Terminating the Patient-Provider Relationship Essay Example for Free

Terminating the Patient-Provider Relationship Essay Introduction Problem Overview With the advent of 21st century medical technology, health care procedures, ethical and legal considerations and scopes of practice among health care providers have become greatly complex. According to Servellen (1997), one of the most confronting issues of the modern provider-patient relationship is the often misunderstanding of accountability, responsibility and liability of care measures towards the patient (p.334). Legal considerations of providing care and duty of obligation of the provider towards the patients start when the health care professional enters into a relationship with a patient. However, the agreement of care relationship does not only require role of the provider. According to Scott, Ed and Scott (2005), compliance of the patient throughout the care procedures rendered by the provider is another significant component of caring process (p.162). In fact, providers include initial assessments on patient’s level of compliance prior to the start of care process, and more importantly, health professionals inform the patient about the written policy imposing the responsibility of the patient to comply with the process of health care interventions. As considered by American Academy of Nurses, if the patient becomes noncompliant or initiates actions violating professional rights of provider or the patient’s rights, the provider possesses the benefit of terminating the working relationships as considered by the appropriate grounds (Scott, Ed and Scott, 2005 p.162). On the other hand, if the provider terminates the relationship, such professional decision now confronts the issue on breaching the pledged role of devoted care and legal duty of service. Termination of patient-provider relationships is confronted by question whether or not conflicts between the professional role of the provider and the legal duty to provide care (Servellen, 1997 p.334). The current implementations of patient care disengagement largely depend on the institutional policy. According to Scott, Ed and Scott (2005), â€Å"termination of the provider-patient relationship is justified when the patient makes a knowing, voluntary election to end the relationship, either unilaterally or jointly with the provider† (p.162). Upon signing the consent of care, both participants of the care process obtain their own roles in the entire procedure of care. Mason (2004) emphasizes that the professional relationship with the patient can just be terminated due to personal or other inappropriate grounds (p.307). Termination of care is only considered ethical and appropriate when (1) the patient has already reached the maximum benefit of the procedure as supported by clinician’s judgment, or (2) when the patient has already achieved cure from the procedure. However, termination of patient-care relationship on the ground of patient non-compliance imposes a conflict issue between duty of care and patient’s participatory role in the process of care delivery. As supported by Servellen (1997), the provider’s duties to the patient, involving a breach of duty, relates to the standards of practice for all health care professionals (p.334). According to Mason (2004), termination of patient care may result to a legal accusation of abandonment, which â€Å"is the discontinuation of an established patient-provider relationship† (p.307). According to AMA, a non-compliant patient is considered as a â€Å"difficult patient† and candidate for the reconsideration of patient-provider termination of care. However, termination of care must follow appropriate procedures without interfering the continuity of patient care. Terminating the patient care somehow conflicts with the element of maintaining the continuity of care. As explained by Carter, Levetown and Foley 2004), noncompliant patients under reconsideration of patient-care termination still possess the rights of continuous care until another health care reliever has been reassigned (p.120). Moscow (2004) points out that terminating patient care without proper reliever of care is automatically considered a liability against the established patient-provider relationship contract (p.120). According to Servellen (1997), despite the protective and patient-focused approaches of the provider, inevitable times wherein a provider is confronted with situations (e.g. DNR requests can sometimes impede to patient’s right of autonomy, etc.) that can possibly or actually impinge patient’s rights can still occur (p.335). According to American Hospital Association (AHA), the four basic consumer rights state that the (1) patient has the right to safety, (2) right to be informed, (3) right to choose, and (4) right to be heard (Servellen, 1997 p.335). Considering these components as part of the reconsiderations in the ethical discussion of patient-provider care termination, it is indeed inappropriate to terminate the relationship set prior to the start of the process. As mentioned by AMA, provision of care towards non-compliant patients is still under the governance of the elements of (1) health care provider’s duty to provide continuous care, (2) fulfilling the expectations of care for the patient, and (3) carrying out the obligations of care (Mason, 2004 p.307). Terminating the care relationship set during the formal contract establishment between the provider and patient is automatically considered a breach in the legal nature of such relationship. Such action is a considerable ground for the legal liability of abandonment. Despite the issue on termination of care, there are still possible grounds wherein a health care’s refusal to care can be considered appropriate. According to Servellen (1997), provider’s may terminate or refuse care process when (1) the procedure caries physical risks to either the provider or the patient, (2) rendered care violates patient’s rights to autonomy and self-determinations, and (3) religious or moral issues followed by either of the two parties (p.335).   