Terminating treatment of a behavioral health patient can be challenging, particularly when the patient’s behavioral well-being is dependent on the medications you are prescribing and the therapy you are providing.*
Case File
During a 10-week period, a 24-year-old law student had six counseling sessions with a psychiatrist at a student clinic. The student had a significant history of behavioral health issues. The psychiatrist prescribed an antipsychotic medication and diagnosed the patient with “delusional disorder grandiose.” (The psychiatrist recognized that the patient exhibited symptoms of schizophrenia, but he decided to document a more “generous” diagnosis, believing a diagnosis of schizophrenia would deprive the patient of the opportunity to practice law.) At the fourth session, the psychiatrist told the patient he was retiring. He told the patient he should continue therapy with another psychiatrist. The patient did not accept his offer of a referral. At the last session, the psychiatrist provided the patient with a prescription for a 30-day supply of the antipsychotic drug and told him to contact his replacement at the student health center to have his prescription refilled.
The patient stopped taking the antipsychotic medication after the prescription ran out and did not seek behavioral health treatment. Eight months later, after a gradual increase in psychotic symptoms, the patient became delusional and fatally shot two students. He was charged with murder but found not guilty by reason of insanity. Following the criminal trial, the patient filed a malpractice lawsuit against the psychiatrist, alleging, among other claims, that he was abandoned when the psychiatrist retired. His argument rested on the psychiatrist’s failure to stress the importance of seeking further behavioral health treatment and continuing antipsychotic medication. The patient’s experts testified that the psychiatrist should have referred the patient to a specific therapist and ensured that an appointment was set. The jury awarded a $500,000 verdict; however, the verdict was overturned on appeal.
Discussion
Although the jury verdict was eventually overturned in this case, the psychiatrist had clearly not expected to spend the first years of his retirement testifying in a murder trial and then enduring a malpractice trial. Personally referring and arranging follow-up appointments may not be necessary for every patient, but this psychiatrist might have avoided a lot of trouble by more thoroughly ensuring the continuity of care for this patient.
Risk Management Recommendations
Consider the following recommendations:
- Emphasize to the patient the need to take prescribed medications and undergo treatment with another behavioral health provider.
- Discuss and document the consequences of forgoing treatment.
- Ensure that the patient understands the importance of following up with another behavioral health provider, and document evidence of the patient’s understanding.
- Explain to the patient why you cannot continue to provide treatment. Make it clear that you are not dismissing the patient because you do not like him or her.
- Make a reasonable effort to secure a new behavioral health provider.
- Allow a reasonable amount of time for the patient to transition to a new behavioral health provider.
- Formalize the termination of treatment in writing (as discussed in the NORCAL case study, “Termination of the Physician-Patient Relationship for Non-Compliance”).
Reference
* Case study derived from Williamson v. Liptzin, 539 S.E.2d 313 (N.C. Ct. App. 2000).
