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 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 Profession4 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 Ethics5 and the Guidelines for Ethical Conduct for the Physician Assistant Profession5 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.
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? Jonsen7 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 ourselves. 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
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.
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.