Terminating your professional relationship with a patient

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
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