Approach Treatment Termination With Care

Three reasons a psychiatrist might consider prematurely ending treatment include the patient’s inability to pay, disagreement about the treatment plan, or a profound ideological difference between patient and provider. In medical ethics, fidelity is the notion that physicians must remain faithful to the patient, placing the patient’s needs above our own. Fidelity is breached if the physician abandons the patient.

Although we cannot be forced to provide treatment to every single patient who requests it, once we have accepted a patient into our practice, it is our responsibility to remain faithful to the patient’s clinical needs and well-being. To discharge the patient because of failure to pay or a disagreement over the treatment plan or ideology is fraught with complexity and may be done only after careful attempts to resolve the problem.

Inability or Refusal to Pay

Section 2, Article 5 of APA’s Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry states, “Psychiatric services, like all medical services, are dispensed in the context of a contractual arrangement between the patient and the physician. The provisions of the contractual arrangement, which are binding on the physician as well as on the patient, should be explicitly established.”

When a prospective patient calls to establish treatment, it is appropriate to discuss the fees associated with treatment. If the patient doesn’t have the means to pay and the physician’s practice setting permits some discretion, an ethical psychiatrist might offer a reduced fee that is realistic for the patient.

If a patient has the means to pay for treatment and refuses to do so, this should first be addressed as a therapeutic issue. Why is the patient refusing to pay? What is being communicated? Only if this has been explored and resolution not achieved should a psychiatrist consider transferring the patient to another practice setting. Even in this circumstance, if the patient is in crisis, the psychiatrist has an obligation to continue to provide care until the patient is either stabilized or transferred.

Disagreement About Treatment Plan

Sometimes a patient wants a treatment with which we are unfamiliar, in which case identifying a provider with that skill and facilitating a transfer may be appropriate. Nonetheless, sometimes a patient simply doesn’t like the treatment plan offered and communicates this through nonadherence, missed appointments, or other behaviors. Informing the patient you are not able to continue treatment and giving 30 days to find a new provider without offering further assistance is likely to be perceived as abandonment.

Patients who insist on a treatment plan that is not consistent with the standard of care is not well served by a psychiatrist who accedes to their demands. Discussing the disagreement about the treatment plan and negotiating a compromise that preserves the treatment relationship, if possible, is a more ethical approach.

Ideological differences

Section 6 of APA’s Principles states, “A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.”

We each have our personal political and moral views, but these will not always be in agreement with our patients’ ideologies. I find racism, anti-Semitism, and other forms of bigotry repugnant, but I cannot prescreen prospective patients to ensure I accept only likeminded individuals into my practice. Rather, I strive to be sufficiently tolerant of and curious about my patients’ beliefs to maintain a helpful relationship with them.

There are certain behaviors that I do not permit in my office because of safety. A patient who wears an NRA cap to an appointment is welcome despite my disagreements with the NRA, but a patient who brings a gun into my office is not. To terminate treatment simply because of a political or ideological difference is a form of abandonment. Even to terminate with the gun-carrying patient is potentially unethical unless I have discussed the limits with him or her, worked to understand the decision to bring a gun to my office, and been unable to reach a safety agreement.

We are not required to continue treatment with patients who do not respect our agreed-upon arrangements or do not benefit from treatment. However, we are not permitted to abandon patients abruptly. We are obligated first to try to understand the problem in treatment and to achieve a resolution or facilitate a transfer of care if that is the best solution. ■