PATIENT MANAGEMENT PROBLEMS
Non compliant Patient
Dentists and staff should rout indy chart lack of cornpliance, Including missed appointments, cancellations, and failure to follow advice to take medications, seek consultations, wear appliances, or return for routine visits. Efforts to advise patients of risks associated with failing to follow instructions should also be. recorded. When the patient’s health may be jeopardized by continued noncompliance, the clinician should consider writing a letter to the patient, which identifies the potential harm and advises the patient that the office will not be responsible if these and other problems develop as a result of the patient’s noncompliance. If the patient’s care is eventually terminated, the accumulation of detailed chart entries documenting the noncompliance should justify why the dentist is unwilling to continue care.
A legal duty is owed to the patient once a doctor-patient relationship is established. This occurs when a patient. has been accepted by the office, the initial evaluation has completed, and treatment has begun. The dentist is
uSUftlly obligated to provide care until the treatment is completed, ‘I here may be in-ranees. however. when it impossible or unreasonable for a dentist to ‘cVlllplde a treatment plan because of several problems. Such problems include the patient’s failure to return for necessary appointments, follow explicit instructions, take medication, seek recommended consultations, and stop activities that may inhibit the treatment plan or otherwise [eopardlze the dentist’s ability to achieve acceptable results. This may include a ‘total breakdown of communication and loss of rapport between the dentist and patient. In these cases it is usually necessary for the dentist to follow certain steps before discontinuing treatment to avoid being accused of patient abandonment. First, the chart must document ·the activities leading to the patient’s termination, The patient should be adequately warned ,(if possible) that termination will result if the
undesired activity does not stop. The patient should he warned of the potential-harm that may result if such activity continues and the: reason why the harm may occur. After being told why the office is no longer willing
. to provide treatment, the patient should be given a real. son able opportunity to find a new dentist (30 to -15 days is common). The office should continue treatment durillg this period if the patient i~ in need of emergency care or care is required to avoid harm to the patient’s health
or to treatment progress. When it has been decided that the dentist-patient relationshipcannot continue, the dentist must take the following steps to terminate the relationship A letter should be sent to the patient, indicating .the intent to withdraw from the case and the unwillingness to provide further treatment. It should include five important pieces of information:
1. The reasons supportin~ the decision t discontinue treatment 2. If applicable, the potential harm caused by the patient (or parent’s) undesired activity 3. Past warnings by the office that did not alter the patient’s actions and continued to put the patient at risk (or jeopardized the dentist’s ability to achieve an acceptable result) 4. A warning that the patient’s treatment is not completed; therefore the patient should immediately seek another dentist or go to a hospital or teaching clinic in the area for immediate examination or consultation. (The clinician .should include a warning that if the patient fails to follow this advice, the patient’s dental health may continue to be jeopardized and any- treatment progress may be lost or
worse.) S. An offer to continue treating the- patient for a reasonable
period and for emergencies until the’ patient locates another dentist ‘This letter should be sent by certified mail to ensure and document that the patient did in fact receive it. If other dentists are treating the patient, the clinician should consider advising them of this decision. The clinician
should cosult local counsel if any cone confidentiality or a particularly sensitive reason decision exists. rhe-dentist Jl1U,t coi.unuv It) remain vailable tor treatment of crncrgencv problems until till’ patient has had adequate time to seck treatme-nt Irom another dentist. This must be in the letter outlined previously. . The dentist must offer to forward copies of all pcrtinent records that affect patient care. Nothing must he done to inhibit efforts of subsequent treatment to complete patient care. Patients ‘who are PLJ~ili\’l f(;; ,1-;. hu.nan imrnunodcficiency virus (HIV) or who (: Slill’ •.ir diseases cannot be terminated because of their disease, because this action
may violate the Hadicapped Civil Rights Act and other federal or state laws. The~l’ Jl”tk!lt~ cannot be refused treatment based 011 their disease. l’,llienh who positive Of have- acquired deficiency syndrome (AIDS) arc onsidered halldi~”.1!’;’ ..’~1under these taws.’ Legal counsel should be If the clinician as another valid rea SOli to tt’lm:!’..ll’!” such d patient. Exceptions do exist to ‘ht..~l’~u,·~, ..<tcd guideline’S. Dell, tists must evaluate each situ;.\i.t11 I arcfullv. Occasions may occur when the dcnfist ll”L” not wish tl~lose contact
with a. patient or lose tilt; ability to observe and follow a complicatlon. Terminating treatment will often anger a patient, who may in turn seek legal advice if experiencing a complication. The office may elect to complete treatment in such cases. If treatment continues. the chart should carefully
reflect all warnings to the patient about potential harm and the increased chance that acceptable results may not be achieved. In certain cases the patient may be asked to sign a revised consent form that includes three important points: ‘ 1. The patient realizes that the patient has been noncompliant or has ot: .erwise not followed advice. 2. The previously mentioned activities either jeopardized the patient’s health nr the dentist’s ability to achieve acceptable results or have unreasonably increased the chances of complication. 3. The dentist will continue treatment hut make- no assurances that the results will be acceptable. Complications may occur requiring additional care. and the patient (or’ the patient’s legal guardian) will accept full responsibility It any of the above events occur and w~ll not hold the dentist responsible.