The Difficult Patient: How to Navigate and Terminate Challenging Relationships
As a healthcare professional, you strive to provide the best care to all patients. However, sometimes you may encounter a patient whose behaviour or demands are unreasonable, disruptive, or even abusive. In such cases, it is crucial to recognise when it is appropriate to terminate the patient-provider relationship before it escalates. This article provides guidance on identifying difficult patients early, handling these situations professionally, and ensuring the safety and well-being of both you and your staff.
Identifying a Difficult Patient
Difficult patients can exhibit a range of behaviours that disrupt the clinical environment and compromise care quality. Some common indicators include:
Excessive Demands: Repeatedly demanding unnecessary tests, medications, or treatments.
Aggression: Verbal or physical aggression towards staff or other patients.
Non-Compliance: Consistently failing to follow medical advice or treatment plans.
Manipulative Behaviour: Attempting to manipulate staff to receive special treatment or prescriptions.
Frequent Complaints: Constantly complaining without reasonable cause or justification.
In rare circumstances, the breakdown of trust between you and a patient means you can’t continue to provide them with good clinical care. This might occur when a patient has, for example:
- Been violent, abusive, or made threats to you or a colleague.
- Displayed other criminal behaviour, such as stealing from you or the premises.
- Acted in a sexual way towards you.
- Persistently acted unreasonably.
You should not end a professional relationship with a patient solely because of:
- A complaint the patient made about you or your colleagues. You must make sure that any complaints or concerns raised by the patient are responded to promptly, fully, and honestly (Good medical practice, paragraph 46).
- The resource implications of the patient’s care or treatment.
Strategies for Early Identification
Initial Assessment: Pay attention during the first interaction. Look for signs of demanding behaviour or aggression.
History Check: Review the patient’s medical history for any red flags, such as frequent changes in healthcare providers or a history of non-compliance.
Staff Feedback: Listen to feedback from your team regarding their interactions with the patient.
Setting Boundaries Early
Setting clear boundaries from the outset can prevent escalation and protect your practice. Here are some strategies:
Clear Communication: Clearly explain your practice policies, including appointment scheduling, treatment plans, and follow-up procedures.
Written Agreements: Consider using written agreements that outline the patient’s responsibilities and the consequences of non-compliance or disruptive behaviour.
Consistent Enforcement: Apply your policies consistently to all patients to avoid any perceptions of unfair treatment.
How to Terminate the Relationship Professionally
If it becomes necessary to end the patient-provider relationship, it must be done professionally and ethically. Here are steps to consider:
Before you end the relationship:
Immediate Termination:
It may be reasonable to end a relationship immediately in certain circumstances. For example, primary care regulations and contracts allow for the immediate removal of patients from practice lists if a patient has been violent or behaved in a way that has caused other people to fear for their safety. You must follow local or national guidance and regulations.
Restoring the Relationship:
Before you end a professional relationship with a patient, you should:
- Tell the patient that you are considering ending the relationship and explain the reasons why.
- Do what you can to restore the professional relationship. This could include setting expectations for the patient’s future behaviour.
- Discuss the situation with an experienced colleague or your employer, or contracting body.
- Seek advice from a safeguarding lead if you are concerned that ending a relationship with a patient could leave them, or someone close to them, at risk of significant harm.
- Ensure that you are acting fairly and not discriminating against the patient (see paragraphs 19, 33, and 56, Good medical practice).
When you’ve made the decision to end the relationship:
- Notify the Patient:
Tell the patient or make arrangements for the patient to be told of your decision and the reasons for it – where practical, this should be done in writing. - Follow Guidelines:
Consult and follow relevant local guidance and regulations. - Ensure Continuing Care:
Make sure arrangements are in place for the continuing care of the patient if they are unable to make arrangements for themselves. - Transfer Records:
Pass on all medical records without delay to ensure continuity of care, in accordance with paragraph 65 of Good Medical Practice. - Record the Decision:
Record your decision to end the relationship, making sure that information recorded in the patient’s records is factual and objective, and does not include anything that could unfairly prejudice the patient’s future treatment.
Documentation:
Document all interactions with the patient, including any incidents of disruptive behaviour or non-compliance. This will support your decision if it is ever questioned.
Written Notice:
Provide a written notice to the patient, explaining the reasons for the termination of the relationship. Ensure that this notice is clear, respectful, and includes a reasonable notice period.
Alternative Care:
Where possible, offer to assist the patient in finding alternative care. Provide a list of other healthcare providers or refer them to a relevant service.
Emergency Care:
Inform the patient that you will continue to provide emergency care for a specified period until they find a new provider.
______________________________________________________________________________________________________________________
Sample Termination Letter
Here is a template for a professional termination letter:
[Your Practice’s Name]
[Your Address]
[City, Postcode]
[Date]
[Patient’s Name]
[Patient’s Address]
[City, Postcode]
Dear [Patient’s Name],
After careful consideration, I regret to inform you that I am no longer able to provide medical care for you at [Practice Name]. This decision has been made based on [specific reasons – e.g., repeated non-compliance with treatment plans, disruptive behaviour, etc.].
We understand the importance of continuous medical care and want to ensure you have adequate time to find another healthcare provider. Therefore, we will continue to provide emergency care for the next [30 days/appropriate period], until [date].
To assist you in this transition, I have enclosed a list of alternative healthcare providers in our area. Additionally, your medical records can be transferred to your new provider upon your request.
We wish you all the best in your future healthcare needs.
Sincerely,
[Your Name]
[Your Title]
[Practice Name]
__________________________________________________________________________________
Support from Incision
Handling difficult patients can be challenging, but you are not alone. As your medical indemnity provider, we offer:
Legal Advice:
Guidance on the legal aspects of terminating a patient relationship.
Risk Management:
Resources and training on managing difficult patients and setting effective boundaries.
Emotional Support:
Our Medico-Legal Advisors are there to assist and listen to you, for you and your staff to cope with the stress of dealing with challenging situations.
Recognising and addressing difficult patient behaviour early is crucial for maintaining a safe and effective practice environment. By setting clear boundaries, documenting interactions, and terminating relationships professionally when necessary, you can protect yourself, your staff, and your other patients. Remember, we are here to support you with expert advice and resources to navigate these challenging situations.
For further information or assistance, please contact our dedicated support team. We are here to help you every step of the way.
