ABC’s of Termination: Clinical, Ethical, and Legal Issues

 

A patient’s symptoms continue to worsen despite all your best efforts. Should you continue as this patient’s therapist?

• A deeply depressed patient drops out of treatment. Do you have any legal or ethical obligations?
• After assisting a patient to achieve some initial success in treatment it becomes clear that she suffers from a disorder that is clearly outside your boundaries of competence. Is it appropriate to continue this patient’s treatment?
• Worrying you might upset your patients, you don’t arrange for coverage while you will be out of town for several days. Is it okay instead for you to check your answering machine for messages periodically?
• As a patient’s balance owed to you grows, you confront him and state that no further treatment will be provided until the debt is paid off. Are you within your rights?
• A managed care company denies authorization for further treatment so you inform your patient that this will be the last session. Have you appropriately upheld psychology’s ethical standards?
• The clinic where you work loses its funding and closes its doors. Concerned about supporting your family and paying bills, you focus your efforts on finding a new position. Have you overlooked any important obligations?
• You provide a patient with the 10 sessions of treatment authorized by her insurance. At the final session you wish her well and are dismayed when she is surprised and upset over treatment ending. Can you effectively defend yourself against charges of abandonment?
• You become ill and must take an extended break from work. Do you have any obligations concerning your patients’ treatment needs?

Psychologists may be confronted by a variety of situations and dilemmas that are relevant to patient termination and abandonment issues. Fortunately, some clear guidance is found in the APA Ethics Code (APA, 1992), Titles 10 and 18 (COMAR, 1992), and relevant case law. Specific ethical standards include terminating services “when it becomes reasonably clear that the patient or client no longer needs the service, is not benefiting, or is being harmed by continued service” (Standard 4.09, p. 1606). This standard also cautions against abandonment of patients and requires pre-termination counseling whenever possible, making needed referrals, and assisting in the referral process. Similar guidance is provided in Title 10 which also requires termination when the patient is not benefiting from treatment, when impaired competence is present, or when an exploitative, multiple relationship is present. Additionally, under these circumstances, patients must be notified of the termination in writing. The psychologist must still make appropriate referrals if ongoing treatment is clinically indicated and assist in the treatment transition.

The APA Ethics Code also requires psychologists to make arrangements that address each patient’s treatment needs during periods of both anticipated and unplanned absences as well as in the event of changing employment or contractual situations (Standard 4.08, Interruption of Services). Also, we are required to discuss with patients any anticipated limitations to treatment that may result from financial or insurance coverage limitations (Standard 1.25, Fees and Financial Arrangements). Further, both the APA Ethics Code and Title 10 mandate addressing such issues in a comprehensive informed consent agreement that is presented when treatment is initiated.

Courts have consistently ruled that licensed health professionals remain responsible for their patients’ treatment either until it is ended by mutual consent, the patient ends treatment, or until treatment is no longer clinically indicated. One may not discontinue a patient’s needed treatment unless referrals to other competent professionals are made and the patient is allowed a reasonable opportunity to begin treatment elsewhere prior to treatment’s being terminated (e.g., Collins v. Meeker, 1967). Otherwise, the psychologist may be liable for harm to the patient as a result of abandonment.

With regard to treatment under managed care, courts have also ruled that if health professionals terminate patients’ needed treatment solely because of adverse utilization review decisions they will be held liable for any damages that occur (e.g., Wickline v. State of California, 1986).

Regardless of the reasons for terminating treatment, the psychologist remains responsible for ensuring each patient’s treatment needs are appropriately met. When unsure, consultation with experienced colleagues and familiarity with relevant standards and laws will be of great help. Finally, clinicians may find the following recommendations of help:

Terminate only when it is clear that the patient will not benefit from further treatment or is being harmed by continued treatment.

Educate the patient about the circumstances under which termination will occur.

Refer the patient to alternative treatment services or offer referrals if further treatment is needed.

Money and managed care issues such as lack of funds and/or adverse utilization review decisions are not sufficient grounds for termination of needed treatment.

Informed consent agreements at the beginning of treatment should address issues relevant to interruptions, absences, and termination.

Needs of each patient should always be assessed and addressed as long as the treatment relationship exists.

Adequate coverage arrangements should always be made when away or over weekends and evenings.

Transfer responsibility for patient care to another competent professional and ensure that treatment has begun before considering your treatment relationship ended.

Ethical standards, laws, and regulations should be understood and followed at all times.

References

• American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597-1611.
• Code of Maryland Annotated Regulations. (1992). Title 10: Department of Health and Mental Hygiene, Subtitle 36, Chapter.05, Code of Ethics and Professional Conduct.
• Collins v. Meeker, 424 P.2d 488 (Kan. 1967).
• Wickline v. Blue Cross of Southern California, 271 Cal. Rptr. 867 (Cal. App. 2 Dist. 1990).

 
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