Risk Management Tip

Termination of the Psychiatrist-Patient Relationship Do’s & Don’ts

DO continue treating the patient until the relationship has been properly terminated.

DO tailor the termination process to meet the needs of the individual patient.

DO discuss the termination process with the patient prior to termination, if at all possible.

DO document the decision-making and discussions involved.

DO know if your state licensing board has specific requirements or regulations regarding termination of the treatment relationship.

Termination by the Psychiatrist in a Non-crisis and Non-emergency Situation

DO know that the termination process consists of the following steps: 1) giving the patient reasonable notice and time to find alternative treatment; 2) educating the patient about treatment recommendations; 3) assisting the patient with finding resources for treatment; 4) providing records and information, as requested; and 5) sending a follow-up letter to the patient.

DO tailor the length of the notice to the patient’s condition and available psychiatric resources in the community.
Comment: Usually, thirty days’ notice of termination is considered adequate. In areas where it may difficult to find another psychiatrist, it may be appropriate to give longer notice.


DO provide the patient with a specific termination date after which you will no longer be available. Comment: Although you are ethically and legally obligated to give notice and assist in finding alternative treatment, if for some reason (including the patient’s unwillingness to cooperate) this is not possible, you are not required to continue treating a patient indefinitely. Be sure to check with your state medical board as it may regulate a different notice period.

DO give explicit treatment recommendations to the patient, and to educate him/her about the need for continued psychiatric care and the potential risks of not continuing with the recommendations for treatment.

DO involve the patient's family members or significant others, if possible and appropriate.

DO give proper and detailed instructions regarding medications.
Comment: Include the name and dosage for each medication as well as any other important information.

DO NOT prescribe large amounts of medications around the time of termination, if possible.
Comment: Additionally, prescribing or re-filling a prescription for a patient after termination re-establishes the psychiatrist-patient relationship, and the psychiatrist must extend the termination time period or, possibly, begin the termination process over from the beginning.

DO provide the patient with resources, e.g. the local community mental health services, a physician referral service, and a reminder that hospital emergency departments are available in the event of an emergency.
Comment: For high-risk patients and for patients who have impaired judgment and no appropriate support system, you may want to provide further assistance.

DO inform patients that a copy or summary of his/her record will be forwarded to the new treater upon receipt of proper written authorization.

DO provide a follow-up letter that contains all the information discussed with the patient.
Comment: A copy of the letter should be filed in the patient’s record.

DO consider sending a copy of the letter via regular mail and a copy via certified mail, return receipt requested.
Comment: Doing so helps ensure that the patient will receive it and provides evidence that the letter was sent . In addition, there may be state requirements regarding mailing follow-up letters.

DO NOT reverse the decision to terminate treatment based solely on the patient’s appeal to do so.
Comment: If you believe that therapy is not working, you may risk liability for continuing to see the patient. Ineffective treatment could be interpreted as substandard care.

Termination by the Psychiatrist in a Crisis or Emergency Situation

DO understand that it is risky –but not impossible- to terminate with a patient who is in crisis.

DO NOT try to avoid liability by terminating treatment with a patient who has become suicidal or who you fear may be a danger to others.
Comment: Terminating abruptly in such circumstances is likely to have the opposite effect. A court is less likely to find that you have adequately discharged your responsibilities when you pull out at the time when you are needed most.

DO understand that even in the event of an unplanned or emergency closing of a psychiatric practice, there remains an obligation to the patients to terminate with as much care as possible.
Comment: It is a good idea to have a written emergency or contingency plan regarding termination and transfer of care in the event of a crisis on the part of the psychiatrist.

Termination by the Patient in a Non-crisis and Non-emergency Situation

DO recognize that patients may unilaterally decide to end treatment.
Comment: When a patient terminates, you should determine whether or not the patient is in crisis. If the patient is not in crisis, then the psychiatrist should offer to provide the same information that is provided in the termination process. If the patient is unwilling to discuss the decision, the psychiatrist’s attempts at communication should be documented and a detailed follow-up letter should be sent.

Termination by the Patient in a Crisis or Emergency Situation

DO NOT assume that you are automatically free of any duty or obligation if you are "fired" by a patient.
Comment: It is important to evaluate the patient’s state of mind and understanding. If you think the patient is unable to make an informed decision, you may need to attempt to follow-up with the patient or involved members of the patient’s support network. Confirmation by letter is important when the patient abruptly or unilaterally terminates treatment, unless the patient has refused to permit such contact.

Financial Issues and Terminating Treatment

DO understand that changes in a patient’s financial situation can often trigger the need to end a treatment relationship, either because of changes in healthcare insurance or because of a patient’s inability or unwillingness to pay for treatment.

DO discuss fees and payment schedules with the patient at the outset of treatment.

Change in a Patient’s Financial Situation

DO find a way to accommodate the patient’s limited resources or terminate treatment appropriately if a patient becomes unable or unwilling to pay for necessary -not optimum- treatment.

DO understand that the care provided must be based upon the patient’s clinical needs and not solely on what services the patient can afford. Comment: You risk liability, if you continue to provide treatment that falls below the standard of care simply because the patient is unable or unwilling to pay for what is needed.

Outstanding Account Balances

DO NOT allow termination to be the first response to an outstanding balance.
Comment: If a patient is delinquent in meeting payment requirements, it is best to discuss the issue with the patient and address the problem clinically before the amount owed becomes substantial.

DO NOT deny needed care due solely to an outstanding balance.
Comment: You must remain available to meet the patient’s needs until proper termination has been effectuated.

Collection Agencies

DO NOT use a letter from a collection agency as a patient’s first notice that treatment has been terminated.
Comment: The issue of outstanding balances should be discussed with patients prior to termination, and they should be educated about your debt collection practices from the beginning of treatment and prior to collections being pursued.

DO make the decision to send an account to a collection agency personally.
Comment: The decision should not be made by the office staff.

DO consult with a local attorney when developing policies and procedures regarding the use of collection agencies to ensure compliance with all applicable state statutes and regulations.

Writing-off Outstanding Balances

DO check on any financial requirements or limitations imposed by third-party payers regarding outstanding bills, co-payments, etc., prior to writing-off outstanding balances.

Abandonment

DO understand that if you do not properly terminate the physician-patient relationship, you expose yourself to allegations of abandonment (i.e., the inappropriate withdrawal of treatment) should litigation or an investigation by the licensing board occur.

DO NOT allow yourself to be manipulated by a patient’s threats of abandonment; if the relationship has been terminated properly this is, by definition, not abandonment.
Comment: The formal termination process is a specific defense against this allegation, and, like all good risk management strategies, its effectiveness as a defense lies in the fact that it primarily serves to support good patient care.

In Conclusion

DO be aware that special circumstances in a given treatment relationship may generate exceptions to the above recommendations.
Comment: Use your professional judgment when terminating the psychiatrist-patient relationship. Consult with your personal counsel or risk manager if you have questions or concerns.

 

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