Supervising Doctors and PA's Sued for Not Prescribing

[drusso]

https://www.clinicaladvisor.com/home/my-practice/legal-advisor/failure-prescribe-pain-medications-suicide/

The expert physician concluded that there was evidence of medical negligence in the treatment of Mr M. Specifically, the expert noted that the care provided by the PA and his supervisors fell below the appropriate standard of care required in such a case. The expert’s report alleged that the PA and his supervisors had:

Failed to properly evaluate, diagnose, and/or treat Mr M who had been dependent on opioids for pain management for well over a decade.
Improperly refused to renew Mr M’s pain medication prescriptions.
Failed to prescribe adequate medication to manage the patient’s evident and well-documented pain.
Failed to provide a taper or bridge medication to help transition off pain medication and to lessen withdrawal symptoms.
Failed to appreciate the physical and mental dangers of acute opioid withdrawal.
Failed to take adequate steps to prevent or minimize the severe effects of withdrawal from long-term opioid dependence.
Failed to refer the patient to a pain specialist or detoxification center after declining to renew his prescriptions.

The expert’s list of the clinicians’ failures was extensive and blamed the supervising physicians as well for failing the patient.

---

Members don't see this ad.

 

[IAmTheOne1]

The majority of us will likely agree that for non-cancer pain, the MME was too high (225/day) and the retiring PCP was over-prescribing.

With that being said, this patient was left high and dry. The appropriate thing to do would have been to provide a bridge prescription (even at a lowered dose if there was fear of prescribing this high of an MME) at the very least and refer to either addiction medicine, pain management, or rehab/detox center. If the PDMP was checked and it was clear that the patient has been on this dose for an extended period of time, there shouldn't be fear of continuing the dose temporarily until a definitive plan can be made.

If the new PCP office had a broad-sweeping policy in place to not prescribe any opiates, this should have been reviewed prior to accepting to initiate care of the patient.

 

[Agast]

Who is left holding the bag for someone like this?

I’ve had opioid orphans show up on my doorstep and I politely tell them I’m not comfortable with their regimen and won’t accept them as a patient. They all have PCPs so does it fall to the PCP? Or do we share responsibility.

 

[drusso]

Who is left holding the bag for someone like this?

I’ve had opioid orphans show up on my doorstep and I politely tell them I’m not comfortable with their regimen and won’t accept them as a patient. They all have PCPs so does it fall to the PCP? Or do we share responsibility.

The opioid refugee problem is real. Every time a pill shuts down or a surgeon with questionable competency leaves town who's been prescribing to patients following bad surgical outcomes, pain clinics are overrun with patients down to their last two fill-in-the-blanks with no refills and no options.

 

[CleanUp]

Such a slippery slope!

1. What is “too high” of a dose in the eye of the public?

2. What does involving a pain medicine specialist have to do with anything? Which one worth her salt will opioids are indicated for non cancer chronic pain?

3. Has anyone died from opioid withdrawal?

4. An evaluation occurs every time the Rx is refilled (or denied). Just because someone has been written before doesn’t mean it has to be continued. Some forget this. Besides, there are emergency rooms who can give a short term supply, if needed.

Like someone said it’s not the poor pain doc who inherits these patients who should be liable. It’s the person who started this and left town.

If the states provided some immunity in this regard we as pain physicians would step up. Until then it is too fraught with liability IMHO

 

[callmeanesthesia]

Thanks for sharing. I’ll now be reminding our referral coordinators to tell all new patients up front that we do not manage opioids.

 

[GoBeers]

who the hell was this "expert physician"

 

[specepic]

part of our NEW PATIENT triage involves finding out whether they are on opioids from somewhere else, and they have to agree they understand we are consulting not rx'ing. This is documented by triage staff prior to appointment

the few times we takeover RX from PCP it almost always goes sideways. the pcp's dont enforce rules or structure and it is a culture shock for the pt

 

[IAmTheOne1]

Such a slippery slope!

1. What is “too high” of a dose in the eye of the public?

2. What does involving a pain medicine specialist have to do with anything? Which one worth her salt will opioids are indicated for non cancer chronic pain?

