Firing Patients Who Disagree With The Plan: What's Your Threshold?

[hippopotamusoath]

I have a patient with a primary psychotic disorder who is currently taking anti-psychotics and doing fine, but wants to stop them. I have tried to address their concerns. I have offered dose changes, medication changes within class to address their side effects, etc. At the end of the day, this patient just doesn't want to take anti-psychotics. Which is fine--I think it's a horrible idea, but it's their body at the end of the day.

I'm thinking about discharging them from my practice over this. I just fundamentally disagree with their decision, and selfishly, I don't want to be in charge of managing the fallout that I think will be coming (decompensation, repeated hospitalizations, you know the drill).

Is this anyone else's practice? How much does it take for you to fire a patient?

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[surfguy84]

I've wondered this. To fire a patient is it just a matter of giving them information about other providers in the area who are accepting new patients?

 

[allantois]

I haven't done this (I don't see many psychotic patients); but I've seen practices in my area discharge patients over this.

 

[nexus73]

IMO, the lawyers have made it this way. You do a good job, make appropriate recommendations, put forth good effort to motivate a person to follow your advice, but they don't. Bad outcome happens related to psychosis, and the first question is going to be who is the doctor who let this happen.

 

[FlowRate]

I've had a few patients who are at least mildly-moderately functional when psychotic and who have good family supports. In those cases, I prioritized the patient-physician relationship over adherence to recommended treatment. And that approach paid off because they felt comfortable coming back to me up to a year later to actually get back on antipsychotics.

I would probably take the same approach with someone with more significant psychosis/less supports but, simultaneously, I'd also be pushing them to establish at a CMHC where they stand some chance of getting connected with more robust services to try and keep tabs on them/get them back into treatment when they do decompensate.

 

[PikminOC]

IMO, the lawyers have made it this way. You do a good job, make appropriate recommendations, put forth good effort to motivate a person to follow your advice, but they don't. Bad outcome happens related to psychosis, and the first question is going to be who is the doctor who let this happen.

Yes I discharge for less.

 

[G Sheb]

Interesting question.
Frankly, this is a question of how much support you have at your clinic.
You shouldn't be dealing with SMI patients with high acuity if you're on your own, and in that case yes, you should discharge them and refer them to an appropriate clinic.
If you do have support, then you should put that patient on the clinc's radar for extra supervision...etc Continue engaging them.
I actually do not think it is appropriate to 'fire' patients for this in large majority of cases. Ultimately one should be acting in the best interest of the patient.

 

[vanfanal]

If you think his psychosis is interfering with decision-making capacity, wouldn't you pursue a CTO?

 

[hippopotamusoath]

If you think his psychosis is interfering with decision-making capacity, wouldn't you pursue a CTO?

I really don't think that. It's a low health-literacy patient who is a little bit concrete, but doing quite well from a psychosis perspective. I think the patient has the capacity to make this decision, I just believe it is a horrible decision and will result in a lot of potential for decompensation, hospitalization, and everything else bad that can come with psychosis. I'm watching a train-wreck in slow motion, and I'm wondering how many people in a similar situation choose to discharge the patient...

 

[TexasPhysician]

I wouldn’t discharge for this. Patients are allowed to make their own decisions, even bad ones. Hopefully the need to restart meds and the trust gained from warnings of this next event will prevent more attempts to stop meds.

Psychotic patients stop meds from time to time. If this is a reason to terminate then I’d argue that you shouldn’t accept them initially.

That said, I get to document my way. My note could read something like:

I have thoroughly discussed the risks and possible consequences of discontinuing medications. The patient is not a current risk to self, others, or acutely deteriorating. The patient is thus not eligible for inpatient hospitalization at this time. The patient currently understands their diagnosis and medication and understands the risks involved with stopping medication. It is likely that severe symptoms will re-occur. There is nothing i can currently do to prevent this future event from taking place. To help prepare for this future event, we have discussed how to restart medication, where to call for an appointment, and what to do if symptoms are severe. The patient has been reminded of local inpatient centers if needed.

