Patient abandonment

The vast majority of chiropractic patients are welcome "members" of any practice. But there are a few who create problems for doctors, staff, and even other patients. Difficulties might involve a failure to understand or accept your practice purpose; sexual advances by the patient; refusal to follow a recommended program of care; numerous missed or cancelled appointments; billing disputes; and rude, antagonistic or disruptive behavior.

When patients become problems, it's tempting to just kick them out of your office and tell them never to return! But if you do, you may be leaving yourself open for a malpractice claim or board complaint for "patient abandonment," alleging that they have suffered injury because you terminated services without sufficient notice.

Most states have chiropractic regulations dealing with the issue, and regard patient abandonment as unprofessional behavior. The Pennsylvania chiropractic statute, for instance, is fairly typical. Categorizing it as "unprofessional and immoral conduct," Pennsylvania law states that patient abandonment is "when a licensee withdraws services after a doctor-patient relationship has been established, by failing to give notice to the patient of the licensee's intention to withdraw in sufficient time to allow the patient to obtain necessary chiropractic care."

As can be seen from this example, three factors must exist in order to be considered abandonment: 1) the termination must be initiated by the doctor, not the patient; 2) it must be done without giving the patient sufficient time to find another provider; and 2) there must be a need for additional care.

The accusation is more prevalent among medical doctors and became a "hot issue" decades ago when M.D.s refused to make house calls, leaving many patients feeling "abandoned" by them. Still, as D.C.s become the targets of more and more litigation by patients, it is important to protect yourself against such claims.

In addition, the "doctor-patient" relationship may be presumed to continue unless formally ended by one of the parties. This can mean continued vulnerability long after the patient has stopped coming to your office.

To avoid a claim of patient abandonment, you need to first establish practice policies regarding patient behavior, which can be explained to all patients verbally or in writing. For instance, your practice should clearly inform patients that they can be terminated for missing a set number of appointments in a row, or for canceling a certain number of appointments within a specified time frame. Your patient education material can likewise include information on paying for services or other problem areas, with specific mention made of your office's right to terminate the doctor-patient relationship if the patient fails to abide by the practice policies.

If a patient violates the policies, you or a staff member should try to resolve the conflict amicably by discussing the situation.  All matters relating to the conflict -- including statements made by the patient -- should be noted verbatim in the patient files.

Should your attempts at a friendly resolution fail and you feel it is mandatory to terminate your relationship with the patient, notify the patient by mail with a certified letter, return receipt requested.

In the letter, clearly state that the doctor‑patient relationship is being terminated and indicate the specific date the relationship will end. Leave sufficient time for the patient to find another doctor, unless the problem is so severe that seeing the patient again would prove extremely risky or detrimental to the office (this may be the case, for instance, if the problem stems from a sexual impropriety on the part of the patient). 

Summarize the patient's status of care and any further chiropractic care you feel the patient needs. Provide information on how the patient can find a new chiropractor (such as checking the telephone directory or though a state chiropractic association).

Keep a copy of your letter and the certified mail receipt in the patient's record, along with any further correspondence you may receive from the patient. If your certified letter is returned to you unopened, keep it in the patient's file, unopened, and send another copy of the letter to the patient via first‑class mail.

It's important to remember that you cannot terminate a patient solely on the basis of disability, race, color, creed, ethnicity, gender or age. All patients must be treated in the same manner, with the criteria for terminating a patient applied equally to all patients. The existence of written office policies will help avoid any perception of discrimination against certain patients for any of these criteria.

By following these steps you will virtually eliminate the chance of any accusation of abandonment, and be providing the most professional and ethical service to all your patients.