3. Has anyone died from opioid withdrawal?

4. An evaluation occurs every time the Rx is refilled (or denied). Just because someone has been written before doesn’t mean it has to be continued. Some forget this. Besides, there are emergency rooms who can give a short term supply, if needed.

Like someone said it’s not the poor pain doc who inherits these patients who should be liable. It’s the person who started this and left town.

If the states provided some immunity in this regard we as pain physicians would step up. Until then it is too fraught with liability IMHO

Opioid withdrawal itself is not life threatening but the psychological manifestations which led to this death are, namely suicide.

ER is not appropriate for this situation.

Blaming the original PCP is fine but it doesn’t solve the problem. This patient and their opiate regimen existed, you cannot undo the past. Saying “well the retiring doc shouldn’t have started these meds in the first place, this is all their fault” doesn’t solve this real person’s problem in the moment that it existed.

Yes, the retiring doc could’ve and should’ve done this, that and the other. But they are long gone in the moment.

The new PCP office needed to, at least temporarily, do something. Can either continue the regimen, taper the regimen, start suboxone, send for inpatient detox.

 

[SSdoc33]

no way.

if that patient get through the door somehow i am still not prescribing opioids.

we can b&tch about all the things wrong with pain medicine, but thank your lucky stars you are not a PCP. id honestly rather be in construction or landscaping, or garbage pick up

 

[A Deep Breath]

Thanks for sharing. I’ll now be reminding our referral coordinators to tell all new patients up front that we do not manage opioids.

I’ve been tempted to do this, but haven’t because referral sources know I don’t prescribe opioids, so they’re asking for my opinion regardless. And I’m not especially in a position to be turning down referrals with a slow growing new practice. When there’s an obvious opioid seeker calling multiple times per day to schedule, we will inform them of my policy.

This strategy has actually worked out well by the numbers. I’ve had a lot of patients get off opioids and fixed their pain with appropriate procedures.

However, I spend way more time than I’d like thinking about upcoming patients who might be expecting me to take over opioids. For my sanity, I may just alert all patients as early as possible.

 

[bedrock]

Thanks for sharing. I’ll now be reminding our referral coordinators to tell all new patients up front that we do not manage opioids.

Agree. Though every patient who requests an appointment to see me is told this and our schedulers are actually very good about screening. That said I do have less than 5 patients on butrans and one on belbucca because they were long term patients of mine and no one would help them. But zero patients on standard opioids and officially I do not manage them.

This situation is why officially I don't manage opioids. It is also why other docs and mid levels avoid opioids such as this scenario and don't let these patients through the front door.

Several docs here on SDN have stated that if they get a trainwreck like this, that they specifically avoid writing a single opioid script so that they don't get sucked into "owning the patient"

This is basically the Kobayashi Maru of pain medicine--
If you don't write anything you can be blamed.
If you give them a single script and the patient ODs with it or more commonly the patient then demands a refill because no one else will and then you'll be blamed if they kill themselves after you don't write the second script!!!

I don't want to make this political, but the biggest thing that would convince me to assist in these scenarios would be national tort reform and national protections for docs trying to do the right thing. Unfortunately the democrats get very large donations from ambulance chasers to specifically ensure that Tort reform doesn't happen.

Utimately patients pay the price.

 

[Laryngospasm]

Agree. Though every patient who requests an appointment to see me is told this and our schedulers are actually very good about screening. That said I do have less than 5 patients on butrans and one on belbucca because they were long term patients of mine and no one would help them. But zero patients on standard opioids and officially I do not manage them.

This situation is why officially I don't manage opioids. It is also why other docs and mid levels avoid opioids such as this scenario and don't let these patients through the front door.

Several docs here on SDN have stated that if they get a trainwreck like this, that they specifically avoid writing a single opioid script so that they don't get sucked into "owning the patient"

This is basically the Kobayashi Maru of pain medicine--
If you don't write anything you can be blamed.
If you give them a single script and the patient ODs with it or more commonly the patient then demands a refill because no one else will and then you'll be blamed if they kill themselves after you don't write the second script!!!

