Termination of services: Reaching the end of your rope

How to deal with difficult patients

By Mindy Owen, RN, CRRN, CCM Chair, Ethics Committee, Commission for Case Manager Certification President, Phoenix Health Care Associates Coral Springs, FL

Most of us have been there — dealing with the patient who refuses to comply with our treatment plan, who is uncooperative and generally unpleasant. For many of these patients, the stress and strain of their illness, disease, or injury, and the abrupt changes in their lifestyles have proved almost too difficult for them to bear, and it's oftentimes the case manager who gets the brunt of their frustration.

While we've all had a case or cases that we'd rather have passed on, is there ever a truly justifiable case that a case manager can terminate at will? Ethically speaking, no, with the exception, of course, of actual or threatened violence and, in some cases, blatant noncompliance or refusal to follow through with treatment plans.

Furthermore, in addition to the ethical dilemmas these cases pose, there also are potential legal ramifications to terminating a case of which case managers need to be aware. The legal issues involve the potential for liability when case closure is done improperly. Generally speaking, there are eight circumstances in which case management services can be terminated without question:

  • Client dies.
  • Client relocates.
  • Client cannot be located.
  • Client is hospitalized, enters a group care facility, is institutionalized, or is not available for services for more than 90 consecutive calendar days.
  • Client no longer needs case management services because of changes in his or her condition or circumstances.
  • Client refuses services.
  • Client requests termination of services.
  • Client refuses to cooperate in the provision of case management services.

Termination vs. abandonment

As mentioned earlier, there is always some risk of liability when a case manager terminates services to clients or patients, especially if the client does not agree with the discharge plan, for example. However, there is a distinct difference between

terminating and abandoning a case. Abandonment, of course, is both an ethical and legal quagmire if it is determined that the case was abandoned and not properly terminated.

To ensure that you are staying within both your ethical and legal boundaries, you must protect yourself against appearing as though you are abandoning the client when situations dictate termination. Clients who accuse case managers of abandonment must prove that the case manager terminated the relationship unilaterally, without reasonable notice, and when further attention was required.

In some cases, it is in fact the client who terminates the services through his or her own actions, albeit perhaps unknowingly or unwittingly on their part. In home care, for example, when clients are consistently not at home for scheduled visits, the clients themselves are terminating the relationship. In such cases, always leave a written note indicating that the appointment or visit was missed and document this in the client's records. You must notify these clients who are unavailable for a specified number of visits that they are constructively terminating their relationship with you and your facility or agency.

In most organizations, a limit of two or three missed appointments is warranted to discharge the client from your services. Afterward, follow up with a written notice to the client that his or her case is closed, document the discharge in the client's medical record, and notify the physician.

Keep in mind that when clients terminate relationships directly with providers and everyone involved in the client's case agrees to the termination, the providers have no liability.

Termination issues

Termination of services gets more ethically challenging in those cases in which the client's insurance no longer covers your services. In these cases, you can first suggest that the clients pay privately, even if you think they have no other resources. Document the offer and the client's response. If the client declines to make other payment arrangements, it is the client who is terminating the services.

And finally, perhaps the ultimate ethical challenge: those clients suffering from mental illness or poor judgment, limited financial resources and no available, willing, or able caregiver. Without your services, the client may suffer injury or further declining health. One way to approach the situation is to have a meeting or conference with the professionals who are part of the treatment team to develop a service discharge plan. This most likely will involve a community resource, such as adult protective services. A realistic discharge time frame is two to three weeks.

In many of these cases, you may need to arrange for transportation for the client if the discharge plan calls for a change in the client's setting. Should the client refuse any of your services or interventions, it is the client who is terminating your services. Document your discharge plan and the patient's response to all recommendations and interventions.

Documentation holds the key

As with all of the duties you perform, documentation is key to protecting yourself and your employer should disputes or questions about your actions arise. In cases of termination, documentation is especially crucial.

Keep these tips in mind when proceeding through termination steps:

  • Print neatly with black ink. Black ink photocopies best.
  • Identify the time and date on every progress note and sign the entry with your title.
  • Document all teaching performed and instructions provided to the client and/or caregiver and always include their responses.
  • Be factual and specific in all documentation.
  • Do not discuss agency problems or staff issues in a client's note.
  • To correct any errors or mistakes in your documentation, do not attempt to erase or blot it out. Instead, draw a thin line through the documentation and write "mistaken entry" above it and sign your initials over it.
  • Never completely cover a mistaken entry.
  • Document all telephone calls, e-mails, and any other communications with physicians, community agencies, and other team members. This should include explanations of what occurred with the patient, what actions were ordered and taken, how they were implemented, and the outcome of those actions.

This may be a difficult and uncomfortable situation for you as a case manager. Your goal is to do your best to keep your patient from harm; however, you need to protect yourself as well. Taking the right steps and documenting the process will protect you and the clients you serve.