 

[Candidate2017]

It seems you are a private practice? Then they should be discharged with referrals to places with wrap around services like hospital clinics or CMHCs. Arguably, if you are a small private practice, you may be doing the patient a disservice by not referring out to higher level, wrap around clinics.

But, there is something to be said about not giving in to fear/avoidance that drives anxiety. I remember in training, our clinic attendings would trick us into telling them which types of patients we disliked seeing, and then flooding us with those patients. In the moment, it was terrible. In the end, it was great because we came out stronger and more confident. Continuing to see this patient and managing their illness could benefit both parties. This patient seems to trust you. Often, people need to relapse several times before gaining insight and turning into one of those elderly schizophrenics who are compliant for decades. Some people get tired of the cycle of meds-capacity-feeling good-stopping meds-hospitalization-meds. Some don't.

Anyway, risk of decompensation or adverse outcomes is always present in any chronic illness, even in the best of circumstances. All we can do for someone who has capacity, is educate on outcomes, risks/benefits, safety plan, document such, and otherwise follow standard of care.

 

[Bartelby]

I agree with TexasPhysician. This situation is not too unusual. I would educate the patient and document carefully. I would also see them on a very regular basis as they stop the medication, and discuss with them how to restart the medication if stopping it is not going well. It can be frustrating dealing with unnecessary decompensation, but I think in this patient population that is not too unusual.

 

[clausewitz2]

Is there a reason you can't keep seeing them after they stop neuroleptics? They are way more likely to agree to this if you reluctantly helped them taper than if you simply refused. Maintaining the alliance also makes it more likely they will be open to going back on them when things come crashing down.

I agree, document the heck out of everything, but this is a pretty common situation among folks who get genuinely psychotic but are high-functioning outside of these acute episodes.

 

[hippopotamusoath]

I wouldn’t discharge for this. Patients are allowed to make their own decisions, even bad ones. Hopefully the need to restart meds and the trust gained from warnings of this next event will prevent more attempts to stop meds.

Psychotic patients stop meds from time to time. If this is a reason to terminate then I’d argue that you shouldn’t accept them initially.

That said, I get to document my way. My note could read something like:

I have thoroughly discussed the risks and possible consequences of discontinuing medications. The patient is not a current risk to self, others, or acutely deteriorating. The patient is thus not eligible for inpatient hospitalization at this time. The patient currently understands their diagnosis and medication and understands the risks involved with stopping medication. It is likely that severe symptoms will re-occur. There is nothing i can currently do to prevent this future event from taking place. To help prepare for this future event, we have discussed how to restart medication, where to call for an appointment, and what to do if symptoms are severe. The patient has been reminded of local inpatient centers if needed.

Thanks, this is probably what I will end up doing. I'm in a hospital-based system with very few resources and a non-functional local CMH scene. Essentially, it's me or no one for this patient, and managing decompensation, hospitalization, and recovery is particularly painful in this resource-poor setting as compared to better-resourced places I've practiced in the past. In my current setting, an ounce of prevention is worth 100lbs of cure, as there is really no realistic pathway to any sort of "wraparound" services, and my own hospital-based setting is designed and resourced for mild/moderate illness at best. What we are actually tasked with is caring for a much more seriously ill population...

 

[hippopotamusoath]

Is there a reason you can't keep seeing them after they stop neuroleptics? They are way more likely to agree to this if you reluctantly helped them taper than if you simply refused. Maintaining the alliance also makes it more likely they will be open to going back on them when things come crashing down.

I agree, document the heck out of everything, but this is a pretty common situation among folks who get genuinely psychotic but are high-functioning outside of these acute episodes.