I don't want to make this political, but the biggest thing that would convince me to assist in these scenarios would be national tort reform and national protections for docs trying to do the right thing. Unfortunately the democrats get very large donations from ambulance chasers to specifically ensure that Tort reform doesn't happen.

Utimately patients pay the price.

exactly this 1000x.. take over these patients or they will sue.. you took over this patient and something bad happened now we sue.. what bunch of b.s.

 

[PinchandBurn]

Agree. Though every patient who requests an appointment to see me is told this and our schedulers are actually very good about screening. That said I do have less than 5 patients on butrans and one on belbucca because they were long term patients of mine and no one would help them. But zero patients on standard opioids and officially I do not manage them.

This situation is why officially I don't manage opioids. It is also why other docs and mid levels avoid opioids such as this scenario and don't let these patients through the front door.

Several docs here on SDN have stated that if they get a trainwreck like this, that they specifically avoid writing a single opioid script so that they don't get sucked into "owning the patient"

This is basically the Kobayashi Maru of pain medicine--
If you don't write anything you can be blamed.
If you give them a single script and the patient ODs with it or more commonly the patient then demands a refill because no one else will and then you'll be blamed if they kill themselves after you don't write the second script!!!

I don't want to make this political, but the biggest thing that would convince me to assist in these scenarios would be national tort reform and national protections for docs trying to do the right thing. Unfortunately the democrats get very large donations from ambulance chasers to specifically ensure that Tort reform doesn't happen.

Utimately patients pay the price.

Also. We as community docs can not take on this sort of patient.

Hospitals and Academia is where these patients should get help from. They get federal subsidiaries and have the resources to address these types of patients..

 

[lobelsteve]

There were many mistakes in this case. The retiring PCP left his patient without clear instructions or referral to a pain specialist. He should have helped Mr M find a new provider who would continue the opioids, or he should have helped the patient to taper off his medications before he left his practice. Instead, the PCP retired and left his patient with no continuity of care.

It is not clear whether the PA had access to Mr M’s previous medical records at the time of their meeting. However, not treating a patient who is opioid-dependent is negligent. Mr M was not offered anything to help with his pain or offered medical management of his opioid withdrawal, a short prescription for pain relief, or a referral to a pain specialist. He was sent home in physical pain with no recourse.

The article listed what the PA did wrong. And what they ought have done. Zofran and Zanaflex, PT, referral for procedure, referral for counseling.

Had similar patient recently who lived here but was going out of state to get Rxs. Failed UDS there. Wanted to establish with me with last pill in hand, no outside records. Denies illicit found on UDS (PCP documented the failed UDS).

I gave him the above. But not the opiates.

 

[Ducttape]

Opioid withdrawal itself is not life threatening but the psychological manifestations which led to this death are, namely suicide.

ER is not appropriate for this situation.

Blaming the original PCP is fine but it doesn’t solve the problem. This patient and their opiate regimen existed, you cannot undo the past. Saying “well the retiring doc shouldn’t have started these meds in the first place, this is all their fault” doesn’t solve this real person’s problem in the moment that it existed.

Yes, the retiring doc could’ve and should’ve done this, that and the other. But they are long gone in the moment.

The new PCP office needed to, at least temporarily, do something. Can either continue the regimen, taper the regimen, start suboxone, send for inpatient detox.

blame does lie primarily on the original physician.

the solution is a systemic one, because unless a systemic solution is made, then these opioid refugees will continue to show up.

1. dont prescribe opioids for nonmalignant chronic pain, unless palliative. to all the PCPs out there - just dont do it.
2. dont refer to a PCP or pain specialist and think that that is the solution. a secondary plan - ie opioid taper - is necessary for when this "plan" falls through the cracks.
3. the new PCP should not be forced to do something they feel unqualified to do.
4. they have options.
- there may be a dose the new PCP feels qualified to prescribe.
- they should discuss opioid withdrawal and provide medications to help with withdrawal.
- they can give information on detox programs.
- they can send patient to ER for emergent psych eval for suicidal ideation if patient expresses such thoughts.

and fwiw, they settled rather than go through a trial, so one can debate ultimate blame.

im pretty sure an expert witness for the defense would show that what the old PCP was prescribing was outside the standard of care (probably at least 225 MED, but some people take 1-2 oxys every 4 hours...), that they did not provide appropriate discharge care, and that they bear the brunt of the responsibility.


