Clinicians occasionally cope with challenging patients. Most of the time, conflicts can be resolved without seeking ethics expertise, and the patient/physician relationship remains intact. However, that is not true in all cases. “Professionalism requires us to act in the patient’s best interest and follow ethical standards. But these challenges can be overwhelming at times,” says William Nelson, MDiv, PhD, director of the ethics and human values program at Dartmouth.
For whatever reason, clinicians simply cannot reach a mutual understanding with some patients. “Clinical responsibility is not without limits. When the patient is so disruptive, noncompliant, or troubling, it really almost compromises safety,” Nelson says.
About 90% of primary care physicians have discharged a patient in the prior two years, for reasons such as persistent disruptive behavior or violation of controlled substance policies.1 “There is a point where there is an ethical justification that you may consider dismissing the patient, as long as you are not discriminating against a person just because of that person’s race or other uniqueness, or in violation of any state statutes, or compromising the person’s health and safety,” Nelson says.
It might be appropriate to transfer that patient to a different care provider. Ethicists can help develop clear guidance and a process for those cases. “It’s important that if there is great conflict with a patient, that clinicians not act in a knee-jerk way,” Nelson cautions.
A primary care practitioner might use ethics practice guidelines to create a consistent approach for dealing with these cases. “This is possible even though you don’t have a formal ethics committee. It doesn’t have to be a formal, fancy policy that gets approved by a board of directors,” Nelson offers.
Many hospitals operate multiple outpatient clinics, some geographically far away. Ethics committees may have addressed disruptive patients, and could share resources with outpatient clinics. “This is especially important due to the increasing number of surgeries done in an outpatient setting,” Nelson says. “Accessibility of ethics resources outside the inpatient setting is really an important issue.”
The American College of Obstetricians and Gynecologists (ACOG) detailed considerations for anticipating conflict, restoring the therapeutic relationship, and ethical guidance for when this is not possible.2 “The potential for conflict is an inherently normal part of human relationships, whether personal or professional,” notes Kavita Shah Arora, MD, MBE, MS, chair of the ACOG ethics committee and a co-author of the committee opinion.
As part of a patient-physician relationship, conflict can arise for various reasons. “While it is tempting to blame this on either the physician or the patient, it is important to remember that the conflict originates in the relationship, rather than a person in isolation,” Arora cautions.
Examples of when the therapeutic relationship cannot be salvaged could include abusive behavior toward the physician or their staff. Patient-centered communication can resolve some conflicts. Formal mediation, such as clinics ethics consultation, may be helpful in extreme cases. “Realigning the therapeutic relationship can address many conflicts, though not all,” Arora says.
REFERENCES
1. O’Malley AS, Swankoski K, Peikes D, et al. Patient dismissal by primary care practices. JAMA Intern Med 2017;177:1048-1050.
2. Ethical approach for managing patient-physician conflict and ending the patient-physician relationship: ACOG Committee Statement No. 3. Obstet Gynecol 2022;140:1083-1089.
It is important to remember that if serious conflict with a patient arises, clinicians should not act in a knee-jerk way. A primary care practitioner might use ethics practice guidelines to create a consistent approach for dealing with these cases.
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