AMA Journal of Ethics^®

Case

Dr. Key, a recognized leader in the treatment of patients with insomnia, particularly enjoyed the challenge of helping people with longstanding and difficult insomnia, whom he was often able to treat effectively. After almost a year of treatment Ms. Miller was proving to be an exception, and Dr. Key was beginning to think he could not help her. She was demanding, often calling his office several times a week, leaving voicemail messages longer than the time allotted. Ms. Miller would refuse Dr. Key's recommendations, making excuse after excuse about why each wouldn't work for her.

When Dr. Key saw Ms. Miller's name on the schedule, he knew the appointment would take at least 45 minutes longer than was scheduled because she would break down crying at the end of the visit, bringing up new psychosomatic symptoms, or threatening to sue Dr. Key when he attempted to conclude the visit. Since her appointment time would run late, the remainder of the patient schedule would become delayed, which would frustrate the other patients who would take it out on the office staff. Dr. Key couldn't understand why Ms. Miller would continue to schedule visits to see him even though she frequently told him their visits weren't helping. He was aware that something about Ms. Miller reminded him of his ex-wife and he couldn't help but feel resentful of the time spent with her. He wondered whether it was ethical to bill for visits which were not productive but he feared asking her not to come back because he knew she would perceive it as abandonment, and he was afraid of being sued.

Commentary

Dr. Key, a prominent specialist in the management of insomnia patients, is faced with a patient he is unable to treat successfully. Ms. Miller refuses to follow Dr. Key's treatment recommendations, while continuing to show up at the clinic, where she often becomes emotional and dramatic, and threatens to sue Dr. Key when he attempts to conclude the visit in a timely manner. Dr. Key develops resentment toward Ms. Miller, in part because she reminds him of his ex-wife. This case raises questions about countertransference, futility of care, and whether and how it is appropriate to sever the patient-physician relationship.

Countertransference

It is normal for an individual's current relationships (Dr. Key's, in our case) to be influenced by those of the past. Transferring feelings one had for someone in the past onto another individual in the present is called transference [1].The patient-physician relationship is subject to transference because the patient's perception of the physician is influenced by prior experiences. These influences can be both positive and negative and can enhance or detract from the present relationship. Likewise, a physician may have an emotional response to the patient based on his or her own past relationships, a response known as countertransference [1].

Countertransference can be considered in both a personal and a more general context. On the personal level, the physician "brings [his or her own] biases and emotional needs to the encounter, resulting in a dynamic interaction that ultimately shapes the outcome of the relationship" [2]. In its more general context, countertransference is an expected response of a physician to a difficult patient; that is, most physicians would be expected to respond to a difficult patient the way Dr. Key does, regardless of past personal experiences.

Dr. Key is clearly experiencing countertransference with his patient, Ms. Miller, as a result of his personal past experiences�although his emotional reaction would probably be shared to some extent by many others for whom the personal connection was absent. The first step in dealing with countertransference is to recognize that it is present. Once the physician recognizes the behavior, he or she can step back and assess the situation more objectively. If the countertransference is resulting from past personal experiences and can be controlled or minimized, then the relationship should continue. If Dr. Key feels that his past is strongly affecting the patient-physician relationship and he cannot alter his feelings and behavior, he should consider removing himself from the case.

Futility of Care

The principle of futility in medical care has been debated and discussed extensively in the literature, particularly in the context of the critically and terminally ill [3]. In this setting, unproven and potentially harmful therapies and standard therapies that will not alter outcomes could all come under the heading of futile. One example of futile treatment is an operation requested by a terminally ill patient that will not affect his or her condition in any beneficial way. In most contexts, physicians are at liberty to refuse patient requests for treatments that, in their clinical judgment, will produce no benefit for the patient. An example of futile outpatient treatment that physicians might decline is a patient's request for antibiotics to treat a viral infection [4]. While these examples seem straightforward, the concept of futility remains controversial, with some consensus evolving only over time [5].

