does premature termination constitute abandonment?
Most clinicians have encountered multiple situations where a patient attends a limited number of sessions and decides to end the treatment relationship, either by no-showing for successive appointments or by declaring that they wish to end the treatment relationship. This can present some difficulty when we believe that such a termination is inadvisable. Many of us have experienced the tension between respecting the wishes of our patients and not wishing to endorse a plan of action that we feel is clinically contraindicated. Most clinicians have wondered whether there is an appropriate legal and/or ethical course of action to take in such circumstances. Professional licenses represent large investments of time and money, and as such we are understandably wary of any situation that could risk these qualifications.
The term that most frequently comes up in these discussions is “abandonment.” The question that is posed is something similar to the following: “if a patient who I believe needs treatment terminates the treatment relationship and I allow it to occur, could that be construed as patient abandonment?” This is a relatively complicated question but reframed in a slightly different way the question becomes somewhat simpler: “what are the duties owed by a mental health professional to his/her patient when the patient terminates treatment against the clinician’s recommendations?”
“Abandonment” is something that occurs when a clinician abruptly drops a patient. Whereas a clinician has many duties that he/she owes to her/his patients, patients do not have similar duties that they owe to their health care providers. Patients cannot “abandon” their therapists. Yet, when patients drop their clinician this does not necessarily mean that the professional duties owed to a patient are completely severed.
From a legal perspective, the answer to the question of what duties are owed to a patient who terminates prematurely is, “that of a reasonable clinician.” This necessarily begs the question, “what is reasonable?” The ultimate answer gets a bit tricky because it depends on a multitude of factors, such as the time spent with the patient, the nature of the patient’s presenting problems, etc. In other words, “it depends.”
As licensed clinicians, we have a professionally sanctioned method for answering the question of what is reasonable: consultation. Formal consultation with a (preferably) more experienced colleague helps us to address the question of how to clinically consider a patient’s actions, which then informs us about our possible course of actions. It is impossible to overstate the importance of documented formal consultation; it is one of the most effective methods for accessing the standard of care.
But once consultation has occurred, what next? Usually at this point the patient has either left or is in the process of leaving treatment and the clinician believes that this is unwise. Absent a credible threat to self or others, the next step is usually to document the patient’s decision and the known reasons for doing so.
In most situations, the course of action is usually to do nothing and not pursue the patient. Absent a risk to self or others we do not intervene. The law recognizes the right of competent adults to make bad decisions. When patients decide to leave treatment they are (of course) free to do so. Partly because of these abrupt terminations, many clinicians try to anticipate these situations in their office policies and procedures documents. In addition to information about billing, emergency contact information, cancellation policies, etc., many clinicians include a section discussing premature terminations. This is a good way for clinicians to advise patients of the nature of treatment, their options, referral resources, and emergency contacts. In rare circumstances it might be appropriate to write a letter to the patient advising them to seek services, but this should only be done after formal consultation with a colleague and possible consultation with an attorney or professional liability carrier.
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