Thanks--I can absolutely continue seeing this patient, and our treatment alliance is very good. After reading everyone's feedback, I realize I probably didn't do a great job of conveying what's giving me pause. I am used to patients stopping meds etc--the thing that is especially concerning is that this particular patient has a relatively high risk of harm to self/others while psychotic (don't want to get into details, but we can all imagine the type of patient, I am sure...). In terms of risk, the situation might be more analogous to having a patient who drinks heavily and keeps a pistol at their bedside for protection, and has chronic suicidality with intermittent fantasies of shooting themselves, but they will give you no assurances that the gun will be removed or even locked, and they want to trial off their antidepressant. It's THAT type of feeling.

More of a situation where the patient's plan is really ill-advised to the point where there's a reasonable chance someone (or the patient) could get hurt, and I'll be left to try to help pick up the pieces afterward, potentially dealing with medico-legal fallout, etc.

Maybe that makes the situation a little bit more clear--not just a run of the mill case of a patient who decompensates and becomes pleasantly psychotic or something like that. Again, I'm obviously trying to be vague for the sake of confidentiality.

 

[hippopotamusoath]

Interesting question.
Frankly, this is a question of how much support you have at your clinic.
You shouldn't be dealing with SMI patients with high acuity if you're on your own, and in that case yes, you should discharge them and refer them to an appropriate clinic.
If you do have support, then you should put that patient on the clinc's radar for extra supervision...etc Continue engaging them.
I actually do not think it is appropriate to 'fire' patients for this in large majority of cases. Ultimately one should be acting in the best interest of the patient.

Thanks, my level of support is poor. At a hospital-based practice with few resources. CMH is not an option. If I maintain them, I will absolutely increase engagement, a greater expectation of regularly making and keeping appointments. That's good advice.

 

[annoyedpsychiatrist]

I typically never fire someone; we agree on a treatment plan, and if we cant agree I inform patient they have the right to a second opinion but if they continue to see me then I hold firm on the treatment plan unless something significant changes. Eventually they stop coming or we agree, but saves you the trouble of firing.

I would obviously fire someone for more serious stuff if they were a significant violence risk or other serious behaviors

 

[clausewitz2]

I don't fire people in private practice often but it sometimes happens. some reasons:

1) getting controlled substances from another provider and refuses to stop when this is brought to their attention
2) keep seeing another psychiatrist and filling scripts from them and don't stop doing this once it is brought to their attention
3) Call me a liar and do not apologize or retract this statement when they have calmed down. We simply do not have the trust to engage in a therapeutic relationship at that point.
4) Threaten violence
5) misses multiple appointments and does not respond at all to attempts to reschedule
6) Moves out of state

 

[comp1]

This is a fascinating question, but it's so specific to the patient and even more so to the clinic setup. A lot of clinics can't fire patients. You can shuffle them around providers (maybe), but if they're on Medicaid or in the VA, they're not going anywhere else. Psychotic patients discontinuing medications is very much more the norm than the an outlier. I don't think there's a lot to be gained from discharging the patient. If this patient indeed has a primary psychotic disorder and not severe personality pathology, you aren't setting any boundaries that they can learn from and that would ultimately help them function in the long term. You're just cutting them loose. Of course you can be sued for anything at any time, physician or not and I'd say there's no particular legal protection in letting the patient go that is greater than carefully documenting the discussion you had with the patient advising them to continue the medications. The comment about getting court ordered treatment is almost hilarious. I've never heard of any legal structure, at least in the US, that would allow such in this sort of setting. 99% of the time psychotic patients just go off meds and don't tell anyone, so you might have a slightly better relationship than average with this particular patient which would weigh towards not letting them go. That's again, assuming that you aren't dealing with severe personality pathology wherein this kind of talk would be common and would be about testing you for abandonment specifically. Sorry for the personality stuff, I just see them confused so often and this particular conversation is so rare in something like schizophrenia.

