Problems arising from beginning and ending treatment with some patients can
place psychiatrists at risk of being named defendants in malpractice suits,
according to David Cash, J.D., an attorney and senior risk manager with
Professional Risk Management Services Inc. (PRMS), the company that manages
the APA-endorsed Psychiatrists' Professional Liability Insurance Program.
Cash spoke at a daylong seminar sponsored by PRMS in New York City in March
(see article at left).
"The existence of a psychiatrist-patient relationship gives rise to
the obligation on the psychiatrist's part to remain available to the patient
and provide care and treatment that meets the standard of care," Cash
The standard of care is a legal concept— not a clinical
one—established by expert witnesses and usually encompassing a range of
But psychiatrists may enter into a psychiatrist-patient relationship
without meaning to, he noted.
In some rare cases, circumstances that may trigger a psychiatrist-patient
relationship include informal advice provided to someone during a casual
conversation or via e-mail, and even an informal lecture or educational
activity, according to Cash.
"It's fairly easy to allege the existence of such a
relationship," he said. Courts tend to adopt the viewpoint of the
patient in deciding whether a psychiatrist-patient treatment relationship
exists, he pointed out.
During an initial visit, forensic evaluation, or consultation,
psychiatrists should explain their role to the patient and document that
explanation. "Clarifying your relationship to the patient at these times
can go a long way in reducing liability risk," Cash noted."
Likewise, the psychiatrist should disclaim the psychiatrist-patient
treatment relationship when lecturing."
Cash also emphasized that improperly or abruptly terminating treatment with
patients can leave them vulnerable to allegations of abandonment.
A psychiatrist may stop treating a patient for any number of
reasons—perhaps the patient is noncompliant, for example, or the
psychiatrist is closing or relocating his or her practice. Perhaps the most
common reason for terminating treatment is that the patient has recovered and
no longer needs treatment.
In cases in which the psychiatrist wishes to terminate the treatment
relationship for reasons other than that the patient has recovered, Cash said,
proper termination procedure involves giving the patient adequate notice that
treatment will be ending (at least 30 days is advised), sending a follow-up
termination letter via regular and certified mail, assisting the patient with
finding alternative treatment when necessary, and educating the patient and
his or her family members about treatment recommendations.
Psychiatrists should also avoid prescribing large quantities of medication
to the patient before terminating treatment, Cash said, and should never
terminate treatment with a patient who has become a danger to himself or
herself or others; however, he added, "if the patient agrees to be
hospitalized, you can safely terminate treatment during hospitalization"
because the patient will be under the care of a psychiatrist who is
responsible for his or her treatment and aftercare plan.
More information and risk management advice are posted online at<www.psychprogram.com/home.htm>.▪