior, failure to follow office policies, etc.
In these situations, providers should consider whether the patient behaviors are a long-standing issue or potentially a manifestation of the current unstable and fragile environment. COVID-19 has taken a significant toll on people’s mental health, emotional well-being, physical health, financial security, etc. The stress and anxiety associated with the pandemic might lead to behaviors or actions that generally are uncharacteristic for an individual. For example:
| Aggressive or Violent Behavior |
|---|
| Violence in healthcare is an all too common issue. When a pandemic is added to the mix, the situation might become even more tenuous. Patients might become agitated more easily, and that agitation can potentially lead to aggressive or threatening behaviors. The stress of COVID-19 also might worsen other risk factors for patient violence, such as psychiatric disorders, behavioral health issues, and substance abuse. If a healthcare provider or staff member feels that a patient’s behavior might become violent, the primary concern should be the safety of patients and staff in the practice. Every healthcare facility should have an established security protocol, with verbal or physical triggers that initiate a call for law enforcement support. Further, all healthcare personnel should receive training on handling these situations and following emergency protocols. For more information, see MedPro’s article From Verbal Insults to Death: The Reality of Workplace Violence in Healthcare. |
- A patient who is rude or belligerent might be reacting to underlying anxiety and stress. Responding with empathy and attempting to de-escalate the situation can help restore order and bring the patient’s feelings into perspective. Additionally, offering patients information and resources related to emotional health and well-being might motivate them to seek needed support.
- A patient who is nonadherent with his/her medication regimen (e.g, not filling prescriptions or hoarding medications) might have concerns about medication costs as a result of lost income due to the pandemic. Working with the patient to find alternative treatment options or community resources to provide financial assistance might help resolve nonadherence and ensure the patient receives necessary treatment.
- A patient who continues to cancel or miss appointments might be fearful of coming into the practice and potentially contracting the virus. Clear communication with patients about safety measures the practice is taking to prevent the spread of infectious diseases can help assuage these fears. Additionally, offering patients options such as telehealth appointments might help address missed/cancelled appointments.
- A patient who misses appointments or deviates from treatment because he/she is unwilling to use telehealth options might have access issues or feel uncomfortable with the technology. Discussing these concerns with the patient, determining whether community resources are available to overcome limited access, and explaining various aspects of telehealth (e.g., how the technology is used, what the patient can expect during a telehealth appointment, and privacy/security measures) might increase the patient’s comfort level and willingness to try a telehealth format.
Although some difficult and nonadherent patient behaviors might be short-term reactions associated with fallout from the pandemic, other issues might persist or endure from pre-COVID-19 times. In these cases, if a provider feels that attempts to address the behaviors have failed, the most suitable option might be to terminate the provider–patient relationship. If this decision is made, the provider should follow the healthcare practice’s formal process for ending a relationship with a patient. That process should take into account:
- Whether attempts have been made to preserve the provider–patient relationship through the provision of patient education, a written patient agreement, or a payment plan (when payment issues are the reason for terminating the relationship).
- Whether the patient’s record contains adequate, objective, and factual documentation that supports the decision to end the relationship. For example, have patient complaints or inappropriate remarks been objectively documented in the record using quotes when possible? Have the dates of missed/cancelled appointments been documented as well as staff follow-up efforts?
- Regulatory, contractual, and professional standards for terminating a provider–patient relationship (e.g., state laws or patient care obligations related to a managed care organization, health maintenance organization, or preferred provider organization).
- Timing of the termination to avoid allegations of abandonment. The provider should consider the patient’s clinical status and availability of other practitioners in the area.
- The termination process, including expectations for notifying the patient in writing and documenting the notification in the patient’s health record.
- Administrative considerations, such as the use of a “no-schedule” list, to ensure that patients who are dismissed from the practice are not inadvertently readmitted.
For more detailed information and guidance, see MedPro’s checklist and guideline on terminating a provider–patient relationship. For specific questions or complex situations, consult with your MedPro senior patient safety and risk consultant or attorney.
