WHEN TO STOP TREATING A PATIENT

2^nd July 2024

Emily Borhan, PRASIS Medico-legal Adviser, writes ...............

Over the last few months, I have had quite a few requests for assistance from people asking if they can stop treating patients who are showing signs of being slightly tricky to deal with.

Often, these patients show signs of difficult behaviour such as being late for appointments, being rude to members of staff, or requesting further surgery or treatment when the clinical result is good.

Firstly, it is important to look at the GMC’s when terminating treatment with patients (https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/ending-your-professional-relationship-with-a-patient/ending-your-professional-relationship-with-a-patient):

3. In rare circumstances, the breakdown of trust between you and a patient means you can’t continue to provide them with good clinical care. This might occur when a patient has, for example:

been violent, abusive, or made threats to you or a colleague
displayed other criminal behaviour, such as stealing from you or the premises
acted in a sexual way towards you
persistently acted unreasonably.

5. You should not end a professional relationship with a patient solely because of:

a complaint the patient made about you or your colleagues. You must make sure that any complaints or concerns raised by the patient are responded to promptly, fully and honestly (Good medical practice, paragraph 46)
the resource implications of the patient’s care or treatment.

It then goes on to say (https://www.gmc-uk.org/-/media/documents/gmc-guidance-for-doctors---ending-your-professional-relationship-with-a-patient-20200121_pd-56007172.pdf):

47. You should only end a professional relationship with a patient when the breakdown of trust between you and the patient means you can’t continue to provide good clinical care to them […]

65. Continuity of care is important for all patients […]

Based on the guidance provided by the GMC, it is clear that terminating treatment with a patient has to be for good reason, and the continuity of the patient’s care is important. Whilst the care you provide for patients undertaking elective treatment in plastic surgery is slightly different to that of medical necessary or emergency treatment, you will still find that your responsibility to the patient remains the same, especially once you have started treatment.

What can you do if you are faced with the situation of wanting to terminate treatment but find that you cannot?

In a simpler example, when a patient has been rude and aggressive, you can write to the patient expressing your disappointment with their behaviour and informing them that rude behaviour is not tolerated in the clinic.

In a more complicated example, such as you have reached the stage where you do not feel comfortable carrying out further surgery, it is slightly harder. You may have a patient who has got a good result but who wishes to improve it further, someone who is unlikely to ever be happy with the result, or you may have someone who needs further surgery but you do not feel comfortable doing it. To simply terminate the relationship in any of these circumstances would not be suitable and may leave you in a vulnerable position and open to potential complaints. However, continuing to carry out a surgical procedure when you do not feel comfortable doing so is also not advisable. There are some things that you could consider doing to help you in this situation, and to help the patient going forward:

Talk to them about the options, your reservations, and the risks that are involved - is there a greater risk of a bad outcome following yet another procedure?
Suggest a second opinion - a second pair of eyes can be really helpful for both sides and your colleague may even make more suggestions, or be happy to continue the treatment.
Do they need to be referred for psychiatric review, is this an issue with body image rather than the result itself?
If there is nothing else you can suggest and you feel confident that you are not leaving the patient medically vulnerable, you can offer the patient a refund of your fees to seek treatment elsewhere.

Conclusion

You may find yourself in situation where you feel uncomfortable performing further surgery on a patient. In this circumstance, you need to ensure that you have done everything within your professional responsibility to make sure that the patient is well cared for going forward. You cannot leave a patient in a medically vulnerable position whether you agree that further treatment is required or not, or simply because the patient has been difficult to manage.

The above guidance has been provided as examples of things you can do to document that you have tried to provide the patient with understanding and knowledge of the situation, and continued care in the circumstances.

Every situation will be different so please always seek advice from the medico-legal helpline to ensure that notification under the policy is carried out correctly, and you are protecting your position going forward.

Emily Borhan
PRASIS Medico-legal Adviser
emily.borhan@m-i-c.co.uk
Tel: 03332408979
Mob: 07498322935