The literature on how to treat the noncompliant patient is scarce. It could be argued that continuing to recommend treatment to the patient who ignores medical advice or fails to adhere to a prescribed therapy is futile. Before making this determination, however, the physician is obligated to explore reasons for the patient's noncompliance and exhaust all means for overcoming it. First, the physician should consider whether the patient understands the condition, the recommended therapy, and the consequences of refusing or failing to adhere to the treatment. This is the process of determining a patient's competency to make health care decisions. Next, the physician should investigate the competent patient's reasons for refusal or noncompliance, explain the available alternative therapies or approaches, and become familiar with the patient's ultimate goals for his or her medical care.

Applying these guidelines to our case, Dr. Key must verify that Ms. Miller is indeed competent and possesses appropriate insight into her sleep disorder, the consequences of chronic insomnia, and the treatment options available. Assuming she is competent, the numerous excuses Ms. Miller offers should be closely examined to determine if there are other factors preventing her from considering or implementing the treatment recommendations. Dr. Key should also review the goals of treatment to ensure that he and Ms. Miller are striving for the same outcome. Finally, it is critical for Dr. Key to understand why Ms. Miller continues to schedule clinic appointments when she believes that the advice she is getting is of no benefit. Looking forward to talking to Dr. Key on a regular basis may be more important to her than adequate sleep. If so, that information opens the door to treatment options that may be more effective.

Termination of the Patient-Physician Relationship

If, after all these possibilities have been closely examined and dealt with, the physician determines that the patient's behaviors are contrary to the mutually determined treatment goals, the physician is ethically permitted to inform the patient that he, in this case, is unable to help the patient and is withdrawing from the case. The notification and subsequent procedure must follow the guidelines of termination of the patient-physician relationship as dictated by state laws and medical boards.

According to the American Medical Association (AMA) Code of Medical Ethics, a physician is free to choose whom to treat (in nonemergency situations), but once a patient-physician relationship has been established, the physician is obligated to provide the patient with consistent, ongoing care as needed [6]. A patient-physician relationship is considered "established" when a physician provides medical care for an individual, by mutual consent, implied consent (i.e., emergency care) or, rarely, without consent (e.g., a court order). In general, this relationship is expected to be one of mutual respect and collaboration, with patients sharing the responsibility for their health care. In the case discussed above, Dr. Key and his patient, Ms. Miller, have clearly established a patient-physician relationship, so their interactions fall generally under this framework. It appears, however, that their relationship has become dysfunctional and cannot be considered truly collaborative. Is it ethical for Dr. Key to terminate this relationship with Ms. Miller?

The principle of respect for autonomy allows patients the right to accept or refuse any medical treatment offered, so long as they sufficiently understand the consequences of their actions. Hence, patients may choose to terminate the patient-physician relationship for any reason at any time. Physicians may also terminate the relationship, although they must offer the patient a valid reason for their action. Much has been written about how, and for what reasons, a physician may terminate the relationship [7-9], though there is little in the literature about what constitutes a valid reason on the part of the physician. Grounds for termination that could be considered to meet this standard include the physician's closing his or her practice (e.g., retirement or moving), completion of a care plan with transfer of the patient's care back to the referring physician, a conflict of interest, patient noncompliance, or, perhaps, the physician's decision that aspects of the relationship are not therapeutic and, hence, not in the patient's best interest.

Guidelines for the process of terminating the care relationship have been established by the AMA and adopted in various forms by state and specialty medical societies. These rules have been upheld by the legal system when challenged [10, 11], and it behooves physicians to be aware of their local policies concerning this matter. In general, the policies encourage physicians to give patients advance notice of their plan to terminate the relationship, agree to provide continued care for a "reasonable" time period (often up to 30 days) or until a new physician is found, aid the patient in locating a new doctor, and transfer medical records to the patient's new physician. It is usually recommended that the physician offer an explanation for the termination of the relationship and keep documentation of the notification (e.g., via certified letter with a return receipt).

Assuming Dr. Key's reasons for wishing to terminate his relationship with his patient are valid and reasonable, it would be ethically acceptable for him to do so, provided he has followed the recommended process.