 

[Stagg737]

A lot of good advice above, and clarification from OP helps. I "fired" a couple of patients in residency, but it was more of a mutual understanding that they didn't what to follow my plan and I wouldn't give them what they wanted (typically benzos) so there was no reason to keep seeing me if I wasn't prescribing anything or doing other interventions. I also agree that I would not fire this patient, but would work with them to taper as low as reasonable and help them understand the possible outcomes if they were to decompensate.

 

[Shotokan-Kata]

Do you think a partial hospitalization program could also help? IOP?

 

[whopper]

Explain to the patient the risks. If they accept the risks and you don't see collateral fallout and a bad outcome won't put you at risk I'd have a high threshold for not terminating treatment.
Collateral fallout? The patient's family freaks out and blames you and makes it their life mission to destroy your career. E.g. patient with a drinking problem doesn't want to stop drinking. Rich parents will try to destroy you if you don't "cure" their son.

Low thresholds: Just like the example above. If there's a lot of toxicity with the case because of factors you can't control I'd have a lower threshold to terminate patient care. Patient refuses recommendations that WILL LEAD TO BAD OUTCOMES that are high risk such as a schizophrenic refusing to take antipsychotics that's been previously dangerous while psychotic-if this is private practice. If this is a PACT Team this is even more reason to have a high threshold and PACT teams have the community resources such as a case manager, better communication with local resources such as police, hospitals (or at least should) for treatment to continue.

High thresholds: Patient doesn't want to stop smoking at this time. Fine. Just once in awhile remind them you can help. Patient uses a substance without any serious current short-term risks such as mild cannabis use. Ask the patient if they are using it to self medicate. If not warn them of the risks, but I wouldn't terminate for that alone. Patient doesn't want to engage in recommended treatment but has a mild problem.

 

[whopper]

3) Call me a liar and do not apologize or retract this statement when they have calmed down. We simply do not have the trust to engage in a therapeutic relationship at that point.

I had a patient change his phone number, not tell my office and we couldn't get in contact via phone. He showed up to the office, angrily demanded to know why we weren't calling him, showed him the number we were calling, and he replied, "that's my old phone number!"

Now I've had patients where this happened and in all other cases the patient pretty much rolled their eyes, felt like an idiot, apologized, then said something to the effect of "sorry my fault. I should've given you my new number." Then we tell them no problem we just want to fix the issue and move on.

The above patient? No. He told me that because I'm an MD I should know how to find his phone number even if he doesn't give us his new cell phone number. I politely told him that his cell phone number is not in a public directory and this isn't the 1990s where everyone had a landline in the White Pages. Also cell phone companies go out of their way to not give out people's phone numbers.

The guy demanded I apologize and said he wanted more professionalism from me and wouldn't drop it. It was to the point where I explained to him 3x there wasn't a way I could get his number short of means such as hiring a private detective that were not reasonable expectations. Other patients in the waiting area were getting uncomfortable as this guy was escalating the issue and raising his voice.

I told him at that point and it had been about 10 minutes to get out of my office and he was terminated. I said it calmly, something to the effect of, "I already explained this to you. There's nothing else to talk about. We no longer have a treatment relationship or anything else to talk about. Please leave my office which is a private establishment and you are no longer welcome." He left but I was ready to have the police called if he kept it going. I sent the termination letter via certified mail.

After he left, well that's where I allowed myself to experience the anger. I said to the office staff, "he's going to have a hell of a time finding a doctor who has a private detective so when he doesn't call the office the office will still knows what's going on." Also I made a sarcastic remark, "I must've missed the class in medschool where they teach you how to find patient's phone numbers that are not publicly listed."

BTW my wife is a DBT therapist. If anything because of her my patience with dealing with inappropriate behaviors like the above became less after going over these behaviors with her. She told me in DBT therapy it's completely within a therapist's place to tell a patient they cannot engage in inappropriate behavior. This is an area I've seen lacking in several training programs. Several health providers confuse compassion with excusing inappropriate and inexcusable behavior.

