Terminating patient care immediately?

[finalpsychyear]

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I understand in most cases a patient needs to be given meds for 30 days and a certified letter. But if a patient verbally threatens your staff and you and verbally states they aren't coming back to staff/provider aren't you allowed to terminate immediately given such circumstances?

 

[birchswing]

Is it a coincidence that your last post was asking if it was OK to stop a patient's benzos cold turkey when covering for another provider?

Edit: Next to last. The last one was about worrying patients would be too impressed with your car.

 

[wolfvgang22]

Is it a coincidence that your last post was asking if it was OK to stop a patient's benzos cold turkey when covering for another provider?

Edit: Next to last. The last one was about worrying patients would be too impressed with your car.

To be fair, I've been threatened before by a person with alcoholism for suggesting we reduce his clonazepam from 4mg daily some quack gave him to 3.75mg daily to begin a slow taper. The guy threatened to kill me. Yes, I terminated care. No, I don't care if people might think I'm mean in this case. I believed the guy. I'd rather work with outpatients who don't threaten to kill me or my nurses. I've had a few patients threaten us with violence over the years, not most, but it should always be taken seriously.

Yes, you can terminate the patient immediately, and you can also call police and file for a restraining order if neccessary if you have been threatened with violence. Send the certified letter, write that last prescription. Make sure your letter spells out he is no longer allowed on clinic premises, or he is trespassing if this is your private clinic. Maybe the next psychiatrist will be a better fit for this patient. I'm sorry you didn't learn this in residency. If this is not your own clinic, speak with your clinic manager about this, or administration if you are in a larger organization and are unclear on what to do. Every clinic should have set written policies about this, and if you don't you should develop one now. Look up your state's relevant regulations on this and follow them.

 

[downwithDTB]

I understand in most cases a patient needs to be given meds for 30 days and a certified letter. But if a patient verbally threatens your staff and you and verbally states they aren't coming back to staff/provider aren't you allowed to terminate immediately given such circumstances?

This is a state specific issue; however, safety first and involve the police if needed!

 

[birchswing]

To be fair, I've been threatened before by a person with alcoholism for suggesting we reduce his clonazepam from 4mg daily some quack gave him to 3.75mg daily to begin a slow taper. The guy threatened to kill me. Yes, I terminated care. No, I don't care if people might think I'm mean in this case. I believed the guy. I'd rather work with outpatients who don't threaten to kill me or my nurses. I've had a few patients threaten us with violence over the years, not most, but it should always be taken seriously.

Yes, you can terminate the patient immediately, and you can also call police and file for a restraining order if neccessary if you have been threatened with violence. Send the certified letter, write that last prescription. Make sure your letter spells out he is no longer allowed on clinic premises, or he is trespassing if this is your private clinic. Maybe the next psychiatrist will be a better fit for this patient. I'm sorry you didn't learn this in residency. If this is not your own clinic, speak with your clinic manager about this, or administration if you are in a larger organization and are unclear on what to do. Every clinic should have set written policies about this, and if you don't you should develop one now. Look up your state's relevant regulations on this and follow them.

I'm sorry you went through that. No one should have to fear for their safety like that.

In the last thread, I wrote how if he did end up just cutting patients off cold turkey, they'd probably go to the ER and get referred to another provider. Then reading this I started thinking some people don't have great coverage or no coverage and avoid the ER like the plague as a result. So it could get bad. I don't want to justify threats of violence, and I certainly wouldn't in the case of a slow taper, but in the case of a cold turkey, that's kind of like cornering a wild animal. Not to say that's what happened. Just that the two posts came close in time.

It's interesting you mentioned your patient had alcoholism. I used to wonder if a patient with no other resort who had been on benzodiazepines but could no longer be on them suddenly would turn to alcohol the way someone prescribed an opioid would turn to heroin when the prescribed opioid was no longer available. I did some research on a recreational drug use forum and according to their accounts using alcohol for benzo withdrawal is more of a nightmare than benzo withdrawal itself. I've never had alcohol in my life so I can't speak to the experience of how they feel compared to benzos. But according to people in this forum who tried using alcohol in benzo withdrawal, they would try alcohol and said it made them worse. Some had both the experience of having come off both alcohol and benzos at different times and said benzos helped coming off alcohol but alcohol did not help coming off benzos. Anyhow quite tangential, but I found it was interesting. I don't know the mechanisms. I assume alcohol is more of a "carpet bomb" and benzodiazepines are more selective.

Edit: I looked it up and it's both a GABA agonist and glutamate antagonist, which would presumably both be beneficial in benzodiazepine withdrawal. But I noted it has a rather short half life (4.5 hours) which may be what makes it problematic.

 

[splik]

I understand in most cases a patient needs to be given meds for 30 days and a certified letter. But if a patient verbally threatens your staff and you and verbally states they aren't coming back to staff/provider aren't you allowed to terminate immediately given such circumstances?

The meds for 30 days thing is a widely repeated myth based on AMA guidance (the AMA are irrelevant) and as mentioned about this is state specific. However, the general wisdom is that you need to give patients whatever supply of medications you feel is appropriate (and or you feel comfortable with). So for example if you deem it appropriate to give nothing you could, and if you wanted to give 3 months worth of supply you could. You just need to document your rationale. Sending a letter via certified mail for termination along with a list of referrals (you must provide some sort of signpost for referrals) is considered best practice as well. You must also offer to provide the patient's medical records to their next clinician, and must never hold patient's records to ransom for unpaid bills.

