Terminating your professional relationship with a patient

Terminating your professional
relationship with a patient
How often have you dismissed a
patient from your care? Why?
How often have you wanted
to? What are the ethical and legal issues
surrounding this question? The following
case includes an unexpected twist to
the problem of terminating a professional
relationship.
›CASE
Mr. James is 90 years old, generally
engaging, alert, well-oriented, and welldressed.
He looks much younger than
his chronological age. His two sons
assist him financially. Recently he has
been musing about how his only daughter
never comes to see him and won’t
help him out financially. Mr. James has
significant anxiety. He has a prescription
for alprazolam (Xanax), 1.0 mg three
times a day, but he complains that the
medication makes him mentally “slow.”
His other health problem is atrial fibrillation
(AF). He refuses treatment for
both the anxiety and the AF.
Over the past 6 months, since Mr.
James was put on the PA’s panel, he has
been calling repeatedly and confusing
earlier discussions he had with the PA
during his clinic visits. Mr. James’ health
insurance plan has a labor-intensive
referral system. He frequently asks,
“Can’t I just have a piece of paper to go
see this doctor or that doctor?”
Mr. James lives with one of his sons
and his son’s girlfriend. The son and
girlfriend drive him to appointments,
but they do not accompany him during
the visits. In the course of the clinic
visit, the PA often gives instructions,
medications, or advice. Later, Mr. James
tells his son what was discussed. The
F.J. Gianola is the department editor for PA
Quandaries and is on the faculty of the MEDEX
Northwest Division of Physician Assistant Studies,
University of Washington School of Medicine,
Seattle. He has indicated no relationships to disclose
relating to the content of this article.
PA QUANDARIES
F.J. GIANOLA, PA, DFAAPA
son then calls the office, is rude, and
yells at whoever answers the phone.
The son also shouts at the person who
does the billing about charges his father
has generated. Recently Mr. James’ son
has been accusing the office staff of
calling the house and hanging up, and
he has yelled at them about referrals his
father needed. The PA’s supervising
physician reports that the son has shouted
at her on the phone as well. His
tirades include such statements as “you
know you called here” or “what kind of
office are you running there?” The PA
finds the son rude all the time. The situation
has become exceptionally stressful
and verges on the intolerable.
›THE ETHICAL QUANDARY
Is it ethical to “fire” a patient because
of the actions of a family member?
›DISCUSSION
Medical indications (beneficence and
nonmaleficence) Mr. James has been
diagnosed with nonvalvular AF. The
American College of Cardiology/
American Heart Association/Physician
Consortium AF and Atrial Flutter
Performance Measurement Set includes
chronic anticoagulation therapy,
monthly measurement of the international
normalized ratio, and pretherapy
assessment of thromboembolic risk
factors. 1 Without therapy, there is a
real risk of stroke. The oft-cited
rhythm management and stroke prevention
arm of the Anticoagulation
and Risk Factors in Atrial Fibrillation
(ATRIA) study noted that the incidence
[of AF] increased with age, with
the highest risk (9%) in the ninth
decade. 2 The authors also projected
that the number of AF patients will rise
to more than 5.6 million by the year
2050 and that more than 50% of affected
persons will be 80 years or older.
Krahn and colleagues, in their 1995
study of the natural history of AF, 3
found a doubling of mortality in
patients with AF compared with patients
in normal sinus rhythm.
Patient preference (autonomy) Mr.
James has declined therapy for AF or
anxiety. He has the right (and some
maintain, the responsibility) to make
an informed choice.
Quality of life (beneficence, nonmaleficence,
autonomy) Mr. James
maintains that the anxiety medication
he was prescribed slows and muddles
his thinking. Moreover, he says the
heart medication is not needed because
the “fluttery feeling” happens less often
than once a week. “I’m 90 years old.
What’s the point of taking drugs? I am
living a good life without them.”
Contextual features (loyalty and fairness)
The specific contextual feature in
this case is Mr. James’ son, who has
been verbally abusive in the extreme to
administrative and medical staff. Mr.
James is cordial and interacts well with
all staff members. Why his son is so
hostile to clinic personnel is unclear. To
date, the son has refused to engage in a
face-to-face conversation with the PA
or the supervising physician.
The Guidelines for Ethical Conduct for
the Physician Assistant Profession 4 states
that a physician assistant and supervising
physician are permitted to discontinue
their professional relationship with
an established patient as long as they
follow proper procedures. Both the
AMA Code of Medical Ethics 5 and the
ON THE WEB
• Sidebar. Resources to
help create a safer working
environment
Please see the online version of
this article at www.jaapa.com for this
enhancement.
www.jaapa.com • APRIL 2009 • 22(4) • JAAPA 57

