ETHICS

 

Abandonment of patient

 

 

Punkaj Govan

SADA head office

 

 

INTRODUCTION

Dentists often encounter situations such as where patients are rude, aggressive, noncompliant, delinquent in paying, do not have their own best interest in mind or believe they have exhausted every option to treat the patient and they need to discontinue the treatment of their patient.

Unfortunately, it is not as easy as merely turning these patients away, cancelling their appointments or closing the doors on them. While it may seem simple to just turn them away, cancel their appointments or close the doors, there are several factors to consider before terminating the dentist-patient relationship. The practitioner needs to make an informed decision and take all necessary actions with complete confidence.

The National Patients' Rights Charter provides: "Continuity of care - No one shall be abandoned by a health care professional who or a health facility which initially took responsibility for one's health without appropriate referral or handover".

Section 27 of the Constitution of the Republic of South Africa 1996 affords everyone a right to health care services and guarantees that no one may be refused the right to emergency health care services. Once a healthcare practitioner accepts a patient for treatment, both an ethical and a legal duty of care arise.

Practitioners have a responsibility to ensure that they terminate the practitioner-patient relationship safely and responsibly. This includes taking the necessary precautions to ensure that the patient is not abandoned and has continuity of care. Failing to meet these obligations could result in a complaint being lodged with the Health Professions Council of South Africa (HPCSA) or even a civil claim against the practitioner. Practitioners need to discharge their duty of care properly to avoid any legal or ethical issues.

To end the practitioner-patient relationship, the practitioner must have good cause. The HPCSA's Guidelines state that a practitioner is required to act in the patient's best interest at all times, even if those interests conflict with their own. The purpose of the recommendations is to shield patients from any discrimination and bias stemming from a practitioner's personal beliefs.

To ensure that the termination of a practitioner-patient relationship is just and equitable, the practitioner should consider the unique circumstances of the patient and apply ethical reasoning. To correct the situation and keep providing patient care, he or she should weigh all available options and actions. Certain cases will be simpler to evaluate than others, in which it will be evident that ending the practitioner-patient relationship is the only viable course of action.

A practitioner may end the doctor-practitioner relationship after it is determined that there is no viable alternative or remedy and, more importantly, that continuing treatment will not jeopardise the quality of care provided to the patient.

Termination of dentist-patient relationship

The following are possible situations, where termination of the practitioner-patient relationship could be justifiable:

• Aggressive, abusive or violent patients: Practitioners also enjoy the constitutional right to security and a safe environment. If a patient is abusive, either verbally, physically or sexually, the practitioner may terminate the doctor-patient relationship for his/her own safety and wellbeing, their staff and possibly other patients.

• Failure to pay fees: It is not reasonable to expect practitioners to work for free. Unless the patient needs emergency care, the practitioner may refer a patient to a colleague who charges less, a clinic or a state facility if the patient is unable to pay the professional fees of the dentist, even after being offered payment plans and/or discounts.

• Dealing with noncompliant patients: When patients fail to comply with recommended treatments, practitioners face potential risks of treatment defects. It's crucial for practitioners to document each instance of noncompliance and assess its impact on the patient's wellbeing. Patients must be informed of the risks linked to noncompliance and warned that continued noncompliance may lead to the cessation of treatment to avoid jeopardising the practitioner. If the patient persists in noncompliance despite warnings, the practitioner may need to consider terminating treatment if the risk is significant.

• Avoiding inappropriate relationships: According to the HPCSA Guidelines, healthcare providers should steer clear of inappropriate relationships with their patients. Such relationships could strain the bond between the provider and patient, leading to its breakdown. Alternatively, they could interfere with the provider's ability to make sound decisions for effective care.

• Religious or personal beliefs: While the HPCSA Guidelines forbid healthcare providers from declining treatment based on religious beliefs, providers are entitled to uphold their own religious beliefs as per the constitution. If giving treatment would require a provider to do something against their beliefs, they can object to performing that specific treatment. However, providers should avoid judging patients or refusing treatment solely because of differing beliefs.

Ending the patient-practitioner relationship must be recorded in the patient's file and the patient needs to understand that they will not be treated by that practitioner anymore. The patient should still get care, though.

The practitioner can tell the patient about the termination through a letter or a meeting, calmly explaining why treatment can't continue. It is important to suggest other practitioners for the patient to see and help them find further care if possible.

Practitioners cannot just stop treating patients without a good reason. Each patient's situation needs careful consideration and steps should be taken to end the relationship properly if needed. Some patients might be harder to deal with than others, and their situations might be unique.

What constitutes "abandonment"?

Patient abandonment happens when a practitioner stops providing care without the patient recovering fully or ends the patient's treatment without enough notice or helping them find another practitioner.

Abandonment may include the following:

• Ending the relationship without providing a reasonable opportunity for the patient to find a new dentist

• Practitioner closing his/her practice without proper notice or instructing them on how they can retrieve their dental records.

• Practitioner refusing to see a patient previously seen.

• Practitioner failing to visit a hospitalised patient.

• Practitioner failing to provide follow-up care.

• Practitioner failing to provide a competent substitute when away from practice or closing the practice.