 

[FlowRate]

I had a patient change his phone number, not tell my office and we couldn't get in contact via phone. He showed up to the office, angrily demanded to know why we weren't calling him, showed him the number we were calling, and he replied, "that's my old phone number!"

We had a parent of a child patient call and leave a complaint for very similar. "No one called us to let us know the appointment was changed!" Clear as day documentation in the chart that two voicemails were left on the listed number by support staff...

The best part? The parent is one of the (non-psych) physicians in our organization.

 

[mistafab]

This is an area I've seen lacking in several training programs. Several health providers confuse compassion with excusing inappropriate and inexcusable behavior.

I think this is lacking in MD providers in general. They tend to be highly agreeable people, and find it uncomfortable to set up boundaries. It takes practice and often supervision. The issue deepens when the provider refuses to acknowledge that their own behavior and lack of boundaries is inappropriate, and begins to see people with good boundaries as 'bad doctors' who 'don't care about patients.'

 

[Desired Member]

I had a schizophrenia patient want to decrease their already very, very low clozapine dose because of some tenuous reason like feeling 8 hrs sleep was too much. I disagreed. I told them risks of going down on the dose and told them I recommended continuing current dose. I essentially documented - patient wants to decrease their dose, I told them that is not my recommendation due to concerns psychosis would worsen and put their safety at risk. (I recommended patient to follow up much more closely because they basically said they planned to decrease the dose anyway despite my recommendation).
I didn't fire them, I scheduled them for follow up very soon, and I documented my recommendations and prescribed according to my recommendations.
At that point, it's on the patient if they don't want to follow your recommendations.
OP, it sounds like this is a difficult case. If I felt someone may be at risk if a patient were to go off meds in future, and pt was planning to go off meds, I may ask patient if it's ok if I contact the at-risk person to warn them that they plan to go off meds. This is a really tough situation and I feel like our current legal system fails us often.

 

[Liquid8]

I usually only move on those who demonstrates a pattern of increasing their medications by far more than what I am comfortable with - usually we're talking about benzos and stimulants. Typically they are impulsive, and will decide on their own to take more than what I’ve prescribed, leading to numerous calls for scripts in-between appointments. I can accept that on occasion people will lose or misplace scripts every now and then, but when it comes with a suspicious dispensing history I start to monitor the dates and amounts very carefully. Fortunately the majority of my patients err towards the side of caution regarding medications, and some are too embarrassed to call if they lose their medications.

There have been a couple that spring to mind – for the first there was hard evidence of them getting their medication dispensed much earlier than appropriate and their reasons for increasing their use were vague and inconsistent, didn’t make any clinical sense and didn’t fit the time line. Eg. “I only increased the medication a few weeks ago,” yet the database dispensing history suggested it had been happening for months, and the admitted that the similar thing had occurred with an overseas psychiatrist. With this one I suspected there was some diversion going on, but wasn’t possible to prove it.

The second was arguably mismanaged before they came to me, being already on 100mg of Ritalin and asking for an immediate increase from the first appointment. Similar to the first case, this one increased without discussion and gave of that same “I’m entitled to a higher dose” vibe and expecting me to go along with it. Same thing happened with long acting options, and I later sent them for a second opinion who agreed with my plan to reduce medication – obviously the patient wasn’t up for that so we parted ways.

I do have a few patients with schizophrenia who are relatively stable, and usually parents or relatives will be the ones contacting me if they suddenly decide to cease their treatments which gives an opportunity to intervene before things go downhill. One of note who doesn't have the best insight usually talks about only agreeing to stay on their antipsychotics for another 3-6 months - despite this it's been about 4 years now and they've remained compliant and kept away form hospital and crisis team involvement. Recently he called, and to my surprise said he needed another risperidone script as he'd been taking a few extra mg of his PRNs. "Someone" had told him to take more, and it wasn't immediately clear if it was the pharmacist, their parents or a hallucination.