According to Carter, Levetown and Foley (2004), the actual patient-provider relationship is founded on trust and relationship, and not merely on legal holds or set contracts (p.120). Considering this as a form of assertion to the later supporting principles of patient-provider relationship termination, the issue on role fidelity arises as another essential consideration aside from autonomy and the contractual-based patient-provider relationship. Carter, Levetown and Foley (2004) emphasize the value of adhering to the moral and professional role of the nurse, and not solely limiting the care provision on to the patient’s level of compliance (p.120). Guided by the principle of â€Å"patient’s best interest† and fidelity, Mezey and Berkman (2000) support the idea pointing out on the idealistic elements of nursing practice wherein professionals should consider their importance in administering care under holistic and universal perspective regardless of potentially solvable conflicts (p.502). Despite of the relationship established after the setting of contact, the provider needs to consider the nature of non-equalitarian partnership and not the coequal partnership; rather, leading, establishment of rapport and serving the best interests to as the patient as the care provider must all be considered.   As supported by Shamus and Stern (2003), patient-provider relationship imposes a duty of unauthorized disclosure of contract care process without appropriate grounds (p.74). The 1996 Health Insurance Portability and Accountability Act (HIPAA) indeed protect the patients from such decisions brought by health care providers. However, compliance and sets of patient’s participatory obligations throughout the procedure count significantly on the entire health care delivery process (Shamus and Stern, 2003 p.74). Insurance of care does not only direct the obligations and tasks towards the provider but also from the patient. According to Earp, French and Gilkey (2007), patient-provider relationship is expected to work as an enhancing strategy for patient’s trust towards their health care provider. Furthermore, such relationship supports a therapeutic alliance and patient care processes involving high levels of trusts, rapport and patient satisfaction (p.195). By this principle, patients are indeed subjected to participate and cooperate in the process of health care delivery. However, in case the patient declines to participate, health care providers must not immediately terminate the procedure since they are no coequals of the patients and resistance towards care measures are sometimes inevitable. According to Rothestein, Brody and McCullough et al. (2001), health care providers must continuously administer care and interventions necessary for the well-being of the patient despite of the non-compliant behavior (p.620). In case the patient becomes notoriously incompliant to either selective or general procedures scheduled for administration, AMA suggests a series of assessment for the noncompliant behavior without involving one’s professional role outside the scope of care provision (Mason, 2004 p.307). Furthermore, the patient’s decision to not comply entirely depends on himself or herself; although, it is an important protocol consideration to check institutional policy for the proper consent documentation of such patient’s behavior. Most public institutions implement waiver signing when the patient refuses to take medications for example. According to Earp, French and Gilkey (2007), this is done for the purpose of formality and protection from possible accusations of abandonment or care quality infringements (p.195). On the other hand, when provider-patient relationship is not anymore pursuing its beneficial state or health care alliance status, AMA suggests the termination of health care management. As supported by Rubenfield and Scheffer (2006), the duty of the provider in relation to the physician-patient relationship includes (1) fulfilling the patient’s expected care, (2) carrying out the health care roles of the provider towards the patient, and (3) delivering care guided by the principles of fidelity and nonmalificence (p.96). If the provider has been determined to satisfy all these criteria, the duty to treat or provide care to the patient is indeed not violated. However, if the patient pursues his or her state of noncompliance despite of the standards of care being administered and the potential of further causing harm to one’s self, terminating the set provider-patient relationship is indeed justified. Nonetheless, as supported by the AMA Code of Ethics in 1998 Doc #1, p.5, â€Å"physicians cannot withdraw from a case without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured† (cited at Rothestein, Brody and McCullough et al., 2001 p.621). The health care provider is still tasked to service the patient until the reliever of care becomes available. Meanwhile, despite the legal recognitions in terminating the provider-patient relationship, the