Verbally abusive patient - discharging question

[paindoc34]

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Hi All,
Hoping to get some advice about a new experience for me. I had a patient who became verbally aggressive and very hostile during a follow-up visit with me over their opioid script. Basically, I had a frank discussion about their non-compliance to my multimodal plan of care (patient has had multiple no shows for recommended procedures) and the fact that they come in every month for opioid and non-opioid refills, without doing any of the other things i suggest (PT, Procedure,etc). Furthermore, UDS x2 detected non-prescribed opioids. I stated that I would not be continuing to write these scripts if they were not willing to be receptive to the other therapies.
They threatened legal action, reporting me to the board, etc.. i ended the visit when their insults became a little personal towards me and my staff. They left before I could discuss weaning / treatment for potential withdrawal.
How do I handle this? Call and let them know they are being discharged for disruptive behavior/UDS? How do I give them medication instructions if they won't hear me out How do I protect myself from being sued or reported for perceived abandonment or lack of time to find a new doctor?

Thanks for your time,
- a fairly green attending

 

[callmeanesthesia]

If you are in a group practice talk to your administrator about discharge procedure. Typically involves a certified letter notifying patient they are being discharged, providing alternative locations, and notifying them of their rights (emergency care for 30 days).
With UDS positive for non-prescribed opioids you are under no obligation to provide a taper. Meds for withdrawal symptoms and referral to suboxone clinic. Document extensively.

 

[soccrwz]

Document verbal abuse/hostile, pt elected to leave prior to discussing other options, DS inconsistent, concern for diversion given no rx meds in system if appropriate, send discharge letter. Document extensively. Pt noncompliant with multimodal plan. Discuss discharge protocol with clinic, but look up d/c procedure ie pt abandonment per your state guidelines.

 

[emd123]

Hi All,
Hoping to get some advice about a new experience for me. I had a patient who became verbally aggressive and very hostile during a follow-up visit with me over their opioid script. Basically, I had a frank discussion about their non-compliance to my multimodal plan of care (patient has had multiple no shows for recommended procedures) and the fact that they come in every month for opioid and non-opioid refills, without doing any of the other things i suggest (PT, Procedure,etc). Furthermore, UDS x2 detected non-prescribed opioids. I stated that I would not be continuing to write these scripts if they were not willing to be receptive to the other therapies.
They threatened legal action, reporting me to the board, etc.. i ended the visit when their insults became a little personal towards me and my staff. They left before I could discuss weaning / treatment for potential withdrawal.
How do I handle this? Call and let them know they are being discharged for disruptive behavior/UDS? How do I give them medication instructions if they won't hear me out How do I protect myself from being sued or reported for perceived abandonment or lack of time to find a new doctor?

Thanks for your time,
- a fairly green attending

You send them a discharge letter by certified mail, and that's it. They have 30 days to find a new doc. For all practical purposes, you're then done. Most states require you to "treat them on an emergency basis" in those 30 days, but true emergencies in chronic pain are rare.

How to avoid board complaints?

Document well. If you get one and you've documented all of the above, you've got nothing to worry about. 99% of the time these patients are all talk and don't do jack.

How to prevent getting sued over this?

Same. Document. Document. Document sound reasoning and make the chart reflect that you had patient safety as #1 on your mind. If you were a lawyer, would you take this numb-skull's case? Hell no. Do the right thing and don't worry about it. Sleep well at night knowing you did so.

 

[Orin]

You have the advantage here if you document thoroughly. Failure to document the interaction, the things you offered, and the abusive behavior will just hurt you, even though it sucks to have to do this. It's difficult for me to understand if you ended the visit or they left, so be clear in your description in the documentation, i.e. "I attempted to counsel them on medication weaning. Unfortunately they became more irate and stormed out before I could do XYZ."

In the future, consider bringing an MA, a scribe, or someone else into the room for these interactions as that gives you another witness to the behavior.

