Welcome to the Ethics Forum! The optometric profession has long recognized its ethical responsibilities to patients, colleagues, other health care professionals and the public. This forum provides an opportunity to review a hypothetical case study containing potential ethical challenges and includes suggestions on how one might handle the situation based upon the American Optometric Association Standards of Professional Conduct and Code of Ethics.

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DISMISSING A PATIENT

Morris Berman, O.D., MS, member of AOA Ethics and Values Committee

Doug Totten O.D., chair, AOA Ethics and Values Committee

Case Study #11

In the monthly review of overdue accounts with her billing manager, Dr. Chen approves seven accounts to go to a collection agency service. The office has a policy to bill the patient three times and then to send a final "going to collections" notice. None of the delinquent account holders have responded to the bills to make a payment or have even called to discuss the situation. The staff member has prepared release of care letters, and Dr. Chen signs them stating, "I don't like dismissing patients, but we have to move on."

Discussion

Most patients are compliant with written and unwritten policies and guidelines that apply within health care offices and clinics. However, there are some patients who make it difficult for staff members and doctors to maintain a mutually respectful relationship. When patients act inappropriately, the doctor may eventually decide to discontinue care to the patient. Reasons that might lead to dismissal of a patient can include:

  • Unreasonable demands or disruptive behavior in office
  • Noncompliance-refusal to follow orders or treatment plans
  • Nonpayment for services rendered
  • Chronic no-show or repeated late cancellation of appointments
  • Evidence of threatening or violent behavior
  • Closure of the office or retirement of the optometrist

When a breakdown occurs in the doctor-patient relationship, it often is best for both parties if the patient finds a new health care provider.1

The AOA's Code of Ethics and Standards of Professional Conduct documents address this topic in several references.2,3 "Optometrists should also strive to ensure that all persons have access to eye, vision and general health care," and with this hold a common goal to care for the people in their communities. Yet, "optometrists, in serving the public, may exercise reasonable discretion in selecting patients for their practices. However, services should not be denied on the basis of discrimination or to patients presenting with emergent conditions."

When the decision has been made to dismiss a patient from care, an important component is to ensure that the patient will have access to care. The Standards of Professional Conduct state, "once the optometrist has undertaken a course of treatment, the optometrist should not discontinue treatment without giving the patient adequate notice and the opportunity to obtain the services of another eye care provider. Optometrists are responsible for ensuring appropriate follow-up care when he or she is not available to render such care."

When releasing a patient from care, the optometrist should follow several guidelines to handle the situation in a professional manner and to be careful not to abandon the patient without providing detailed instructions and a course of action.

Practical Protocols when Dismissing a Patient

The following strategies can help protect doctors from liability and accusations of patient abandonment while also providing a clear plan and advising for a patient to transition to another provider.4

1. Document the offending behavior.

Record specific notes into the health record including details of the patient behavior leading to the dismissal. It can be helpful to list proposed solutions or directives that were provided to the patient in an effort to continue care for the patient and avoid the release of care.

2. Provide written notice.

The optometrist should issue a written termination letter (such as a certified letter with return receipt requested) to the patient prior to the effective date of termination. The letter should clearly state a termination date (with a 30-day advance notification recommended) and the reason for termination. It is best to be succinct (patient has been noncompliant with the prescribed contact lens regimen) and it is generally not necessary to provide a highly detailed description of the offending behaviors in the letter.

3. Supply a list of suitable alternative providers.

The letter should contain a list and contact information for suitable health care providers in the area. With certain managed care plans, it may be appropriate to provide referral information to the patient's insurance network.

4. Time the termination properly.

Avoid withdrawing from treating the patient when the patient is in medical crisis, unless the patient requires the services of a different specialist and arrangements have been made for transferring the patient's care to such a specialist. Continue providing treatment during the intermediate period following issuance of the termination letter and prior to the effective date of termination. The optometrist should communicate to office staff members that the patient is still welcome to schedule an office visit and/or arrange for services prior to the effective date of termination.

5. Examine managed care contracts and communicate with health plans.

If you are a participating provider in a managed care network or clinic in which the patient is covered, review the provider agreement for language related to the termination of the optometrist-patient relationship. Some managed care contracts may contain language requiring specific justification for release of care along with specific notice requirements. If in doubt, it may be wise to contact the payer, explain the situation, and work to satisfy both the contract terms along with your own procedure to help prevent problems at a later date.

6. Provide access to medical records.

State that a copy of the discharged patient's medical records will be provided to the patient's new doctor after notification in writing that the patient has authorized the records transfer. Some states have laws that require that records not be withheld solely because of a patient's inability or refusal to pay.

7. Communicate with everyone else in the practice.

Be sure to apprise all associates and office staff members of the termination to avoid inadvertent reestablishment of the physician-patient relationship. For example, an appointment scheduler who is unaware that a patient has been issued a withdrawal letter might schedule a new appointment for that patient beyond the termination date. This could be viewed as renewing the doctor-patient relationship even if the scheduling of the encounter was not intended.

8. The doctor should make the decision.

Finally, the treating doctor should be the one who makes the determination to terminate the doctor-patient relationship rather than another staff member. By remaining personally involved, the doctor can help ensure that reasonable efforts have been made to avoid the dismissal and that protocols have been followed appropriately.

Conclusion

The vast majority of optometrist-patient professional relationships are very healthy. However, situations do arise where the patient care relationship is not favorable and a patient must be released from care. When this unfortunate occurrence happens, and even after efforts have been made to correct the situation, it is prudent for the optometrist to follow a process when discharging a patient. The dismissal of a patient should be handled in a professional and respectful manner while being cognizant of protocols to protect the patient and optometrist.

Reading References:

1. medicaleconomics.modernmedicine.com/medical-economics/news/removing-patient-yourpractice-physicians-legal-and-ethical-responsibilities?page=full, retrieved August 18, 2017.

2. American Optometric Association, Code of Ethics. www.aoa.org

3. American Optometric Association, Standards of Professional Conduct. www.aoa.org

4. medicaleconomics.modernmedicine.com/medical-economics/news/removing-patient-yourpractice-physicians-legal-and-ethical-responsibilities?page=fullhttp://www.capson.com/blog/7- essential-tips-for-dismissing-a-patient-from-your-practice, retrieved July 12, 2017.

About the Authors:

Dr. Berman serves as dean, MCPHS School of Optometry, in Worcester, Massachusetts. He is a member and former chair of the AOA Ethics and Values Committee and the ASCO Ethics Educator's SIG.

Dr. Totten is in private practice in Norton Shores, Michigan.