question still lies if whether or not the provider breaches his or her professional role as the higher component of the alliance considering the noncompliant state of the patient. Statement of the Problem The participation of both parties in the patient-provider relationship is an important consideration to the entire success of the health care delivery process. Once the provider accepts the task pf providing care to the patient, it is lawfully and professionally understood that the provider agrees to setup a transactional bond with the patient. According to AMA code of ethics, the setting of contract between the provider and the patient includes participatory roles from the two parties, and compliance to the higher participant of the alliance, the health care provider, must take the lead of health care management (Rothestein, Brody and McCullough et al., 2001 p.621). Added by Earp, French and Gilkey (2007), â€Å"patient-provider relationship is even ideally characterized by high levels of provider informativeness, interpersonal sensitivity and partnership building† (p.189). However, in some instances, patient may pose as the incompliant participant of the body system, which can greatly compromise the delivery of care as well as the role function of the provider. As emphasized by Servellen (1997), if the patient manifests a noncompliant behavior towards the care being provided by the assigned health care professional, the code of ethics should rather consider the termination of the bonded agreement than forcing the two participants to maintain their relationship since this can actually be detrimental to both patient’s health and provider’s role (p.336). Hence, termination of patient-provider relationship in relation to patient’s incompliant behavior can be possibly done via appropriate process of separation mandated by the institutional policies. It is important however to consider the validation of the provider’s claims followed by the written acknowledgement signed by the patient. After establishing an agreement of termination, the provider is expected to maintain the level of care being provided to the patient until the endorsement of the patient’s care to the assigned reliever. AMA has imposed significant abandonment liabilities once the provider terminates the established relationship without properly engaging to the set institutional policies. According to Rothestein, Brody and McCullough et al. (2001), terminating the established relationship between the provider and the patient without properly notifying, validating and documenting the said action will immediately resort to legal liabilities (p.621). Termination of patient-provider relationship must be laid down to the patient for recognition and prevention of legal accusation of abandonment. Despite the valid points and supporting rationales in terminating the patient-provider relationship, the issue still lies questioning the appropriateness of termination in relation to the ideal practice of role fidelity and duty of care. Due to this very reason, we have proposed a descriptive and non-experimental study analyzing the legal, ethical and moral nature of terminating the set patient-provider relationship. The objectives of the study proposed are as follows: To determine the ethical stand point of terminating patient-provider relationship in relation to the ideal principles of (a) duty of care and (b) role fidelity To determine the perceptions of the patients on the potential effects of terminating patient-provider relationship towards the level of trust and health care satisfaction Scopes and Limitations Due to the continuously evolving policies of health care system, changes in the patient-provider relationship have also evolved progressively. Despite the idealistic principles of fidelity and duty of care, health care providers still encounter inevitable instances wherein the client becomes non-compliant towards selective or general interventions implemented as part of the care process. According to Servellen (1997), instead compromising the care delivered to these patients, code of ethics have now reconsidered the procedure-based termination of patient-provider relationship to prevent the delivery of reluctant or incompetent care management due to patient’s incompliance (p.327). However, Carter, Levetown and Foley (2004) and Mezey and Berkman (2000) assert that terminating patient-provider relationship violate the principles of duty of care and role fidelity since it is always the task of the provider to carry-out the needs of the patient as guided by the principle of â€Å"patient’s best-interests† regardless of the patient’s response to health care. In this proposed study, the primary goal is to determine whether or not the ideal principles of health care (role fidelity and duty of care) are breached once the provider terminates the established relationship with the patient. At the end of the study, the following questions must be answered: What are the supported grounds for terminating patient-provider relations approved by AMA and AAN? Cite the legal, ethical and moral comparisons between the two policies. Does the health care provider breach the established relationship once he/she requested for termination due to incompliant behavior? Significance of the Study Despite the defined institutional policies supporting the process of termination, the issue on breached principles of health care still remains questionable. Federal health care organizations, such as AMA and AAN, have clarified the issue and process involving