Being a doctor requires dedication, smarts, and-often-a strong stomach. You can't be queasy at the sight of blood or internal organs. And you have to touch patients who might be dirty, unkempt, or worse, as in this case:
"An elderly patient I've been seeing for years is becoming less able to care for herself," a doctor recently e-mailed me. "She smells of urine, is incontinent, and has roaches crawling all over her. I don't want to touch her as every time I move an article of clothing a bug crawls out. Also, I'm concerned about her pronounced odor and the effect it has on the other patients in the office. Can I discharge this patient?"
A good, but perhaps ultimately futile, first step in a situation like this would be for the physician or nurse to talk to the patient about proper cleanliness and habits of daily living. If there are health risks, those will have to be addressed. Family can be helpful if they're willing to become involved. If the patient requires assistance with daily living, the caregiver must be involved.
You can expect that a patient whose problems are severe isn't going to keep an appointment with a specialist. Again, that's where the caregiver comes in. If the patient's poor hygiene is the fault of the parent, guardian, or caregiver, you might need to contact your local child- or adult-protection agency. Most states have laws requiring physicians to report cases of suspected child or elder abuse.
Since you enter into the doctor-patient contract freely, you can end it at any time-except in an emergency, and on the condition that you follow the proper procedures to avoid abandonment claims. Start by sending the patient or his guardian a letter by certified mail, return receipt requested. Here's an example:
"I'm writing to inform you that I will no longer be able to serve as your physician as of [date]. As you'll likely need medical attention in the future, I suggest that you find another physician to care for you. If you're not acquainted with another doctor, I recommend that you call the local medical society [phone number]. Should an emergency arise before the date indicated above, you may contact me for treatment.
"Since the records of your care are confidential, I need your written authorization to make my records available to the physician you choose. Please return the enclosed authorization form to me as soon as possible.
"Although I can't continue as your physician, I extend to you my best wishes for your future health."
It's unnecessary, and in this situation may be gratuitous and harmful, to indicate why you're terminating the relationship. Put a copy of the letter and the postal documentation into the patient's chart.
Be sure to give the patient adequate time-a month should suffice-to find another physician in the appropriate specialty in your area. In the meantime, you're obligated to render necessary treatment and emergency care until she finds a new physician. That goes for anyone you dismiss from your practice: your noncompliant patients, the obnoxious or violent ones, and, heaven forbid, those infested with creepy crawlies.
The author, who can be contacted at firstname.lastname@example.org
, is a healthcare attorney in Mt. Kisco, NY, specializing in risk management issues.
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