Unilateral termination of treatment

[Amygdarya]

Kind of a random question but I'm curious: if a patient that has an established treatment relationship with a psychiatrist decides to quit the treatment unilaterally for whatever reason (moving to a different city, family/job pressures that don't leave time to see a psychiatrist, doing it on an impulse or whatever other reason), when does that psychiatrists's responsibility for the patient end? I.e. will the psychiatrist be in trouble if the patient's condition worsens soon after quitting? Or is it like once the patient quits unilaterally, the psychiatrist is off the hook right away? If not, how can psychiatrists protect themselves with quitting patients?
(I understand that it's different when it's the psychiatrist who initiates termination; that situation has been discussed here before.)

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[smalltownpsych]

In my mind, it would depend on why the patient terminated and what treatment had entailed prior to this sudden termination. In other words, if you are providing reasonable care and patient decides to quit treatment and decompensates and hurts themself or others, I don't think that a reasonable judge or jury would hold you liable. On the other hand, if you are not following an established standard of care and this might have been the precipitant for patient's abrupt termination, then you might have a bit more liability. I also think time has a role too. Much greater chance of being held liable if patient walks out of your office and starts shooting as opposed to it happening a year down the road. There is no firm time limit on this as it is all decided on a case by case basis and by precedent. I am not familiar with any precedent setting cases where the doc was held liable after patient terminated, most of them involved concurrent treatment, but that doesn't mean it hasn't or won't happen.

The one thing that could get someone in trouble is a Tarasoff type of situation where there was some documentation that the patient had communicated threats and the treating psychiatrist or psychologist took no appropriate actions. Also, I could be wrong, but that has been expanded based on a recent ruling to mean not just a threat to an identifiable individual which is why a psychiatrist and I eventually contacted law enforcement regrading a patient's escalating threats despite them not being directed at a specific individual.

 

[666357]

They're still your patient, and your responsibility, until the termination of treatment. If they end it, you need to document it. If they just stop coming and their treatment requires ongoing follow-up appt's, you need to send a letter of termination with the caveat that you'll treat them under emergent situations for 30days until they find a new provider. Ideally, you'll want to meet and decide mutually to end treatment. I send out termination letters based on risk. A high risk patient who is noncompliant is a liability. The best thing you can actually do for them is terminate your relationship when they become repeatedly noncompliant- they need to develop insight into their illness and you're just enabling them and reinforcing that behavior when they stop coming and are high risk for suicide, mood or psychotic episodes, etc. I have my staff call high-risk no-shows and reschedule them. If they fail to show up for a 2nd appt in a row, I send out a termination letter. If my staff contacts them and they decline to follow up, I add a two sentence note to the effect that I attempted to follow up, they declined treatment, and that the relationship is ended. If we're unable to reach them, we document and try again within a week. If we're unable to get in touch, we send out a termination notice stating our attempts to reach them.
With low-risk patients (ie ADHD, situational anxiety, etc), I leave it open-ended. Some prefer to be able to call when they need to come in for a f/u appt. If they tend to be quick follow up types, I allow it. If they require a lengthier session, I tell them they need to adhere to the treatment regimen and require them to show up at they're scheduled appt's, mainly because it's more difficult to work those patients in on a walk-in basis.
Bottom line, follow up with high-risk no-shows. Cut loose non-compliant patients. Document. It's better for them. It's better for you. It lowers your liability. It's better for your business (if you're self-employed). Always explain the need for patients to show up for their scheduled appointments and that you'll be unable to treat them if they cannot show up for them. Managing your risk gives you peace of mind.

 

[PikminOC]

I don't leave anything openended

 

[Ceke2002]

Interesting this topic has been bought up, because I'm currently in this situation myself (sort of, or at least I will be). My husband and I will be moving interstate sometime next year, my Psychiatrist is aware of this, and obviously that I will be terminating treatment with him when the time comes. I am currently seeking a Psychiatrist I can hopefully transfer to when we move, and my current Psychiatrist has been assisting me with that (knowing that I still have some trust issues with Psychiatrist I don't know, he has already taken it upon himself to very kindly ring colleagues interstate, and provide me with a short list of recommended providers); however, there is clearly a chance that I won't necessarily just be able to move and go 'hey presto, new Psychiatrist' so my current Psychiatrist has also offered to try and maintain some level of email contact with me, in the interim, until I have found someone I feel comfortable enough with to transfer my treatment over to. My current treatment has also shifted, by mutual discussion and agreement, from a long term psychodynamic type approach, to more of a focused CBT one.

Once I have terminated treatment, and moved interstate, even if I do maintain short term email contact with my current Psychiatrist, whilst I am looking for a new provider, I certainly don't feel as if he would still have a duty of care towards me, nor would I expect him to be held accountable if my condition were to deteriorate for any reason.

