Introduction

Terminating a patient-provider relationship involves several legal considerations, and as a result, some Advanced Practice Registered Nurses (APRNs) often question if they should maintain or terminate a patient relationship. Fortunately, terminating the patient-provider relationship is a rare occurrence. Grossier et al. (2021) reported that during a five-year period, 55% of primary care providers terminated one patient, 11% terminated two patients, and 33% terminated three patients. This article will highlight legal considerations associated with APRN-initiated termination of patient relationships.

When Should an APRN-Provider Relationship be Terminated?

APRNs should consider terminating a patient relationship under specific circumstances. Examples of such circumstances include:

• Frequent no-shows and violation of established no-show policies (Groisser et al., 2021).
• Bullying, abusive, violent, disruptive, or inappropriate behavior to APRNs and/or practice staff (O’Malley et al., 2017).
• Non-compliance with established treatment regimens (Groisser et al., 2021; O’Malley et al., 2017).
• Treatment demands that the APRN is unwilling to provide (e.g., controlled substances) (Pope, 2019).
• Financial obligations to the practice, despite offering a payment plan (Pope, 2019).
• Patient threatens to or files a lawsuit or complaint which will deteriorate the APRN-patient relationship (MedChi, n.d.)
• APRN leaves the practice or opts to disenroll with a third-party payor (Wright & Paris, 2017)

Terminating an APRN-patient relationship is not an easy decision and may subject the APRN to accusations of patient abandonment. However, APRNs should understand that they are not required to accept all patients into their care, particularly in an outpatient setting. In fact, if at the first visit the APRN determines the relationship if not a good fit, the APRN should refer the patient to another provider. After an APRN-patient relationship has been established and a decision to terminate the relationship has been made, APRNs must understand State of Delaware regulations.

State of Delaware Regulations

Patient abandonment is commonly defined as terminating a patient-provider relationship without adequate notice for patients to secure alternative medical care, thereby representing a breach of duty. According to the Delaware Code, before terminating a patient-provider relationship, APRNs must provide at least 30 days’ notice to patients with a letter mailed via first-class mail and an electronic medical record message for patients who have requested to receive electronic messages (Delaware Code Online, n.d.). Patients must be provided with information on how to obtain their medical records, the name, phone number, and address of healthcare providers in the area who may be accepting new patients, and the date that APRN services will no longer be provided (Delaware Code Online, n.d.). Although not required by the State of Delaware, best practice includes sending the letter via certified mail, sending a follow-up letter at the end of the 30-day notification period, and including a medical record release form with each mailing.

Proceed With Caution

Terminating a patient-APRN relationship requires careful consideration. Patient-APRN relationships cannot be terminated for discriminatory reasons (Brightwell & Cahill, 2021). Examples of protected categories by the Americans with Disabilities Act, the Civil Rights Act, and the Affordable Care Act include age, gender, race, disability, sexual orientation, English proficiency, and HIV-positive status, among others (Brightwell & Cahill, 2021). Violations may result in substantial civil and administrative penalties (Brightwell & Cahill, 2021).

APRNs should also avoid terminating a patient in the acute phase of treatment (e.g., pregnancy, chemotherapy, and psychiatric crisis) unless a seamless transfer of care can occur to an accepting provider (Brightwell & Cahill, 2021; MedChi, n.d.). Care should be provided to patients in rural areas and by subspecialized APRNs until care can be transferred to another qualified provider to avoid claims of patient abandonment. Finally, third-party payor contracts may dictate requirements to terminate patient-APRN relationships. For example, terminating a patient during the global post-operative period may be a contract violation (Brightwell & Cahill, 2021).

Additional Guidelines for Termination of the Patient-Provider Relationship

Wright et al. (2017) recommended establishing a clearly defined policy for terminating patient relationships. Such policies should be developed in collaboration with legal and risk management experts. Once a policy has been established and prior to terminating a patient relationship, APRNs should consider attempting to repair the relationship through counseling or a contract for care (MedChi, n.d.). Occasionally, patients are noncompliant for reasons unclear to the APRN. Counseling and contracts for care may help to restore the relationship, provide an understanding of the patient’s needs, and serve as a warning to patients that continued, unchanged behavior may result in termination. Finally, documentation is paramount to protecting APRNs from claims of abandonment or discrimination. APRNs should document problem behaviors and noncompliance to support any claims that the provider terminated the relationship inappropriately.

Conclusion

In conclusion, terminating a patient-APRN relationship is a delicate process that requires careful consideration and documentation. Compliance with requirements outlined in the Delaware Code will aid in avoiding claims of patient abandonment. Ultimately, adherence to ethical standards, empathy, and clear communication will support an amicable termination of the patient-APRN relationship.