• Practitioners verbally expressing to the patient that they will not treat them anymore but do not follow up in writing.

• Practitioner refuses to schedule a follow-up with a noncompliant patient but they have not followed the steps required for termination.

• Practitioner will not schedule a follow-up with a patient who owes back payments but the practitioner has not properly discharged them.

• Practitioners continually "underservice" their patients, so that they must seek healthcare from somebody else, this may amount to "constructive abandonment" because it forces the patients to terminate the practitioner-patient relationship.

• The patient needs ongoing treatment which the practitioner refuses or fails to provide.

• Failing to contact patients who miss appointments to follow up and schedule further treatment.

• Failing to communicate about urgent medical issues with patients.

• Scheduling appointments so far in the future that the patient's condition deteriorates.

• I ntentionally refusing to continue treatment of a patient without justification.

When it is not patient abandonment

Although patient abandonment is a serious issue, there are circumstances where doctors and other healthcare providers are allowed to end a relationship. Dentists may stop treatment without it being considered patient abandonment if:

• They do not have the necessary training or knowledge to continue treatment.

• They do not have the supplies or resources to continue treatment.

• A conflict of interest arises.

• Patients violate the policies of the doctor or behave inappropriately, such as verbally abusing the care provider.

• Patients violate the doctor's policies.

• Patients repeatedly miss or cancel appointments.

• Patients do not comply with care recommendations.

How to avoid an unprofessional conduct claim

To avoid ending up before the Health Professions Council for patient abandonment as a form of unprofessional conduct, practitioners must follow certain steps. To avoid abandoning the patient, dentists may discontinue treatment after reasonable notice has been given to the patient by the dentist of his intention to discontinue treatment and that the patient has had a reasonable time to secure the services of another dentist or after all other dental treatment begun has been completed.

Practitioners are advised to:

• Provide written notice of the termination date.

• Give the patient a reasonable time to get emergency treatment and medication.

• Provide written recommendations of other practices where the patient may seek care.

• Instruct the patient of specific steps they need to take to obtain their medical records.

• Advise what emergency care will be provided until the patient finds another dentist.

• Refer the patient to another practitioner or provide details of other practitioners the patient may consult with or make arrangements for further treatment if he/she is not going to continue with the treatment of the patient.

Process

• You should inform the patient in writing about your concerns and due to a breakdown in the dentist-patient relationship. You should inform patients that this is in the best interests of all concerned. If you have a contract for a long-term treatment, termination must be in accordance with the contract taking into account whether the patient's treatment is likely to be compromised.

• Provide reasons for arriving at your decision and that all options were considered and all other measures exhausted to resolve the issues.

• You will inform the patient that you are willing to assist during transition to another facility, including referral to your colleague, provide copies of records, or it can be sent directly to a practitioner of their choice if the patient has provided details.

• All copies of correspondences must be kept in the patient file and record all conversations with the patient.

Before taking action

It can be useful to discuss the situation with senior colleagues before officially ending the relationship. The responsibility for ending the doctor-patient relationship rests with the practitioner. Do not delegate it to another staff member.

Communicate openly

When ending the relationship, aim to communicate in person with the patient. You should ensure the patient is adequately informed and understands their decision. Be honest, while still being sensitive to the patient's feelings.

Try to ensure the patient does not interpret the ending of the relationship as a personal rejection. You should explain that the doctor-patient relationship relies on mutual trust. When this has broken down, it can compromise patient care, so it is in the patient's best interest to transfer to another practitioner.

Remember to remain calm and polite during all interactions.

Follow up

Follow your discussion with an email or letter to the patient ensuring you have clearly communicated your decision. If the patient requires a review of their condition or medication within a certain timeframe, highlight this in the letter. Where the patient has not complied with or completed treatment, explain the consequences should they continue to go without appropriate treatment. If the patient is undergoing treatment by a specialist that you referred to, inform the specialist about the termination of your dentist-patient relationship).

The transition

Give the patient a reasonable timeframe to find a new dentist. You may need to assist vulnerable patients such as those with complicated dental issues or patients in a regional setting with limited options.

Reassure the patient that you will, within the agreed timeframe, provide care for any dental problems that arise. Advise them to attend the local emergency department or urgent care centre for immediate care needs

Transfer the files to the new doctor or practice

To ensure continuity of care, advise the patient that you will provide a copy of their dental records to their new practitioner after receiving the patient's consent (it may be unwise to charge the patient for this service).

Advise all practice staff

Advise your practice staff that your relationship with the patient has ended and they should not make further appointments for the patient after a specified date.

Make sure all staff at the practice, including other practitioners, are clear about what the termination means for the practice. There may be other practitioners in the practice who are happy to treat the patient, or it may mean that no dentist in the practice will see the patient.

It is a good idea to place an alert on the patient file to ensure all staff members, including new staff unfamiliar with the patient, are aware of the situation.

Initiate steps to collect your fees

Instruct debt collectors or attorneys to take steps to recover your unpaid account.

 

REFERENCES

1. HPCSA Guidelines for good practice in the health care professions national patients' rights charter, para 2.11, Booklet 3        [ Links ]