 

[wolfvgang22]

(the AMA are irrelevant)

I love this. I can't recall the last time the AMA represented either my interests or my patient's interests rather than their own self serving interests.

That said , if everyone is following AMA guidelines in your area, wouldn't that then be the "standard of care" expected?
I'm in favor of not leaving patients hanging without meds anyway, so I tend to write a 90 day refill to patients I terminate, and will sometimes refill non controlled meds once more, given there aren't many timely options for care in my area. It seems most patients wait 6 months to establish with a psychiatrist outside my organization. I only write one 30 day script of controlled substances.

 

[whopper]

State Specific.

E.g. in Ohio it was codified into law that you are to provide a termination letter via certified mail and offer up to 1 month's worth of medications.

I currently practice in Missouri. There is no codified state law on how to terminate patients. Despite this I still follow the above because a lawyer could pull the argument that despite that there aren't codified laws that the standard of care in many states follow the above so this should be a standard-of-care argument and not one already codified into state law.

Many sources also recommend a referral to 3 sources. Again this may not be in your state's laws but a lawsuit could argue that this is the standard since it is recommended in several sources that are considered respected such as medical textbooks and lectures.

The meds for 30 days thing is a widely repeated myth based on AMA guidance (the AMA are irrelevant)

I wouldn't push this argument. In several occasions courts have used AMA or APA guidelines as an acceptable standard. In many SCOTUS cases they invited APA opinions to help them guide their judgments. If you didn't break a state law you could still lose a non-criminal probate case such as a malpractice or abandonment case. Those cases don't involve breaking state or federal law but violating civil laws.

Standard of Care need not be codified into law. E.g. I'd bet appropriate insulin dosages aren't codified into law. If a doctor gave too much insulin I'm sure the court wouldn't rely on state laws to determine if the doctor committed malpractice but practice guidelines available through several sources such as scientific studies, practice guidelines, and AMA recommendations.

Bottom line: certified mail, 1 month's worth of prescriptions (but you could argue that you won't do this if you have reason to believe giving 1 month's worth is dangerous for this specific patient), 3 referrals, follow state laws and look them up but if there aren't any still do the above just in case. If there are no state laws on this issue and you don't do the above you have a wiggle-room argument that you didn't break the law but the plaintiff lawyer could still accuse you of not following the standard of care. You wouldn't have broken state law but you could have broken civil law.

One more thing, aside from the law, the ethics and good practice. 3 referrals, certified mail and 1 month's worth of prescriptions is just (usually) good solid practice in termination, looks more professional, and is usually the right thing to do.

 

[Sushirolls]

I'm substituting certified mail with internal Luminello message and attached letter, the same one that gets sent by regular mail.
If people get their intake, and e-sign all the policies with me before their appointment, it's just as good (I posit better) communication line then certified mail.
Come in electronically, can end electronically.

 

[finalpsychyear]

State Specific.


One more thing, aside from the law, the ethics and good practice. 3 referrals, certified mail and 1 month's worth of prescriptions is just (usually) good solid practice in termination, looks more professional, and is usually the right thing to do.

Solid advice and exactly what I was planning to do even though I am angry of the verbal abuse my staff and I endured along with the trespassing into my office room while in session with another patient.

I will learn from this and beef up my office security and realize now that I should always have some type of tazer/mace with me as the situation this time was only verbal but next time you never know. Very helpful advice guys and this did not have anything to do with my NP benzo post as alluded to above.

 

[whopper]

though I am angry of the verbal abuse my staff and I endured along with the trespassing into my office room while in session with another patient.

One could argue that, and you could put this in the chart, that if there are controlled substances you don't feel comfortable giving them out based on his literally illegal actions strongly suggesting strong impulsivity.

In a case like this where the 1-month prescription issue is at question there are alternatives. E.g. "I did not prescribe the 1 month supply sometimes given upon discharge due to the patient suggesting they'd be at high risk and instead prescribed a 1 week supply with referrals to seek immediate care at a detox/rehabilitation facility" with a referral to such facilities.

You could also call the police and tell them the above patient did this because by walking into another patient's session this intruder is breaking the law. I can tell you this, had someone done this in my practice I would've contacted the police even if they left my office cause you are allowed to report such patients to the authorities and they are arguably an immediate danger since they willfully broke the law and in a violent and intrusive manner.

If there is a state law mandating the 1-month supply you likely have no choice, but if there's no state law the above could be an option. If your practice already has a lawyer ask them about beefing yourself up. E.g. consideration of a the lawyer sending a note saying he is not to enter your facility again. Also what my practice does is if we terminate a patient we have a list of patients who are not allowed to ever come back to the office for any doctor cause many of them will just call up the other doctors who don't want to take terminated patients from the other doctors for obvious reasons.

 

[wolfvgang22]

What happens to me a lot is that patients will fire me because I won't prescribe them benzos or more benzos, call me mean and uncaring, and then see every other doctor in the VA before coming back months later to see me because "Those other doctors are dinguses" or "they don't know what their doing" per the patient. I told one guy "Aww, I bet you say that to all the docs!"

 

[MLT2MT2DO]

What happens to me a lot is that patients will fire me because I won't prescribe them benzos or more benzos, call me mean and uncaring, and then see every other doctor in the VA before coming back months later to see me because "Those other doctors are dinguses" or "they don't know what their doing" per the patient. I told one guy "Aww, I bet you say that to all the docs!"

I'm surprised they don't threaten or write their senator. Sounds like your VA is less susceptible medical terrorism than ours was