 

[Shikima]

If terminating treatment. Be sure to send a letter, let them know you'll cover for a month for prescription needs and emergencies and that you give them a listing of alternative services in their area. Once that time frame is up, you're done.

 

[splik]

why are you asking this question?

if the patient is moving etc then I will usually provide them with with adequate refills until they can find a new psychiatrist and try and help them with it if they ask. btw the whole one month thing is a guideline, we are not compelled to do this, you can decide how much, if any, meds to prescribe (sometimes I will offer up to 3 additional refills if patient is stable and I know they will have a hard time finding another doc, in other cases, nothing at all). You can also decide to provide some meds and not others. As long as you explain your reasoning, and send a letter to the patient, you're good.

if they are nasty piece of narcissistic work and fire me because of their cluster b issues, they can f**k right off as far as I'm concerned. Letter sent. no meds or refills. goodbye and good riddance (you can see i have a quite a strong negative countertransference towards certain patients!)Though I've had some patients flee treatment and it has been my fault (for example pushing harder than they were ready for etc) and in the case I will keep the door open, send a letter apologizing for driving them away, and offer to help them establish care with someone else if they would like.

The only thing you absolutely have to do is provide records to the next psychiatrist in a timely manner. you can't withhold them due to unpaid bills etc

 

[666357]

"btw the whole one month thing is a guideline, we are not compelled to do this, you can decide how much, if any, meds to prescribe"

True, but most medical board have guideline for this and 30 days is the convention in most states. However, you're not necessarily obligated to continue any and all medications. If someone was terminated because they were abusing prescription medications or street drugs, then you can withhold any controlled substances. If BZD withdrawal is a concern, you can advise them to go to the nearest ED for inpt detox.

"The only thing you absolutely have to do is provide records to the next psychiatrist in a timely manner. you can't withhold them due to unpaid bills etc"

No, but you can make them pay for the records first (at least in my state). To clarify, you can't hold them until they pay any past due balances, but you can hold them until they pay the fee for copies and S&H. In my state, it's $1 for the first 25 pages, 50 cents per page thereafter, $5 search fee, and actual shipping costs.
Also, if your therapy notes are integrated with your SOAP note, then you may redact that data.

 

[splik]

"The only thing you absolutely have to do is provide records to the next psychiatrist in a timely manner. you can't withhold them due to unpaid bills etc"

No, but you can make them pay for the records first (at least in my state). To clarify, you can't hold them until they pay any past due balances, but you can hold them until they pay the fee for copies and S&H. In my state, it's $1 for the first 25 pages, 50 cents per page thereafter, $5 search fee, and actual shipping costs.
Also, if your therapy notes are integrated with your SOAP note, then you may redact that data.

im talking about providing records to other providers, which you can't charge for

 

[666357]

im talking about providing records to other providers, which you can't charge for

Maybe in your state, but not mine:

(2) Access. On the request of a patient, and with the authorization of the patient, a physician should provide a copy or a summary of the medical record to the patient or to another physician, attorney or other person designated by the patient. By state law, a physician is allowed to condition the release of copies of medical records on the payment by the requesting party of the reasonable costs of reproducing the record. Reasonable cost as defined by law may not exceed one dollar ($1.00) per page for the first twenty-five (25) pages, fifty cents ($.50) per page for each page in excess of twenty-five (25) pages, a search fee of five dollars ($5.00) plus the actual cost of mailing the record. In addition, the actual cost of reproducing x-rays or other special records may be included. Records subpoenaed by the State Board of Medical Examiners are exempt from this law.

Note: Emphasis is mine. Also, it does go on to say that it would be courteous to waive the fee if another doctor requests the chart or if the pt is poor, but you're not required to do so.

 

[Therapist4Chnge]

1. Know your state laws, as some states can have funky wording or pick an arbitrary number of days, number of referral names, etc.
2. Consult with someone locally, just in case. You could also call the licensing board anonymously (sometimes, not always) and ask.
3. Document, document, document.

I never leave anything open-ended because you just never know. Thankfully in my practice it is standard practice to terminate following evaluation…and that is that. For on-going treatment, I would definitely document calling, mailing a letter w referrals (and instructions, as appropriate), and anything else your state may require. Tarasoff is a fun twist in all of this, as previously mentioned. Best of luck.

 

[VA Hopeful Dr]

Generally speaking, if the patient terminates the relationship then it ends at that time and you have no further responsibilities. If we terminate, we're expected to continue care for some amount of time to avoid abandonment (usually 30 days, but each state will have different standards).