the termination of patient-provider relationship on the grounds of non-compliance and failure to adhere to the provider’s instructions. According to Servellen (1997), during the times of the HIV epidemic, termination of care is considered professionally inappropriate; hence, care provided towards these HIV patients became detrimental to the patient’s health due to the reluctance and exaggerated care measures implemented by these providers (p.327). The issue involving the termination of such established relationship covers both ethical and legal principles (e.g. role fidelity, duty of care, etc.) governing the pledged role of the provider and the assigned participatory role (e.g. patient’s rights, patient’s task of compliance, etc.) of the patient. Clarifying the care issues on the termination of patient-provider relationship is significant due to the following reasons: By understanding the limitations and defined grounds of terminating the patient-provider relationships, the study can aid in identifying the relationships of ethical principles that shall answer the confronting issue of patient-provider relationship By understanding the legal and ethical considerations on patient-provider relationship termination, the study can help in defining policy proposals on the proper procedures for implementing the termination of patient-provider relationship   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The conceptual framework of the study illustrates the proposed program of implementation addressing the issue on termination of patient-provider relationship. The conceptual framework is based from the primary goal of the study – to determine the standpoint of the termination of patient-provider relationship. By determining the subjective responses from two types of samples, patients and nurses (selected â€Å"provider† population), the procedure should be able to reveal the ethical justifications and oppositions on the subject of terminating patient-provider relationship due to noncompliance. After determining the collation of responses, the procedure analyzes the data in order to obtain significant relationships pertaining to the issue on breaching the principles of role fidelity and duty of care upon termination of such care contracts. Program Proposal f.1. Research Design   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The study proposes a non-experimental and descriptively designed survey methodology as the program for analyzing the issue on termination of patient-provider relationship. Using the perception-based methodology, the study explores the different insights of the two parties involved – patients and nurses/ providers – in the issue targeted by the study. The proposed program utilizes open-ended questions depicting the different possible perspectives of the samples – approval, opposition, suggestive– towards the issue imposed. The design of the study relates to the patterns illustrated on the conceptual framework. The emphasis of the survey questions is derived from the primary goal of the study – to determine if whether or not the termination of patient-provider breaches the concept of role fidelity and duty of care.   The collated responses obtained from the survey are compared to the ethics analysis condu cted in the literary reviews. f.2. Samples and Sampling Technique Used   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The study aims to achieve the total target population of 100 patients and 100 nurses proportionately divided into two different sample hospital locales. Using a simple random sampling method, selection of patient respondents is guided by the following criteria: (1) 18 and above, (2) patients must be admitted within the hospital premises for at least two days, and (3) must be conscious and coherent. On the other hand, sampling criteria among nurses are as follows: (1) must be licensed professional, (2) must be employed and working within the hospital premises, (3) must have at least 2 years of nursing experience from the surveyed hospital locale or other institution. f.2. Data Gathering Procedure   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Data gathering procedures shall be composed of two different methodologies: (a) ethics analysis conducted in the literary reviews and (2) survey methodology implemented on two groups of samples. Ethics analysis from the literature reviews comprise of the different ideas answering the ethical disputes on termination of patient-provider relationship. In the process of ethics analysis, the principles of role fidelity and duty of care involved in the issue are the emphasis of the analysis. The main objective of this procedure is to answer the ethical standpoints of the issue based on whether the termination violates the principles of role fidelity and duty of care. On the other hand, the second methodology deals with the perceptions answering the issue on breached principles of role fidelity and duty of care through the termination of patient-provider relationship. After gathering the results of the two data sources, the integration of data is conducted aiming to answer the primary goal of then proposed study. f.3. Instrumentation   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Survey questionnaires are the primary instrument used for the gathering of data and responses from the qualified samples. The questions used have been derived from three categories inclined to the different possible responses of the respondents. Categories used include (1) approval, (2) opposition, and (3) suggestive. Using open ended-questions according to the four categories, the respondent must select their preferred side among the four categories. Approval selection depicts their positive response over the termination of patient-provider relationship, opposition is the reverse,   and suggestive implicates the possible changes they want. The results of the survey are collated for the purpose of analysis and implications of data. f.4. Program Implementations   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   In the process of implementing the proposed program for evaluation and assessment of the issue, methodologies shall comprise (a) ethics analysis via records review and (b) the qualitatively designed survey of the chosen sample population. Implementation process shall begin with the gathering of records and reviews on issues and bioethical discussions on termination of patient-provider relationship. In the process of analyzing the obtained data, the study shall document (a) the ethical principles associated to the termination issue, (b) the conflicting ethical principles, and (c) the violated ethical principles upon implementation of the issue. After gathering these three components, the data shall be analyzed drawing appropriate implications from the documentation acquired. With the acquired results from ethics analysis, we shall now relate these to the two principles – role fidelity and duty of care that are hypothetically breache d upon terminating patient-provider relationship.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   After the application of the second procedure, the survey methodology shall now begin its pilot study with a smaller sample population of at least 10 qualified respondents from the chosen research locales. During the process of pilot testing, the research processes involving the survey questions, respondent interaction, collation of data, analysis and interpretation of data shall be tested for validation and revision in case necessary. After the pilot study, the actual survey procedure shall commence targeting a population of 100 qualified respondents from each of the two hospitals chosen. Furthermore, 100 target samples from each institution shall be divided into two comprising of 50 qualified nurses and another 50 qualified patient respondents. The total sample population shall therefore be 200 qualified respondents.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   After gathering the survey results using open-ended questions and simple random sampling technique, the results shall be collated according to the three categories of the questions used -(1) approval, (2) opposition, and (3) suggestive. The results shall be analyzed according to the data obtained from the records review. Implications associated to the ethical issue proposed (termination of patient-provider relationship) shall be drawn from the results of the interview. With the implications and analysis of the survey results, the next procedure integrates the study results from the records review and survey results to draw the general relationship between the perceptive study and theoretical ethical discussion on the issue proposed. Finally, the results drawn from the integration should answer the primary goal of the study.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   1.5. PICO Analysis Table 1: P.I.C.O Analysis Population The main subjects concerning the research topic are the patients and associated providers, such as nurses and physicians. Program implementations involve similar sample groups as well (patients and nurses). Intervention Ethics analysis on patient-provider relationship utilizes the general overview of nursing and clinical care procedures (e.g. medication administration, wound care, etc.). On the other hand, the program implementation utilizes two interventions, specifically (a) Survey with corresponding questionnaires and (b) records analysis. Comparison Variable comparisons involve (a) patient perception versus (b) nurses perception on whether or not termination of patient-provider relationship violates the principles of duty to care and role fidelity. Outcomes Expected results of the study differentiate among the two parties involved. Nurses perceive the termination an ethical consideration under the basis of noncompliance and breach in the contract of relationship set prior to care delivery. Meanwhile, patients perceive the termination as an ethical breach since the tasks of the nurses must always comply with the duty to care and role fidelity. Conclusion In summary of this research proposal, we aim to determine the ethical standpoint of terminating patient-provider relationship on the grounds of patient incompliance despite the set agreement and principles governing the role of the health care provider. Since termination of patient-provider relationship has already been acknowledged by federal organizations (e.g. AMA, AAN, etc.), we determine if such termination of accounts on the basis of patient’s incompliance breaches the ethical principles of role fidelity and duty of care. In order to strengthen the ethics analysis of the issue, we have incorporated a descriptively designed survey method to obtain the perceptive response of both patients and nurses towards the imposed issue. After collating the results of the survey, the next step is to integrate the results obtained from the records review and from the survey conducted. References Carter, B. S., Levetown, M., Foley, K. M. (2004). 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