Non-Compliant Patients: Deciding to Treat or Withdraw from Care

Authored by Richard Small, J.D.

This article reviews key considerations and best practices when considering withdrawing from care due to patient non-compliance.

Withdrawing from care can be one of the most difficult decisions dentists make and is usually a last resort. The decision is even more complicated when non-compliance and risks evolve over time. Withdrawing is easier when the reasons are documented clearly and contemporaneously. Engaging in strategies to gain compliance and document non-compliance are critical to protecting you and your practice.

Patient autonomy

ADA ethical principles and state law recognize patients’ rights to refuse care or select alternatives. Dentists also have autonomy; they do not have to treat every patient seeking care.

While dentists have a general duty to complete care they start, they also can withdraw, terminate care or dismiss patients, if justified. Dentists may consider withdrawing when patients fail to satisfy their obligations such as failing to follow instructions, repeatedly canceling appointments, not remitting payment, engaging in disruptive or abusive behavior that upsets staff and/or other patients, or withholding important health information.  The most common reason for withdrawing involves patient non-compliance that is likely to harm the patient’s dental health or jeopardize successful treatment.

Abandonment

ADA rule 2F essentially requires a dentist to provide patients with reasonable notice of the decision to terminate care and sufficient time to find a new dentist so treatment is not unreasonably interrupted or delayed. State laws are similar.¹

When patients make decisions likely to jeopardize their dental health, or insist on inappropriate care, withdrawing can be done without abandoning the patient. Charting the basis for withdrawal and properly putting the patient on notice of the decision reduces the risk of an abandonment claim. Every case should be independently evaluated.

Chart Patient Non-compliance and Failure to Satisfy Obligations

Patients should be advised of likely consequences associated with their decisions (examples: tooth loss, increased pain or infection, the need to redo treatment at the patient’s expense). Efforts to educate patients, gain compliance and maximize your ability to achieve acceptable results establish good faith and reasonable actions. This should be charted.  When efforts to gain cooperation and compliance fail withdrawing from care is an option. University of Minnesota Dental School published its patient dismissal policy, but each situation should be independently evaluated.¹

Compliance Letters

Good communication skills and charting practices reduce abandonment claims. When minor compliance issues become part of a bigger problem jeopardizing patient health, withdrawing from care might be on the horizon. One goal of withdrawal letters is to confirm a mutual understanding that the doctor-patient relationship has ended and why.

First Letter: Minor indiscretions usually don’t justify withdrawing. If they continue to occur or escalate, consider sending the patient an informational letter encouraging improved compliance. Summarize the patient’s non-compliance, advise of possible consequences if it happens again, and relay what you expect the patient to do going forward. Ask the patient to contact you immediately if they are unable to comply or if they wish to discuss the situation. Send the letter and all future compliance letters by certified mail with a copy to the file.

Second Letter: If the patient’s actions continue and are likely to jeopardize your ability to achieve optimal results or minimize risks, consider sending a follow-up letter. Remind the patient of your first letter, what you required and that continued non-compliance is jeopardizing their dental health. If the situation continues, you might have to end the doctor-patient relationship. You cannot and will not be responsible for complications you cannot control or address (list “such as …”) if the patient fails to comply. Specify what the patient needs to do and the consequences of failing to do so. Improved compliance might be unrealistic.

The Last Resort – Withdrawal Letter

If your patient’s actions will likely generate unacceptable results or risks, it may be in the patient’s interest to find a new dentist whose advice the patient will follow (or go to a dental school clinic, etc.).  The doctor-patient relationship necessary for acceptable care is lacking. In your withdrawal letter, list dental conditions that need immediate attention and the consequences of failing to do so. You cannot and will not be responsible for treatment your patient did not complete. Dentists typically give the patient 30 days to find a new dentist. Dentists can offer to see the patient for emergencies during that period (perhaps at no cost). Relevant records can be forwarded to the new dentist upon request, with the patient’s HIPAA authorization.

Ending the Relationship – Closure Letter

You can write patients to confirm that they have elected to terminate care at your office and to encourage them to complete care you assume is being pursued with another dentist.  If they still want to complete care with you, document their position, whether you agree or not, and why. If you conclude the situation is unacceptable, you don’t have to continue in most cases as long as they have other treatment options.  The content of a closure letter is similar to a withdrawal letter, except termination was the patient’s decision. You should not let a patient’s desire for care you consider sub-standard supersede your professional judgment.

Informed Refusal

If patients elect a treatment alternative likely to generate acceptable but not optimal results, you might decide to remain involved.  Consider asking patients to sign an informed refusal form documenting that they rejected your recommended care but accepted an option with reasonable limitations. This document, like the series of withdrawal letters, shifts some of the liability to the patient.

Informed refusal may not be advisable if the risks are unreasonable. Lawyers can accuse you of supervised neglect if you remain involved while patients deteriorate and suffer injury on your watch.

Strongly consider seeking advice from local counsel when considering informed refusal or withdrawal to ensure you comply with state law and local ethical considerations.

You should seek the advice of legal counsel licensed in your state when considering withdrawing from care issues. If you have questions related to this article or your other insurance policies, please contact me.

About the Author

Richard Small, JD, Risk Management Consultant | Dental & OMS Practice | Dyste Williams
Richard Small, J.D., is a nationally recognized speaker on risk management in the dental practice environment.  Mr. Small practices law in Michigan and spent the first 20 years of his law practice defending dentists in court in Michigan and other states.

Richard Small, J.D. | Risk Management Consultant |952.843.4434| rsmall@dystewilliams.com0

¹ADA Principles of Ethics and Code of Conduct, 2020 American Dental Association, ada.org/ethics  

²University of Minnesota School of Dentistry Patient Dismissal Policy, 2018, dentistry.umn.edu