(and opioid withdrawal rarely kills unless there are concomitant severe underlying health issues - ie cardiac)

 

[kstarm]

I think this article does bring up a good question. I have taken the stance with these referrals that it is bupe or taper off which has worked well for me. I do now have a number of geriatric patients and legacy patients on bupe. If I retire in 10 years what do I do with them. In the current climate the amount of work to find people to take these patients over sounds daunting. Just offer taper as I get to 1 year out from retiring. Just retire and say, well I'm done someone else needs to figure it out?
I'm actually more concerned about my partner who has lots and lots of people on very low dose opioids.

What is your exit plan for your COT patients when you retire, leave practice, etc?

 

[SSdoc33]

I don't want to make this political, but the biggest thing that would convince me to assist in these scenarios would be national tort reform and national protections for docs trying to do the right thing. Unfortunately the democrats get very large donations from ambulance chasers to specifically ensure that Tort reform doesn't happen.

this may be true, but please provide evidence that this is the case. most of what i am finding is the contrary

 

[bedrock]

I think this article does bring up a good question. I have taken the stance with these referrals that it is bupe or taper off which has worked well for me. I do now have a number of geriatric patients and legacy patients on bupe. If I retire in 10 years what do I do with them. In the current climate the amount of work to find people to take these patients over sounds daunting. Just offer taper as I get to 1 year out from retiring. Just retire and say, well I'm done someone else needs to figure it out?

What is your exit plan for your COT patients when you retire, leave practice, etc?

Just give them a full 60 day notice including written notification.

 

[Ducttape]

i plan on telling people 6 months before retirement date. gives patients time to talk to PCP, call to get in to see new pain doc, or elsewise. inaction on their part says a lot.

1-2 months before retirement, there will either be transfer of prescriptions to new doctor, or a prescription with explicit taper instructions

after that time, they can try to contact me at the nursing home ill be at, but they are otherwise on their own...

 

[buddababa]

i plan on telling people 6 months before retirement date. gives patients time to talk to PCP, call to get in to see new pain doc, or elsewise. inaction on their part says a lot.

1-2 months before retirement, there will either be transfer of prescriptions to new doctor, or a prescription with explicit taper instructions

after that time, they can try to contact me at the nursing home ill be at, but they are otherwise on their own...

i hope if they try to contact you, you wont be in a nursing home, rather enjoying early retirement in a tropical paradise!

 

[Ducttape]

older when i had kids. and half my career was not as a well-compensated pain physician.

odds are that i will keel over in the office some day...

 

[cowboydoc]

i plan on telling people 6 months before retirement date. gives patients time to talk to PCP, call to get in to see new pain doc, or elsewise. inaction on their part says a lot.

1-2 months before retirement, there will either be transfer of prescriptions to new doctor, or a prescription with explicit taper instructions

after that time, they can try to contact me at the nursing home ill be at, but they are otherwise on their own...

This sounds like a fantastic, responsible plan. Most aren't as diligent/thoughtful as you.

older when i had kids. and half my career was not as a well-compensated pain physician.

odds are that i will keel over in the office some day...

How do you plan to predict your death 6 months in advance and communicate that plan to your patients and other clinicians?

 

[Ducttape]

actually......

 

[au bon pain]

This is basically the Kobayashi Maru of pain medicine--
If you don't write anything you can be blamed.
If you give them a single script and the patient ODs with it or more commonly the patient then demands a refill because no one else will and then you'll be blamed if they kill themselves after you don't write the second script!!!

I don't want to make this political, but the biggest thing that would convince me to assist in these scenarios would be national tort reform and national protections for docs trying to do the right thing. Unfortunately the democrats get very large donations from ambulance chasers to specifically ensure that Tort reform doesn't happen.

Utimately patients pay the price.