Here's a more detailed guide that's not bad for things to consider:

Terminating Patient Relationships

If it becomes necessary to end a patient relationship, it is critical to end the relationship in a manner that will not lead to claims of discrimination or abandonment, litigation for alleged professional negligence, or complaints to administrative agencies.

www.thedoctors.com

 

[GoBeers]

I've had three patients write complaint to insurance panel after I refused to continue their previous opioids regimen. 1) i stopped giving patient tramadol after she tested positive for non-prescribed opioid. 2) i stopped giving patient norco after he tested positive for non-prescribed opioid. 3) i refused to refill a patient's norco for her fibromyalgia. All three complained that I wasn't listening to their concerns and that I wasn't treating their pain. of course none of them mentioned anything about opioids specifically.

my practice manager then drafts a letter documenting our side of the story . so far no issues with the insurance companies.

It's almost amusing to see how these patients go out of their way to complain about you when their time could probably be spent doing more productive things.

 

[lobelsteve]

My turn:

I discuss the possibility of a personality disorder and substance abuse disorder. I offer counseling and treatment for those things. The patient gets angrier and more hostile. I tell them they should leave now because I reported them to local police and narcotics squad for diversion. Clock is ticking....listen for sirens. I throw my pen out the door and laugh as I tell them I do not have a pen to write them anything else.
Bye Felicia.

(True story)

 

[deleted875186]

With a documented inconsistent urine x 2 this is straightforward, I will often tell people I cannot possibly continue any opioids because they violated the agreement, blah blah blah. I keep it as non confrontational as possible, document exactly what I told them. Typically will tell the patient I can do non opioids and injections etc.

If abusive towards you or staff, I will discharge from care as above with a list of other providers, will say something like “patient yelling, confrontational, blah blah, often quote some stuff they said, there’s doesn’t appear to be a doctor patient relationship, discharging from practice”.

 

[paindoc34]

Thank you all for your replies and advice! I really appreciate it.

 

[Ducttape]

Document.

In particular in the chart document their no shows. Document their abnormal UDS. That alone should have triggered you to stop prescribing previously.

Document the specific insults especially if there were inappropriate slurs and definitely document how uncomfortable and threatened you felt during the interaction.

If there have been interactions with other staff, document them too.

In your certified letter you have to provide 30 days emergency care. That does not include prescribing any more opioids. Given the abnormal uDS you should not prescribe any further opioids.
If they have severe withdrawal symptoms, then they can go to ER or talk to their PCP or seek addiction care or you can give them a few days of tizanidine and ibuprofen - and tell them to hydrate.

 

[Pain Applicant1]

Hi All,
Hoping to get some advice about a new experience for me. I had a patient who became verbally aggressive and very hostile during a follow-up visit with me over their opioid script. Basically, I had a frank discussion about their non-compliance to my multimodal plan of care (patient has had multiple no shows for recommended procedures) and the fact that they come in every month for opioid and non-opioid refills, without doing any of the other things i suggest (PT, Procedure,etc). Furthermore, UDS x2 detected non-prescribed opioids. I stated that I would not be continuing to write these scripts if they were not willing to be receptive to the other therapies.
They threatened legal action, reporting me to the board, etc.. i ended the visit when their insults became a little personal towards me and my staff. They left before I could discuss weaning / treatment for potential withdrawal.
How do I handle this? Call and let them know they are being discharged for disruptive behavior/UDS? How do I give them medication instructions if they won't hear me out How do I protect myself from being sued or reported for perceived abandonment or lack of time to find a new doctor?

Thanks for your time,
- a fairly green attending

At the beginning my practice I experienced this because I wouldn't assume opioids for pts and they saw me as the gatekeeper.

When something like this surfaces, I explain that I must respond to the UDS otherwise there would be no point for me to order it. I can get in trouble if I don't respond to it and I'm sorry but i can't prescribe anymore. I can't afford to lose my license, the DEA, I have a family to support etc..... I try to direct their anger away from me so it doesn't get confrontational. Most of the time it works but it's come close to a physical altercation in the past. In that case, I let them say their piece and I tell them they're making me feel uncomfortable. I then stand up and say they must leave now. I then tell my staff while the pt still hears me that if they don't leave she should call the police as the pt will be considered trespassing.

I document everything including that the pt became combative and abusive and I felt threatened for me and my staff.