PA QUANDARIES
“The complicating issue here is that the
person who is doing the endangering is not
the patient but a family member.”
Guidelines for Ethical Conduct for the
Physician Assistant Profession 5 provide
specific procedures in greater detail.
Neither publication deals with a family
member as the cause for termination of
the professional relationship.
The Charter on Medical Professionalism’s
“Principle of primacy of patient
welfare” states:
This principle is based on a dedication
to serving the interest of the patient.
Altruism contributes to the trust that is
central to the physician-patient relationship.
Market forces, societal pressures,
and administrative exigencies
must not compromise this principle. 6
PAs also have a moral duty to self
and family. 7 Safeguarding one’s health
and life seems vital in the ethical analysis
of any threatening situation. In a
previous installment of this column, we
discussed the duty to treat in times of
health and safety disasters. 8 Does the
same duty to treat exist when personal
threat, abuse, and possible injury are
being committed by a member of your
patient’s family?
Is there reason to be concerned
about threats and verbal abuse? In
2000, 48% of nonfatal occupational
injuries from violent acts or assaults
happened to those in the health care
or social service fields. From 1996 to
2000, there were 69 homicides in
health services, as reported by the
Bureau of Labor Statistics (BLS), 9
which considers the actual number of
incidents to be much higher. The
underreporting may be due to the perception
that some assaults are part of
the job in health care. Other providers
may believe they provoked the assault
or that the institution and the health
care system caused frustration that was
significant enough to incite these acts.
58 JAAPA • APRIL 2009 • 22(4) • www.jaapa.com
According to the Guidelines for Ethical
Conduct for the Physician Assistant
Profession, PAs have an ethical obligation
to ensure that each patient is provided
proper care. 5 Can the moral
duty to one’s safety override the commitment
to the patient? Jonsen 7 and
others acknowledge that the patient
who makes explicit threats against others
weakens the commitment to maintain
care. The moral duty to self, family,
other patients, and the community
supports this position.
The complicating issue here is that
the person who is doing the endangering
is not the patient but his son.
To “fire” a patient from the practice
should be an exceptionally uncommon
occurrence. Even more unusual is to
do so because of the actions of a family
member. There are no data regarding
incidents of violent acts by family
members perpetrated upon PAs.
When deciding whether or not to
“fire” a patient, a careful deliberate reasoning
process should be undertaken.
Not every difficult patient, for example,
one who does not adhere to a specific
therapeutic regimen, is drug-seeking, or
has personality disorders, should be dismissed
because of the challenges of providing
treatment. Wasan and colleagues
made an astute observation and comment
at the conclusion of their paper:
The difficulty with difficult patients
has less to do with such patients’
behaviors themselves and more to do
with the feelings their behaviors evoke
in their providers. Frustration, anxiety,
guilt, or dislike on the part of patient
or provider can inhibit or even damage
the doctor-patient relationship.… 10
Difficult economic times such as
those we are living in often produce
more disquiet in our patients and our-
selves. There are more violent episodes
by patients and family members in hospitals,
emergency departments, and outpatient
clinics. A number of resources
can assist in creating a safer environment
for all (see “Resources to Help
Create a Safer Working Environment”
in the online version of this article).
The decision to dismiss a potentially
violent or abusive patient from the
practice presents an ethical and moral
quandary. And if a family member is
causing the disruption, the quandary is
even more complex and uncommon.
Each case of terminating your professional
relationship with a patient
is contextual. Using a casuistic casebased
analysis that draws upon the
reasoning of similar past problems
to elucidate solutions to new problems
is one approach to resolving this
quandary. JAAPA
REFERENCES
1. Estes NA, Halperin JL, Calkins H, et al; American College of
Cardiology; American Heart Association Task Force on
Performance Measures; Physician Consortium for
Performance Improvement. ACC/AHA/Physician Consortium
2008 Clinical Performance Measures for Adults with nonvalvular
atrial fibrillation or atrial flutter: a report of the
American College of Cardiology/American Heart Association
Task Force on Performance Measures and the Physician
Consortium for Performance Improvement. J Am Coll
Cardiol. 2008;51(8):865-884.
2. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed
atrial fibrillation in adults: national implications for rhythm
management and stroke prevention: the AnTicoagulation
and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA.
2001;285(18):2370-2375.
3. Krahn AD, Manfreda J, Tate RB, et al. The natural history
of atrial fibrillation: incidence, risk factors, and prognosis
in the Manitoba Follow-Up Study. Am J Med. 1995;98(5):
476-484.
4. Termination of the physician-patient relationship. Code of
Medical Ethics of the American Medical Association.
American Medical Association: Chicago, IL; 2006:240
5. Guidelines for Ethical Conduct for the Physician Assistant
Profession. http://www.aapa.org/manual/22-EthicalConduct.
pdf. Accessed March 11, 2009.
6. ABIM Foundation, American Board of Internal Medicine;
American College of Physicians-American Society of
Internal Medicine; European Federation of Internal Medicine.
Medical professionalism in the new millennium: a physician
charter. Ann Intern Med. 2002;136(3):243-246.
7. Jonsen AR, Siegler M, Winslade WJ. Contextual features.
Clinical Ethics: A Practical Approach to Ethical Decisions in
Clinical Medicine. New York, NY: McGraw Hill; 2007:163-164.
8. Gianola FJ. The duty to treat and the realities of the 21st
century. JAAPA. 2007;20(8):48-49.
9. Guidelines for Preventing Workplace Violence for Health Care
and Social Service Workers.http://www.osha.gov/Publications/
OSHA3148/osha3148.html. Accessed March 11, 2009.
10. Wasan AD, Wootton J, Jamison RN. Dealing with difficult
patients in your pain practice. Reg Anesth Pain Med. 2005;
30(2):184-192.

RESOURCES TO HELP
CREATE A SAFER
WORKING ENVIRONMENT
■ Guidelines for Preventing Workplace
Violence for Health Care and Social
Service Workers
www.osha.gov/Publications/
OSHA3148/osha3148.html
■ Guidelines for Security and Safety of
Health Care and Community Service
Workers
www.dir.ca.gov/dosh/dosh%
5Fpublications/hcworker.html
■ When it’s right in front of you:
Assisting health care workers to
manage the effects of violence in
rural and remote Australia
www.nhmrc.gov.au/publications/
synopses/hp16syn.htm