This is spot on...and extra props for the reference. Best option is to pre-screen. But should one slip through (and assuming no clear patient red flags) then depending on your stance and state you practice in, probably the best 2 options I can think of are:

A) Have every patient new patient sign, as part of treatment agreement before seeing you, a form informing them that the initial visit is for consultative/recommendation purposes only and that does not mean an ongoing doctor-patient relationship will be established and there is no guarantee of anything being prescribed. If they don't sign, they cannot be seen. When patient asks you to anyway, refer them to what they already signed.
-and/or-
B) Decide to prescribe with the clear understanding to the patient it is only for the purposes of dignified taper...and that every single prescription will be for a fewer # than the prior and without exception. Speed of which will depend on the clinical picture.

the solution is a systemic one, because unless a systemic solution is made, then these opioid refugees will continue to show up.

Exactly. There needs to be recognition that these folks are the byproduct of the combination of a failed therapeutic paradigm within a very imperfect health care "system." Nobody really knows what the"correct" thing to do is for legacies. As such, at a minimum, a wider medico-legal birth needs to be given for docs who chose to stick their necks out and try to help manage these patients.
As an imperfect starting point, but at least a starting point, having something roll out (like the 2016 opioid CDC guidelines) to specifically address legacies that has multiple pain physicians as authors could get the ball rolling.
Otherwise what you're left with is the perpetual collection of "interest" groups all pointing fingers and delivering empty commentary without a wisp of a pragmatic framework to go forth with and try to help these patients.

 

[mdo1738]

Ultimately the retiring PCP is the only one who should be held liable. It was his obligation to have a viable management strategy in place before he retired. “Keep my prescriptions going at 225 daily MME until they show up with zero meds on the pain doc’s doorstep after I retire” is not a viable strategy. His obligation to attempt tapering before he retired. If he’s not smart enough to design a taper, it’s his obligation to try to find pain doctors before he retires, and have that patient start seeing that pain doctor before he retires as well. If he can’t do that, then it’s his responsibility to just give the patient meds for symptomatic management of withdrawal. And if he can’t do any of those things, then sue him.

The new pain clinic had zero obligation to prescribe any opioid, let alone what the original doc was doing. But I will say, even though there should be no legal obligation, it is a bit shortsighted on their part to not make part of their new patient triage process making it explicitly clear (and acknowledged by the patient in writing) that the clinic is under no obligation to prescribe anything at all. Having the patient’s signature a couple weeks in advance on something stating he understands he is not entitled to an opioid prescription would render all that moot.

 

[cowboydoc]

Ultimately the retiring PCP is the only one who should be held liable. It was his obligation to have a viable management strategy in place before he retired. “Keep my prescriptions going at 225 daily MME until they show up with zero meds on the pain doc’s doorstep after I retire” is not a viable strategy. His obligation to attempt tapering before he retired. If he’s not smart enough to design a taper, it’s his obligation to try to find pain doctors before he retires, and have that patient start seeing that pain doctor before he retires as well. If he can’t do that, then it’s his responsibility to just give the patient meds for symptomatic management of withdrawal. And if he can’t do any of those things, then sue him.

The new pain clinic had zero obligation to prescribe any opioid, let alone what the original doc was doing. But I will say, even though there should be no legal obligation, it is a bit shortsighted on their part to not make part of their new patient triage process making it explicitly clear (and acknowledged by the patient in writing) that the clinic is under no obligation to prescribe anything at all. Having the patient’s signature a couple weeks in advance on something stating he understands he is not entitled to an opioid prescription would render all that moot.

What will they do to the retiring doc, take away their license?

 

[mdo1738]

What will they do to the retiring doc, take away their license?

It said it was a lawsuit, not a board action. He has no need for his license but does have need for money.

 

[PinchandBurn]

What will they do to the retiring doc, take away their license?

How about if retiring MD worked as a hospital employee?

If He likely belongs to a hospital group and assumed when he retired someone from his group would tk over. Is tht the MDs fault or the hospital?

 

[Ducttape]

it is still his patient. he still bears responsibility to ensure safe transfer of care.