Risk Management

Charges of Abandonment by Noncompliant Patient

Digest, Spring, 1992

ALLEGATION  Insured ophthalmologist was charged with abandonment by a patient after terminating care due to poor compliance with treatment.

DISPOSITION  Insured wrote off the patient’s bill. No payment was made by the insurance carrier (OMIC).

Background

One of the most difficult things a physician sometimes must do is to terminate the doctor/patient relationship. The decision to terminate a relationship is not only an emotional one but can have medical and legal ramifications as well.

Case Summary

The patient was a 30-year-old female who underwent a radial keratotomy of the left eye by another physician. Postoperatively, the eye resulted in a marked overcorrection with a hyperopia in excess of +12. The patient did not want to wear glasses or contact lenses to correct the problem and was referred to the OMIC insured for evaluation. To help correct the problem, the insured performed a procedure whereby he sutured the radial keratotomy incisions to help stabilize the wound. A detailed informed consent was obtained. Although there was noted improvement in the visual acuity, the patient continued to complain of monocular diplopia, fluctuating vision and photophobia. However, the patient failed to keep several post-op appointments despite letters and telephone calls from the insured stressing the need for follow-up. She was also noncompliant about taking prescribed medication.

The patient elected to see a corneal specialist and the insured transferred the medical record to the specialist and advised the patient that he wished to discontinue serving as her ophthalmologist. The patient threatened legal action if the insured stopped seeing her.

Outcome

The OMIC insured wrote off her bill and the patient did not take legal action. OMIC closed the claim without making any payment. The insured ophthalmologist did several things that were instrumental in minimizing the chance of a lawsuit. First, he discussed the procedure and all possible risks, complications and alternative treatments available to the patient. He obtained a detailed consent form and made no guarantees as to the outcome of the surgery. After the procedure, the insured thoroughly documented in the chart when the patient failed to comply with treatment and followed up with several letters expressing concern and disappointment that she had not kept her appointments. The insured also communicated the need for follow up so that the medications could be adjusted and the cornea monitored for continued healing, and he mentioned the adverse consequences of continued noncompliance. Furthermore, the insured wrote to the patient to advise that he was discontinuing his service as her ophthalmologist and to suggest that she select an ophthalmologist who could continue to care for her. Finally, he wrote off the remainder of the patient’s bill without suggesting there was any improper care or liability.

Risk Management Principles and Commentary

Although there is no guarantee that every ophthalmologist who terminates the doctor/patient relationship will have the same result as this insured, there are some guidelines to follow which may protect one against a claim of abandonment.

• Discuss the procedure with the patient thoroughly and document the risks, complications and alternative methods of treatment;
• Document in detail the patient’s noncompliance with treatment and failure to keep follow-up appointments;
• Write or telephone the patient communicating your concern and the consequences of noncompliance and document that communication;
• Suggest that the patient obtain a second opinion;
• Write to the patient noting the reasons why you are terminating the relationship and recommending that the patient obtain another ophthalmologist for continued care.

A note of caution: In this situation, the patient had already sought the care of a corneal specialist and had requested the ophthalmologist forward the medical records to the specialist. Also, the patient’s condition was not critical. Terminating the relationship did not carry any risk to the patient, which may not be the case in other situations. However, in the absence of a critical condition requiring continued medical attention, terminating a doctor-patient relationship may become necessary in some instances.