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FAQs About Patient Conflicts

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Q: What should I do if a patient refuses testing needed to rule out life-threatening conditions?

A:

Physicians are obliged to suggest treatment that, in their best medical judgment, is appropriate for the individual patient. However, a competent patient may refuse any treatment.

 

A physician who encounters a patient who refuses recommended testing or treatment is advised to discuss or maintain an ongoing dialogue with the patient concerning:

  1. what the testing/treatment entails
  2. why it is the recommended course of action
  3. the risks and benefits of the proposed testing/treatment
  4. the risks of not having or delaying the testing/treatment
  5. any alternatives that are possible. Such dialogues and the patient’s refusal should be carefully documented and include the patient’s signature whenever possible. 

Q: What steps should I take to resolve a conflict about a patient's advance directive?

A:

In Massachusetts, the patient’s designated health care proxy is recognized as the highest legal authority over the patient’s care and treatment—even if in conflict with a patient’s advance directive. Physicians practicing in other states should check with their legal counsel to determine the authority of proxies.

 

If no proxy has been designated and a conflict arises, the health care team needs to select a member to talk to the family. That individual should acknowledge the conflict, begin and sustain dialogue with family, listen to the family concerns, and offer emotional support. Discrepancies between the patient’s wishes and those of the family should be addressed.

 

If a resolution cannot be reached, contact the institution’s designated ethics or legal consultant. Institutional policies for dealing with conflict typically outline procedures for appointed individuals or the ethics committee to undertake. If it cannot be settled within the institution, the case is then brought to court.

 

Carefully document all discussions with family members and all decision points of the patient's treatment. Following a systematic process in accordance with institutional policy is essential in advocating and providing care and treatment for a patient.

Q: How can I avoid allegations of patient abuse?

A:

Allegations of patient abuse arise when patients contend that the physician violated one of the professional boundaries that describe the limits of the physician-patient relationship for personal benefit. Boundary violations in this context imply physician behavior that seems to exploit a patient either sexually, financially, or emotionally. Examples include: making arrangements to meet with a patient outside of regular office hours and/or out of the normal office setting; accepting or giving expensive gifts to patients; entering into financial deals with patients; and sharing an inappropriate amount of information about the physician's private life or using the patient for emotional support. 

 

Avoiding boundary violations, or the perception of them, is the most effective way to avoid allegations of patient abuse. Physicians can best protect themselves from these allegations by developing and nurturing a caring, respectful relationship with patients, thus keeping misunderstandings to a minimum. For patients new to the physician’s practice, the presence of chaperones or additional caregivers during certain examinations or procedures can reduce concern for both patients and providers. Empathy for the patient, sensitivity to cultural differences, and a willingness to explain the reasons for treatment that may seem to the patient to be unnecessary or embarrassing are all indicative of a respectful relationship.

Q: How can I safely terminate a relationship with a difficult patient?

A:

  • Notify the patient in writing, preferably by certified mail
  • Provide the patient with a specific reason for the termination
  • Agree to continue as the treating physician for at least 30 days
  • State clearly the date termination becomes effective
  • Recommend or provide information for identifying physicians of the same specialty
  • Offer to transfer records to the new physician upon receipt of a signed authorization to do so
  • Offer to see the patient in cases of emergency within a stated period of time after termination
  • Include the above referenced items in the letter notifying the patient of the termination

Because legal requirements for terminating a patient relationship vary by locale, physicians should check the state policies where they practice. Careful documentation of patient non-compliance, disruptive behavior, or evidence of poor rapport will serve as the basis for the explanation and defense of the rationale for a termination of the relationship should the action be challenged.

 

This advice is adapted from Risk Management Principles & Commentaries for the Medical Office, published by the AMA/Specialty Society Medical Liability Project.

Q: When is it inappropriate to terminate a patient relationship?

A:

Attempting to terminate a relationship in an emergency or urgent care situation, with a patient in the latter stages of pregnancy, or with a patient who may not be mentally competent, is not recommended. If termination is not currently an option, the physician should work with the health care team to develop a coordinated approach to dealing with the difficult patient. Liaison psychiatry programs and social work services can often provide valuable assistance.

 

Occasionally, particularly in rural areas, only one specialist may be available to treat the patient's condition. These situations require more creative approaches to provide support for a troubled relationship and may necessitate a more active role by the physician in planning alternative care arrangements.

 

Terminating a relationship with a patient who is HIV-positive, or who has a diagnosis of AIDS should be treated no differently than other situations. Carefully document the rationale for the termination in the medical record and follow the other steps listed above. The timing of the termination may also be critical if a claim emerges. A physician who terminated a patient close to the time he or she learned of the patient's HIV status, or when insurance coverage was dropped or reduced, might have difficulty convincing a jury such action was not discriminatory.

Q: Is reporting of inappropriate transfers under EMTALA (COBRA) mandatory?

A:

Yes.

 

The federal law requires that any hospital report improper transfers to the appropriate state or federal agency within 72 hours of the patient's arrival from another hospital. Institutions may want to provide for notification to administration or the risk manager if they have received an apparent inappropriate transfer. Any action that needs to be taken can be discussed with the “referring” hospital.

Q: Do I have to forward records to another physician for a patient who has failed to pay me?

A:

Yes.

 

Upon receipt of the patient’s written authorization, a physician must forward copies of the medical record, regardless of the patient’s payment status. In Massachusetts, the Board of Registration in Medicine (BRM) regulations allow a physician to charge a “reasonable fee” for the expense of providing a copy of the record, but specifically prohibit prior payment of the charges connected with that care as a condition of making a copy of the record available. A physician could be subject to disciplinary action by the BRM for violating this regulation.


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