By David O. Hester, FASHRM, CPHRM, Director, Department of Patient Safety and Risk Management at The Doctors Company
Using appropriate guidelines can prevent a malpractice claim.
The American Dental Association’s Code of Professional Conduct states:
“Once a dentist has undertaken a course of treatment, the dentist should not discontinue that treatment without giving the patient adequate notice and the opportunity to obtain the services of another dentist. Care should be taken that the patient’s oral health is not jeopardized in the process.”
The health and well-being of a patient is always a primary concern. However, when it’s necessary to end the relationship, dentists should follow acceptable protocols to withdraw from the dentist-patient relationship. If appropriate protocols are followed, the dentist decreases the probability that a patient’s charge of abandonment will be successful.
Under some circumstances, dissolving the dentist-patient relationship is appropriate. These include, but are not limited to:
- Treatment non-adherence. The patient does not or will not follow the treatment plan recommended by the dentist, unrelated to the patient’s ability or circumstances.
- Follow-up non-adherence. The patient consistently cancels follow-up appointments or does not appear for scheduled appointments.
- Verbal or physical abuse.
- The patient or a family member uses inappropriate language with the dentist or office staff.
- The patient exhibits violent behavior or makes threats of physical harm.
- The patient exhibits extreme anger that jeopardizes the safety and well-being of office personnel and other patients.
- Nonpayment. The patient has multiple unpaid bills and has declined to establish a payment plan with the dental practice.
In other circumstances, additional steps or a delay in withdrawing from the dentist-patient relationship may be necessary. These circumstances include, but are not limited to:
- Acute treatment phase. Do not withdraw from the relationship when a patient is in an immediate postoperative state or acute treatment phase.
- The current dentist is the only option for the patient’s general or specialized dental care. When the dentist is the only source of care within a reasonable driving distance, he or she may need to continue treating the patient for current or follow-up care.
- Discrimination. The dentist-patient relationship cannot be terminated solely because a patient is diagnosed with AIDS/HIV, is disabled or for any reason in which a patient is in a protected class. Dentists must follow the requirements set forth in the Americans with Disabilities Act. Dental practices also must follow nondiscrimination rules as set forth by Department of Health and Human Services, including conspicuous placement of the required Americans with Disabilities Act poster in the dental office
When appropriate circumstances exist to withdraw from the relationship, dissolution should be completed formally. The dentist should notify the patient of his/her decision to withdraw from the relationship in writing. The written notice should be mailed to the patient by regular and certified mail, return receipt requested. Maintain copies of the letter, the original certified mail receipt and the original certified mail return receipt, regardless of whether the patient signs for the certified letter. Maintain all forms of written communication in the patient’s dental record.
The written notice should include these components:
- Effective date. The effective date of the withdrawal should provide the patient with a reasonable time period to establish a relationship with another dentist. Thirty days from the date of the letter is usually adequate; however, allow for any state regulations addressing termination that may be required in your practice venue. The relationship can be ended immediately under these circumstances:
- The patient has terminated the relationship.
- The patient or family member has threatened the dentist or staff or has exhibited threatening behavior.
- Interim care provisions. Offer interim care; however, true emergency situations should be referred to an emergency department.
- Continued care provisions. Offer suggestions for obtaining continued care. These suggestions may include referral services such as dental societies and/or community services. Do not recommend another dentist by name.
- Requests for copies of the dental record. The written notice should include an offer to provide a copy of the dental record to the patient’s new dentist. Include a HIPAA-compliant authorization form and notify the patient that you will provide a copy of the records when the form has been signed and returned to you.
- Patient responsibility. Advise the patient that ongoing dental care is recommended and should be pursued.
- Reason for termination. A specific reason for termination is not required. In some instances, it is acceptable to use the catchall phrase “inability to achieve or maintain rapport” or to state, “The therapeutic dentist-patient relationship no longer exists.”
Although there are situations in which it is acceptable to withdraw from the dentist-patient relationship, a dentist should exercise caution to recognize acceptable circumstances before any action is taken. The dentist should ensure that appropriate steps are followed to reinforce that a patient receives ongoing dental care. Also, if established protocol to withdraw from the dentist-patient relationship is followed, it could reduce the probability that a patient will pursue an abandonment claim.
Under all circumstances, it is recommended that dentists exercise caution and request assistance from a patient safety risk manager or the Department of Patient Safety and Risk Management to address specific dentist-patient relationship scenarios.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
Reprinted with permission. ©2017 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.