By Christine Lehmann, MA

Some patients continually cancel their appointments, ignore your medical directions, treat your staff rudely, or send you harassing emails.

Do you have to tolerate their behavior?

No, these are all appropriate reasons to terminate patients, attorneys say. Patients also can be dismissed for misleading doctors about their past medical history, chronic drug-seeking, displaying threatening or seductive behavior toward staff members or physicians, or any criminal behavior in the office, experts say.

But even if a reason seems legitimate, that doesn't make it legal. Doctors should consider whether the reason is legal, said Chicago-area attorney Ericka Adler, JD, a partner at Roetzel & Andress, who advises doctors about terminating patients.

"Although a physician may think a reason to terminate a patient is legitimate, they should always be mindful of whether there is a legal concern at issue and consult with counsel if they're unsure," Adler said.

Terminating patients for an "illegal" reason such as discrimination based on race or gender or sexual orientation — even if couched as a legitimate patient issue — could open the practice to a lawsuit, Adler said.

Doctors also want to avoid patient abandonment claims by talking to the patient about problems and documenting them as they arise. If they can't be resolved, doctors should ensure that there's continuity of care when patients change physicians, said Adler.

About 90% of physicians have dismissed at least one patient during their career, according to a study of nearly 800 primary care practices. The most common reasons were legitimate: a patient was "extremely disruptive and/or behaved inappropriately toward clinicians or staff"; a patient had "violated chronic pain and controlled substance policies"; and a patient had "repeatedly missed appointments."

Jacqui O'Kane, DO, a family physician at South Georgia Medical Center in rural Nashville, Georgia, said she has dismissed about 15 of 3000 patients she has seen in the past 3 years at the clinic. Before she dismisses a patient, she looks at whether there has been a pattern of behavior and tries to talk to them about the problem first to find out if there are other reasons for it.

She also gives patients a warning: if the unacceptable behavior continues, it will lead to their dismissal.

When Patients Cross a Line

O'Kane warned an elderly man who used the N-word with her that she wouldn't tolerate that language in her office. Then, when he later called her front office employee the N-word, she decided to dismiss him.

"I said, 'That's it, you can't say that to someone in this office. I already told you once and you did it again. I'm sorry you have to find another doctor,' " said O'Kane.

Another patient crossed a line when she missed four appointments, refused to come in, and kept sending O'Kane long messages on MyChart demanding medications and advice. One message was fairly obtrusive: "If you don't give me something stronger for my nerves TODAY, I am going to LOSE MY MIND!!!" O'Kane said the patient wrote.

"I then told her that's not how I run my practice and that she needed to find someone else."

Another common reason doctors dismiss patients is for nonpayment, says Adler.

Recently, however, some patients have also begun demanding their money back from doctors for services already received and billed because they were unhappy about something that occurred at the doctor's office, said Adler.

"I advise doctors to respond: 'We disagree that you didn't get the service but we will give you your money back and we're also terminating you from our practice.' At that point, the doctor–patient relationship has become impossible," said Adler.

How to Dismiss Difficult Patients Ethically and Legally

According to the Council on Ethical and Judicial Affairs, a physician may not discontinue treatment of a patient, if further treatment is medically indicated, without giving the patient reasonable notice and sufficient opportunity to make alternative arrangements for care.

Terminating a patient abruptly without transferring their care could lead to a claim of patient abandonment and the physician being called before a licensing board for potentially violating the state's Medical Practice Act, said Adler.

Doctors can take these six steps to set the stage for dismissal and avoid a claim of patient abandonment.

1. Create written policies. Medical practices can describe their rules and behavior they expect from patients in these policies, which can cover, for example, payment, treating staff with courtesy, and medications. "When the rules are in writing and patients sign off on them, that gives doctors a certain comfort level in being able to refer to them and say that the patient hasn't been compliant," said Adler.

She also recommends that your practice create a policy that doctors should let the patient know about their concerns and meet with them to discuss the problem before receiving a termination letter.

2. Document any consistent problems you're having with a patient: When you start having problems with a patient, you should document when the problem occurred, how often it occurred, any discussions with the patient about the problem, warnings you gave the patient, and if, and when, you decided to terminate the patient.

3. Meet with the patient to discuss the problem. "Talking and meeting with a patient also allows the physician to assess whether there's another issue. For example, is there a mental health concern? Is there a financial reason for nonpayment or no-shows? There are multiple benefits to finding out what the problem is," said Adler.

Once you've decided to terminate a patient, here's what you should do:

4. Allow enough time for the patient to find alternative care. Adler recommends giving patients 30 days' notice, and that physicians offer to provide emergency care during that time. However, if the patient is undergoing treatment or has other challenges, more time may be needed to transfer care.

"It's important to consider the patient's context — if the patient is receiving cancer treatment, or is in a late stage of pregnancy, or lives in a rural area where few specialists are available, you may want to treat them longer — at least until they finish their treatment," said Adler. Also, states may have their own requirements about minimum notice periods, she said.

5. Provide patients with written notice that you intend to terminate their care.

Adler recommends that each letter be tailored to the patient's specific circumstances. "You could spell out a patient's history of noncompliance or nonpayment or inappropriate conduct because it's been documented and the patient is already aware of it from a previous discussion," she said.

Adler also recommends that doctors consult with legal counsel when in doubt or if contacted by the patient's lawyer. Some lawyers will draft the termination letters, she said.

6. Include the following information in the written letter: The date that they will no longer receive care, how they can obtain copies of their medical records, and how they can find a new physician by providing contact information for a state medical association or similar organization, which often maintains a database of clinicians by specialty and location.

The letter should also state that the doctor will provide emergency care during the 30 days. Adler also recommends sending the notice by certified mail.

O'Kane said she may be more likely to give patients a second chance because she practices in a rural underserved area, and she understands that her patients don't have many other options for healthcare. She also has developed a reputation for being willing to take on difficult patients that other physicians didn't want to deal with, she said.

She encourages physicians to talk to patients to find out why, for example, they may not be compliant with medications.

The patient may say, "I had to choose between paying for medications and putting food on the table,' " said O'Kane.