Author Response
We appreciate the opportunity to respond to this important question. Clinicians are frequently faced with situations where the standard risk management advice about the termination process does not quite match with their practice setting. In general, the termination process in an academic setting should be very similar to the process in a private, group or facility practice.
You have described important points to include in termination discussions. Of particular importance is educating patients about the nature of their condition and the importance of continuing in treatment. This issue was raised in a North Carolina case [Williamson v. Liptzin, 539 S.E.2d 313 (N.C.App. 2000)] involving a psychiatrist (Dr. Liptzin) who treated a student (Mr. Williamson) at a university health center. Dr. Liptzin retired shortly after Mr. Williamson presented for treatment. Dr. Liptzin had discussed his retirement with Mr. Williamson and suggested that he see someone regularly for therapy. Because the patient was undecided about his summer plans, Dr. Liptzin instructed that if he returned home, he was to receive care from the community health center or his family physician; if he remained at school, he was instructed to return to the campus health center to continue treatment with Dr. Liptzin's replacement. Mr. Williamson did not continue in treatment, but did well over the summer and in the fall, passing all of his law school classes. Over the Christmas break Mr. Williamson began to decompensate, and in January 1995 he fatally shot two students and injured several others. After Mr. Williamson was found not guilty by reason of insanity at his criminal trial, he sued Dr. Liptzin for malpractice.
Among Mr. Williamson's complaints was that Dr. Liptzin had not discussed the severity of his disease or the likely prognosis should he fail to continue in treatment. The jury found Dr. Liptzin liable, and awarded $500,000 to Mr. Williamson. Fortunately the appellate court, finding that the case should never have even gone to the jury, reversed the trial court. The appellate court focused primarily on the fact that Mr. Williamson had been stable for eight months after he stopped treatment and had successfully completed an entire semester of law school. The appellate court unanimously found that under these unique circumstances, Dr. Liptzin could not have foreseen the tragic events that unfolded.
Patients often do not remember all the important points discussed during the termination process. Having a copy of a letter covering the points you mentioned can be a great reference for the patient and may further encourage and enable him or her to continue in treatment. Ideally, clinicians and campus health administrations will work together to find a way to provide follow-up letters to all patients who are leaving treatment (for whatever reason). One potential solution where, as in your situation, mailing addresses are not known would be to provide the letter during the last treatment session. However, if this is not possible, the chart should include a note indicating what was discussed with the patient prior to termination of the treatment relationship, as well as why a copy of the follow-up letter could not be provided to the patient. Should there ever be a question, having a copy of such a letter in the patient record or documentation of the termination process and discussion provides very strong evidence that a thorough termination process took place.
With regards,
Jacqueline M. Melonas, RN, MS, JD
Senior Vice President, Risk Management, PRMS, Inc., Arlington, Virginia