 

[Amygdarya]

Thank you for your responses everyone! This has been a very informative/insightful discussion.

why are you asking this question?

etc

Well, as I'm contemplating my specialty choice, I'm trying to consider all things specific to psychiatry that could scare the cr*p out of me Some of my other concerns, such as personal safety, have been discussed here ad nauseum, but I don't think this topic was discussed before.

 

[splik]

ah okay, well just remember aside from derm, psychiatry has the lowest rates of malpractice and most cases are thrown out. regardless are chances are you will be sued even if you do everything right

 

[hamstergang]

Well, as I'm contemplating my specialty choice, I'm trying to consider all things specific to psychiatry that could scare the cr*p out of me

How is this topic specific to psychiatry?

 

[Amygdarya]

ah okay, well just remember aside from derm, psychiatry has the lowest rates of malpractice and most cases are thrown out. regardless are chances are you will be sued even if you do everything right

Well, that's reassuring haha (seriously though, I do know that most physicians get sued at some point over the course of their practice even if they don't necessarily do anything wrong)

 

[Therapist4Chnge]

ah okay, well just remember aside from derm, psychiatry has the lowest rates of malpractice and most cases are thrown out. regardless are chances are you will be sued even if you do everything right

Does anyone know what speciality has the highest % of cases settled or lost? OBGYN? One of the Surg sub-specialities?

 

[splik]

Does anyone know what speciality has the highest % of cases settled or lost? OBGYN? One of the Surg sub-specialities?

either ortho or neurosurg - spinal surgery in particular. on is up there too of course

 

[Amygdarya]

How is this topic specific to psychiatry?

Because of the chronic nature of most mental illnesses, where treatment adherence is critical to preventing decompensation and to some (arguably large) extent depends on treatment alliance with psychiatrist, and where acute decompensation can result in actual harm to self and/or others.

 

[Shikima]

Because of the chronic nature of most mental illnesses, where treatment adherence is critical to preventing decompensation and to some (arguably large) extent depends on treatment alliance with psychiatrist, and where acute decompensation can result in actual harm to self and/or others.

But not the CHFer who loves to go to the Chinese buffet and not use his BPAP. No decompensation there....

 

[Amygdarya]

But not the CHFer who loves to go to the Chinese buffet and not use his BPAP. No decompensation there....

Ha, I expected this kind of response. Sure, all patients are free to harm themselves in all kinds of ways. However, therapeutic alliance is more important in psychiatry (as a practicing psychiatrist you probably know this better than I do), and breach of alliance can lead to dropping out of treatment and decompensating. Alternatively, as splik alluded to above, patients may quit if a psychiatrist pushes too hard, or they can drop out because of some transference reaction etc, all of which seem to be less of a factor in other fields of medicine. To put it more concisely, the way I see it (and, obviously, I'm just a medical student), physician-patient relationship plays a bigger role in psychiatry - both in adherence to treatment and as a treatment itself - so if a patient quits abruptly and decompensates, I will wonder if there was a breach in therapeutic alliance and if I am ultimately culpable.

 

[Jules A]

Ha, I expected this kind of response. Sure, all patients are free to harm themselves in all kinds of ways. However, therapeutic alliance is more important in psychiatry (as a practicing psychiatrist you probably know this better than I do), and breach of alliance can lead to dropping out of treatment and decompensating. Alternatively, as splik alluded to above, patients may quit if a psychiatrist pushes too hard, or they can drop out because of some transference reaction etc, all of which seem to be less of a factor in other fields of medicine. To put it more concisely, the way I see it (and, obviously, I'm just a medical student), physician-patient relationship plays a bigger role in psychiatry - both in adherence to treatment and as a treatment itself - so if a patient quits abruptly and decompensates, I will wonder if there was a breach in therapeutic alliance and if I am ultimately culpable.

I believe the instances when a patient isn't compliant secondary to something the provider did or didn't do are few and far between. While I appreciate your thoughtfulness it is more likely the majority of cases of dropping out of treatment have more to do with the fact that mental health patients are historically non-compliant for a whole host of reasons including the disease process itself and psychosocial issues. Not that a therapeutic alliance isn't helpful just that I wouldn't spend too much time analyzing your role every time you have a patient who is non-compliant.

 

[Shikima]

In short, you're trying too hard.

 

[smalltownpsych]

In short, you're trying too hard.

On the other hand, better that they are trying too hard as a student as opposed to the alternative. Somewhere between youthful optimist and cynical old burnout is hopefully where we all end up. Lately I've been feeling a little too far to the grumpy old man side so it is nice to get a bit of vicarious optimism from time to time. That is one good thing about students. It also eases my stress to see them worrying about stuff we don't really need to worrry about. Now back to my battle with county attorney over this involuntary commitment. Ugh

 

[Amygdarya]

In short, you're trying too hard.

Ok