I'm no attorney but i don't believe you're abandoning anyone. Usually, there is no need to discharge since the pt is likely opioid seeking so s/he probably won't come back. You can't protect yourself from being sued but you can protect yourself if you are sued with your documentation. I doubt any attorney would even take this case. I wouldn't worry about the lawsuit, I would be more concerned about pt violence towards you. This is unlikely and rare but probably far more likely than a lawsuit.

 

[geauxg8rs]

At the beginning my practice I experienced this because I wouldn't assume opioids for pts and they saw me as the gatekeeper.

When something like this surfaces, I explain that I must respond to the UDS otherwise there would be no point for me to order it. I can get in trouble if I don't respond to it and I'm sorry but i can't prescribe anymore. I can't afford to lose my license, the DEA, I have a family to support etc..... I try to direct their anger away from me so it doesn't get confrontational. Most of the time it works but it's come close to a physical altercation in the past. In that case, I let them say their piece and I tell them they're making me feel uncomfortable. I then stand up and say they must leave now. I then tell my staff while the pt still hears me that if they don't leave she should call the police as the pt will be considered trespassing.

I document everything including that the pt became combative and abusive and I felt threatened for me and my staff.

I'm no attorney but i don't believe you're abandoning anyone. Usually, there is no need to discharge since the pt is likely opioid seeking so s/he probably won't come back. You can't protect yourself from being sued but you can protect yourself if you are sued with your documentation. I doubt any attorney would even take this case. I wouldn't worry about the lawsuit, I would be more concerned about pt violence towards you. This is unlikely and rare but probably far more likely than a lawsuit.

If anyone in the office was a party to any of this make sure they document it in the chart. Even if they just heard it and it wasn’t directed at them. Certainly document if they were being yelled at. Create as many written accounts in the chart

 

[BobLoblaw78]

Do you need wean/taper if they have other opioids? Do you feel comfortable providing opioids when they are combining them with other opioids that may cause respiratory depression and death? Did they at least test positive for the opioids you were prescribing? If not, then no need to taper.

After thinking all of this, I would likely still do it for CYA but it would be rapid taper with clonidine if needed for symptoms

 

[lobelsteve]

Do you need wean/taper if they have other opioids? Do you feel comfortable providing opioids when they are combining them with other opioids that may cause respiratory depression and death? Did they at least test positive for the opioids you were prescribing? If not, then no need to taper.

After thinking all of this, I would likely still do it for CYA but it would be rapid taper with clonidine if needed for symptoms

That's some dumb ashh nonsense. In the esteemed words of Steven M. Lobel, MD LLC, " So that last Rx you gave, was that a going away present?"

And that was on the stand. The judge laughed as did the DEA agent behind the prosecutor. The doctor on the defense went white.

 

[Pain Applicant1]

I use a laptop and I type when I'm meeting with pts for efficiency. One of these opioid pts who was upset about my refusal to prescribe opioids actually stood up and hit my laptop so it closed (I think that might have been considered assault). He then told go ahead, I'll give you the first shot. I stood up and told him to give me a break. I walked out and told him to get out of my office or I'm calling the police and I'll ask for him to be arrested for trespassing. Fortunately, he left without further incident.

 

[Laryngospasm]

weaning when testing positive for illicits or diverted meds is nonsense.

 

[NJPAIN]

I use a laptop and I type when I'm meeting with pts for efficiency. One of these opioid pts who was upset about my refusal to prescribe opioids actually stood up and hit my laptop so it closed (I think that might have been considered assault). He then told go ahead, I'll give you the first shot. I stood up and told him to give me a break. I walked out and told him to get out of my office or I'm calling the police and I'll ask for him to be arrested for trespassing. Fortunately, he left without further incident.

Who needs this crap?? Are you prescribing opioids currently?

 

[Pain Applicant1]

Who needs this crap?? Are you prescribing opioids currently?

At the beginning of my practice, I was turning away probably most of the patients because I was inundated, for various reasons, with high-risk opioid patients. Now I can't even think of any opioid pt I'm not comfortable managing. Most are medicare and/or still working with really no other options. I don't do high-dose opioids and I think they're helpful to some degree.

Most suboxone pts have been decent as well. Nearly all are medicaid and many if not most are freshly released from prison.

