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Sparks was admitted to the hospital on August 5, evaluated by the consulting internist on the 6th, with surgery planned for the 7th. The internist was unable to report his findings to Hicks before the scheduled surgery, so Hicks decided to postpone it, discharge the patient and reschedule for the next week. The internist’s report later confirmed Hicks' concerns that there was a total occlusion of the right internal carotid artery, and 50% obstruction of the left internal carotid artery.
The patient's son became enraged when he heard about the postponed surgery. Dr. Hicks’ notes in the medical record include these observations:
“Unfortunately, her son became quite irate at the fact that we are not able to operate when we had originally planned. . .”
And, he threatened . . . that if we sent her home over the weekend, he was going to call her attorney. In my opinion, the sequence of events has resulted in a basic destruction of the mutual trust necessary for me and the patient to proceed with an operative intervention. I have given her the name of (several other physicians). . .(T)hey have agreed that she could come in to see them in their office next week, if she so desired."
A nurse’s notation in the record for the same day adds, “the patient requested Dr. John Coat’s office phone number. States she was instructed to follow up with him in the future.”
Ms. Sparks sued Dr. Hicks for abandonment because he discharged her from the hospital and because he refused to perform the surgery; the trial court in Oklahoma dismissed the case. Sparks appealed and it went up to the Supreme Court of Oklahoma. Oklahoma’s Supreme Court had not previously considered what the legal standard should be in a case alleging abandonment by a physician. The justices decided to uphold the earlier dismissal of the case and they define the standard this way: a physician may terminate a physician-patient relationship --when further medical attention is needed-- only after giving reasonable notice and affording the patient an ample opportunity to secure medical attention from other physicians.
The Court relied heavily on Hicks’ documentation in deciding that he did not abandon Sparks. While Hicks appropriately referred Sparks to other providers, the notice that is generally provided to patients is 30 days or more. The court undoubtedly took into account the fact that Hicks’ arrangements ensured continuous coverage for the patient as well as the fact that her condition did not necessitate urgent treatment. The court was also persuaded by Hick’s belief that continuating the relationship would be impossible, because the patient no longer trusted him.
Discontinuing the treatment of a patient because of a breakdown of the physician-patient relationship is always a difficult process. Physicians who want to terminate treatment should take three steps:
1. inform the patient about his or her need for future treatment;
2. inform the patient that they will no longer provide the treatment and, if possible, explain why they will not continue to provide the treatment. And
3. assist the patient, if possible, in transfering care to another competent physician who will provide necessary services. Assisting the patient in this regard usually consists of providing the patient with the names of other physicians who are available to treat the patient.
Obviously, the patient must not be in need of urgent or immediate treatment such that a transfer of care to another physician would adversely impact upon his or her health.
Usually, providing the patient with 30 days notice is recommended.
What is most compelling about this decision, however, is the reliance by the Oklahoma Supreme Court on the documentation by the physician in the medical record. In cases where a physician intends to discontinue treatment against a patient's wishes, documentation of why a physician chooses to discontinue the treatment and the information provided to the patient, is absolutely critical. The provider might also seek advice from hospital counsel about the governing laws and regulations in a particular state. If the patient decides to bring an action against the physician, either in a medical malpractice action alleging abandonment and negligence, or in a complaint before a medical licensing board, the individuals reviewing the complaint will rely heavily upon the contemporaneous notes made by the physician. These notes should detail the interaction with the patient and attempts to transfer the patient to an appropriate other physician.
The more detailed and explicit these notes are, the more likely the person reviewing the notes will feel comfortable in dismissing the charges against the physician and determining that the patient was treated fairly and professionally under these difficult circumstances.
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