Ethical Considerations in the Termination of Patient Care
The ACOFP Ethics Committee is offering this column to provide a forum for discussion of medical ethical questions.
By David A. Plundo, DO, FACOFP
It is a rare patient who does everything a physician advises. No matter how technologically advanced we get we still see these patients and they continue to tax our resources and our emotional energy. Unfortunately, great harm may come from failing to follow medical advice.
The most obvious consequence of patient noncompliance is the failure to receive the benefit of the medical treatment. These patients tend to invoke anger and resentment in physicians who may then look to invoke some form of the “three strike rule” and terminate care of the patient. Legally it is possible to discharge a patient from your practice as long as you follow the established guidelines that exist within your state.
However, one must keep in mind that laws only tell us what should not be done while a code of ethics guides us in what should be done. So the question should be is it ethically responsible to terminate care of a patient?
Terminating Care of Patient
A 46-year-old male presents to the office as a new patient. He has a history of diabetes mellitus, hypertension, hyperlipidemia and alcohol abuse. Over the course of multiple visits he proves to be noncompliant with the medications prescribed by you and is consistently late for his appointments. He becomes verbally abusive with the office staff when he is made to wait in the waiting room, which makes the other patients in the waiting room visibly uncomfortable.
This unfortunately, is an all too common occurrence in many family physician practices. There are actually three issues that need to be addressed when we consider terminating this patient from the practice.
1) Clinical Issues
Is it ethical to discharge a patient who comes for his office visits but does not take the medications that are prescribed for him? Are the expectations clearly defined and understood?
2) Practice Issues
Should a patient be discharged for chronically showing up late for their appointments?
3) Societal Issues
Should the patient’s right to autonomy (choosing not to take the medications) override medical interests? Should the patient have the right to be verbally abusive to the staff and should this override the staff’s right of safety?
Is it ethical to discharge a patient because they are a challenge? The doctor patient relationship is at the heart of all clinical encounters. The essential elements of this relationship are communication, respect, professional honesty and trust. The physician must share some of the responsibility for shortcomings in the relationship. Good interpersonal skills along with an understanding of the patient’s values and expectations are important.
Expectations
The physician’s expectations should be discussed allowing the patients to share their own expectations. Then an opportunity for each side to modify these behaviors and expectations should occur through identification and open discussion. All of the issues including the abusive response of the patient to the staff can at times be remedied by an effective physician/ patient communication. The majority of these issues tend to occur with patients who are either new to the practice or have not yet developed an effective communication relationship with the physician.
Good for Practice, Patient and Society
Ethical decisions should be based not only on what is good for the practice but the patient and society as well. The issues in this case require consideration regarding the scope of patient autonomy, informed refusal, compliance with the established treatment plan and safety of the staff and other patients. The value of autonomy in healthcare must be a constant reminder that “the right to choose is not limited to the right to choose correctly.”
Autonomy
While autonomy is a fundamental principle we must not forget that it is a dual principle as rights correlate with duties. The patient’s right to autonomy has an inherent and simultaneous duty to respect the rights of others, the practice and society.
The patient maintains the right to refuse treatments if the consequences of doing so have been fully explained (informed refusal), understood, and documented by the physician.
The physician has a duty to the patient to continue to care for him in the best of their ability respecting the limitations set down by the patient as long as there is no direct negative consequence to the physician, the practice or society.
The ethics of the healthcare system revolve around the principle of individual autonomy. Legally competent individuals have the right to make decisions about their lives and healthcare as long as their decisions do not violate another person’s rights.
The clinical issues in this case result from the conflict between the patient’s autonomy and the practice and society’s duty to support his autonomy. The physician’s ethical duty is to first do no harm to the patient, the practice or society.
Only when it becomes clear that it is no longer in the best interest of the patient to continue care should the decision to terminate be considered. This decision must never come easy.
It must be fair and not influenced by the physician’s own views about the patient’s lifestyle, culture, race, gender, sexuality, social status, or perceived economic worth. The decision to terminate a patient must involve ethical considerations, which at times, may be unclear.