Anchors Aweigh

The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.
Hippocrates, in Aphorisms I

On my first night float call, I admitted a man named Mr. Crown (name changed) from a very flummoxed EM resident. It seems that he developed viral myocarditis two years ago, in Arizona, and was lucky to receive a cardiac transplant there. After his transplant, Mr. Crown led a rootless life, crisscrossing the country between Tampa and Las Vegas, losing his insurance and medical team. Poor adherence led to fulminant acute rejection, which nearly killed him last Thanksgiving. Untroubled by this close call, the patient continued to miss appointments. Meanwhile, chronic hypertension and steroid-driven diabetes remained unchecked.

Review of his chart showed that he was hospitalized twice, at Clifton the month prior, for DKA and diastolic heart failure. Grade 1A cellular rejection was present on septal biopsy. Advanced stable chronic kidney failure was noted, ascribed to nephrotoxicity of his immunosuppression. He was terminated from Emory Healthcare under the claim of already being accepted to his home transplant center. Upon a closer look, though, this had not been confirmed by social workers, the grounds for termination were not clearly documented, and there was no statement from the attending cardiologist.

I learned that he was without insurance, but had applied for an emergency Medicaid exchange. So now here he lay, with diastolic failure of his allograft, progressive advanced kidney disease, and with no means of affording the quaternary care he desperately needed. Fortunately, the medical team was able to secure private coverage, and I have since learned that he was accepted to another heart center here in the city. A crisis had been foiled.

Legal stipulations regarding termination of the physician – patient relationship (PPR) are codified in the AMA Ethics Opinion (8.115, 1995) and upheld in Georgia by the court precedent of Norton vs Hamilton (89 GA 1955, S.E.2d 809). There are five necessary ingredients to be immune from a claim of abandonment

  1. sufficiently advanced notice (thirty days) or immediate transfer of care to a skilled practitioner,
  2. an explanation of grounds of expiry
  3. access to a copy of medical records
  4. termination must necessarily be delayed if the patient is in an acute phase of disease or treatment (e.g. perioperative, serious illness, first trimester pregnancy)
  5. termination must also be postponed or if the patient lacks the means to establish care at another site (e.g. limited transportation, cognitive impairment)

The annulling provider is merely advised to provide assistance and resources to simplify the transition of care, but is not legally beholden to oversee and assure its closure. For example, a list of nearby clinics and phone numbers may be provided, but there is no mandate to formally sign out the case to another provider. The extent of the physician’s duty at this point is undefined, but it is made clear that the ultimate responsibility now rests with the patient. The ambiguity of these duties leads to many ethically grey situations.

During the same week I met Mr. Crown, my colleague Dr. Malloy took care of bewildered lady with anaplastic lymphoma who was admitted to a private hospital under emergent circumstances (cord compression syndrome) and given a partial course of induction chemotherapy. Once the patient was deemed to have achieved a partial clinical response, she was discharged between cycles and beseeched to seek follow up oncologic care with us at Grady. She arrived at the emergency room near midnight. She was scared, confused about her treatment plan, and sans medical records. Theoretically, the patient was indeed properly discharged, fulfilling all of the criteria set forth above, but her clinical status was clearly jeopardized in the process. She was precious cargo, handled carelessly. Stories like this, in which uninsured patients are expelled from the temporary haven of one healthcare system after an emergent illness, and then told to establish care though the portal of the emergency department of another one, are eloquently depicted in the documentary The Waiting Room by Peter Nicks.

Despite the veil protection offered by the law, we continue to meet patients who are rescued from oblivion just in the nick of time, like Mr. Crown. Other patients are not so lucky. They may be given fair notice, and maybe even a generous bridge of medications or therapy; but they lack the provisions to make the transition for themselves. Like wayward ships, they become lost. On any given day in my clinic, I am guaranteed to meet one or two patients who were released from care elsewhere, and simply gave up in defeat after attempting to navigate our system.

I am starting to think that the current laws are not strong enough. The thirty day grace period is a slick device whereby a provider may escape from his accountability to the patient by providing one extra refill. One might argue that this interlude is the most critical juncture in all the patient’s course. It is hard to release a vulnerable patient to the open market, just as it is to release an injured bird to the cold winter air. Perhaps it would be more ethical to maintain the therapeutic relationship up until the transfer of care has been confirmed and finalized.

I also speculate – there is no literature on this particular topic – that some fraction of PPR terminations are due not to lack of interpersonal antagonism or lack of specialized services, but rather, to reimbursement structures that are outside of individual physicians’ control. For example, managed care organizations with capitated patient visits may be forced to discharge large groups of patients when the profile of accepted insurance plans changes. I have met several metal health patients who could not be seen by their longtime psychiatrists due to lack of Medicaid acceptance. They were provided with a month of medications and a farewell wish. Clearly, system-wide reforms are needed to address this particular loophole.

In this age of colossal public safety nets, such as Grady Hospital, there is a false sense of security that we will always catch patients when they fall. But we forget that each fall comes at a permanent cost – whether it be progressive rejection of a precious transplanted heart, relapse of an aggressive lymphoma due to one oncologist’s misplaced faith in the ability of his patient to fend for herself and resume her next cycle of chemotherapy on time, or decompensated psychiatric disease in a patient who has run out of medications at the end of her grace period. When we terminate a relationship with our patients, even when it is done out of the best possible intents, we let the ocean carry the ship, and can only hope for a safe landing.


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