Some time ago a suboxone pt showed me a knife. S/he didn't pull it on me but showed it to me. I didn't like that so that pt is now gone.

Most have done pretty well seem to be appreciative. Coincidentally, my front desk just told me that a suboxone pt became irate yesterday because the pt was called in for random strip count and UDS. The pt ran his mouth and made a gesture and shape of a gun with his/her hand when s/he was leaving. S/he didn't point his/her finger at anyone but made gunshot noises when leaving.

This is a big no-no for me. I can't let the suboxone pts run the show. During the next appt I'm going to let the pt know the rules of the suboxone program or this person will have to go elsewhere. I'll have to do while trying to not let this person get worked up about it.

 

[NJPAIN]

What’s your definition of high dose?
Did you feel that you have so much experience and “radar” that you don’t worry about about the safety of you and the staff?
Are these patients the bulk of your business?

 

[Ducttape]

"During the next appointment"???

what next appointment? someone threatens the staff in that manner need to be discharged.

 

[Ducttape]

What’s your definition of high dose?
Did you feel that you have so much experience and “radar” that you don’t worry about about the safety of you and the staff?
Are these patients the bulk of your business?

high dose technically: >90 MED

high dose in my mind: any dose in a particular patient that i worry may misuse/abuse/divert or could have serious side effects

 

[drrosenrosen]

This is all good advice. I would add something: when documenting, use fact-based language. If you want to quote something the patient said that was particularly abusive or inflammatory, try to make it a direct quote in quotes. Don't use judgment based language like "pt became hysterical" or "pt stormed out", but instead say things like "pt became very irate and raised their voice, used foul language, slammed a clipboard on the countertop so hard that it shattered" (had that one happen). "Pt left prior to my ending the encounter and did not wish to discuss further treatment options".

Anything involving actual threats of violence could potentially become court documents so try to document exactly what patient said or did that was perceived as threatening, who it was directed to, if there were witnesses, etc.

 

[Pain Applicant1]

What’s your definition of high dose?
Did you feel that you have so much experience and “radar” that you don’t worry about about the safety of you and the staff?
Are these patients the bulk of your business?

I would say nearly all of my opioid pts are on less than 20-30mg ME. I personally consider that to be a moderate dose but not sure what other people think. My practice is split between procedures, suboxone, opioids, and non-opioids.

I guess safety is always a concern but that goes through all of healthcare. I believe we take the largest slice of the pie when it comes to being recipients of workplace violence. It's not limited to pain of course. My bro-in-law who is an ED doc got sucker-punched by a pt a few years ago. He was given a nice shiner. Procedures can also lead to violence. When I was at Hopkins a pt upset about his mother's surgery shot a surgeon in the stomach. A few years later something similar happened at one of the Harvard hospitals.

I see Medicaid suboxone because I know no one else will see them. Many of these clinics are cash only. I live in the same town where I work and I don't want people desperate for opioids roaming around the same area that my kids play in.

 

[Pain Applicant1]

"During the next appointment"???

what next appointment? someone threatens the staff in that manner need to be discharged.

The problem with discharging the pt for that is that they can become even more irate putting us at even higher risk for violence. Most of the time if I gently explain my position gingerly it seems to get through to the pt. It's not simple to stop someone from using suboxone like that and the outcome can be very unpredictable. Suboxone is a crutch for many people. They are scared to withdraw and some people will turn into monsters to prevent it from happening.

For the record, I'm confident in my ability to handle myself if the need arises. I've been in enough fights as a kid and trained in a few things throughout my life. My main concern is someone coming after me with a gun.

 

[Ducttape]

there are ways of mitigating this. for me, having them come back for another appointment is not one of them.

i would be condoning their violent behavior and aggression. that isnt conducive to my relationship with them and clearly i wont ever trust them again. even the patients i have seen with the absolute worst pathology causing the most imaginable pain have not threatened me. its only the addicts that mention violence.

i agree, sending them a discharge letter and washing your hands is not a great solution. better is the "i dont think this is working out for us, and we will never see eye to eye on your treatment. clearly you are frustrated, and you should see someone who you can feel more comfortable with."

"call this guy, his name is lobel, great guy. talk to him about cars."


my concern: allowing them to come back again may give them access to the staff and myself to gun violence.

 

[lobelsteve]

there are ways of mitigating this. for me, having them come back for another appointment is not one of them.

i would be condoning their violent behavior and aggression. that isnt conducive to my relationship with them and clearly i wont ever trust them again. even the patients i have seen with the absolute worst pathology causing the most imaginable pain have not threatened me. its only the addicts that mention violence.

i agree, sending them a discharge letter and washing your hands is not a great solution. better is the "i dont think this is working out for us, and we will never see eye to eye on your treatment. clearly you are frustrated, and you should see someone who you can feel more comfortable with."

"call this guy, his name is lobel, great guy. talk to him about cars."


my concern: allowing them to come back again may give them access to the staff and myself to gun violence.

My staff does my mitigation ahead of scheduling. Said no to 3 consults today. Based on PCP notes lacking adequate info and PDMP showing nothing I can to to help. I do have a new nurse who really does a great job on the phone telling the patients NO.

 

[BobLoblaw78]

That's some dumb ashh nonsense. In the esteemed words of Steven M. Lobel, MD LLC, " So that last Rx you gave, was that a going away present?"

And that was on the stand. The judge laughed as did the DEA agent behind the prosecutor. The doctor on the defense went white.

Which part? My questions? Me providing reasons wean isn’t needed? Or me saying I would probably rapid taper? I don’t follow.

I guess some going away scripts to leave my practice as a bribe??? Again. Don’t follow your case either. You were crossexaming the defendant?

 

[lobelsteve]

Which part? My questions? Me providing reasons wean isn’t needed? Or me saying I would probably rapid taper? I don’t follow.

I guess some going away scripts to leave my practice as a bribe??? Again. Don’t follow your case either. You were crossexaming the defendant?

Never provide an rx to a patient who broke the rules or failed uds that is not adequately accounred for in your documentation.


I was hired by the government to take down a drug dealing doctor. I was the expert for the prosecution and was being questioned on rhe stand by the defendant physician.

 

[BobLoblaw78]

Never provide an rx to a patient who broke the rules or failed uds that is not adequately accounred for in your documentation.


I was hired by the government to take down a drug dealing doctor. I was the expert for the prosecution and was being questioned on rhe stand by the defendant physician.

Okay. I think it reads that he had previous failed UDS but not current. He had continued prescribing. And he was wanting to stop prescribing because the patient was not doing PT and procedures that he recommended. This can have the appearance of scripts for shots. Especially if failed UDS was in the past but you didn't stop prescribing at that time, but want to stop now that they won't get shots/PT. I would still do a rapid taper or find him someone else to prescribe since it does look like rules may not have been consistently enforced. I would hate for this specific case to be overly scrutinized for OP because it seems like he has been bullied, he is sincerely asking for help but obviously has lack of experience in this (may not have dotted t's and crossed i's). This makes me think 2 things:

1. Pretty hard to die from opioid withdrawal. Maybe should just turn loose but I would CYA, live and learn.
2. I'm glad I don't prescribe opioids.

In the esteemed words of Steven M. Lobel, MD LLC

Reminds me of Big Trouble in Little China "Just remember what ol’ Jack Burton does"

 

[Pain Applicant1]

there are ways of mitigating this. for me, having them come back for another appointment is not one of them.

i would be condoning their violent behavior and aggression. that isnt conducive to my relationship with them and clearly i wont ever trust them again. even the patients i have seen with the absolute worst pathology causing the most imaginable pain have not threatened me. its only the addicts that mention violence.

i agree, sending them a discharge letter and washing your hands is not a great solution. better is the "i dont think this is working out for us, and we will never see eye to eye on your treatment. clearly you are frustrated, and you should see someone who you can feel more comfortable with."

"call this guy, his name is lobel, great guy. talk to him about cars."


my concern: allowing them to come back again may give them access to the staff and myself to gun violence.

I would have to have them come back either way. When it gets to this point I would much rather tell them this face to face. It's uncomfortable but at least I can gauge their reaction and try to calm them down if necessary.