When personality disorders threaten the doctor-patient relationship

When personality disorders threaten the doctor-patient relationship

Summary:

As a psychiatrist, you may find that the very conditions for which patients consult you make it difficult to treat them. This is particularly true for patients suffering conditions such as narcissism and other personality disorders. 

ArticlesManaging difficult patients
06 / 05 / 2016

As a psychiatrist, you may find that the very conditions for which patients consult you make it difficult to treat them. This is particularly true for patients suffering conditions such as narcissism and other personality disorders.

At Avant, we receive a number of telephone calls to our Medico-legal Advisory Service from psychiatrists finding it difficult to manage the ongoing treatment of such patients. This is because the very nature of their disorders can undermine key elements of an effective doctor-patient relationship: mutual trust, confidence and clear communication. This begs the question of when can you terminate the relationship with a patient and how best to carry this out.

When can you terminate the doctor-patient relationship?

In general terms, you can end the treating relationship with a patient in any circumstance where the necessary trust and confidence is lacking. In the example of a patient with a personality disorder, this situation may arise if the patient refuses to listen to and follow your medical advice and does not demonstrate any faith in the advice and treatment you are recommending. This can manifest by, for example, the patient not taking medication prescribed, failing to attend scheduled appointments or by being aggressive or inappropriate in their behaviour towards you.

In these circumstances, you can decide that it is in the best interests of the patient’s ongoing treatment to terminate the doctor-patient relationship with them. This is not a decision to be taken lightly. In the first instance, we recommend you explain your concerns to the patient to see whether this leads to any improvement in their compliance or behaviour to be able to continue treating them.

It is necessary to avoid terminating the doctor-patient relationship during an emergency or when care is required for an acute illness. Care may also need to be exercised when terminating the doctor-patient relationship at any pivotal time in the patient’s treatment; for example, after starting them on a new medication or course of treatment.

How to terminate the treating relationship: key steps

If all else fails and the treating relationship must end, there are a number of steps that need to be taken:

  • It is preferable to speak to the patient and explain your concerns and that you cannot continue to treat them. This should be done by you personally. It may sometimes be appropriate to have someone else present at that discussion, as a support person for the patient or to assist you in managing the patient.
  • Follow this up with a letter to the patient. Avant has a number of sample letters we can provide as a starting point in our Risk IQ Fact Sheet: Ending the doctor-patient relationship and you can send your draft letter to Avant for review before sending it to the patient. (The exception to this approach would be if the patient has been verbally or physically abusive or threatening, in which case a telephone call, followed by a letter is appropriate).
  • Ensure that the patient has continuity of care and that their treatment does not suffer. You should liaise with the patient’s general practitioner, if possible, advising them that the patient is no longer under your care and of the need to arrange the transfer of care to another psychiatrist. You may wish to contact colleagues to discuss taking over the patient’s treatment. You may provide the general practitioner and the patient with a list of practitioners with suitable expertise (particularly if their needs are quite specialised).
  • Provide a summary of your records and copy relevant documents for the patient’s new treating psychiatrist, if requested with the appropriate authority or to the patient directly. If providing the records to the patient directly, consider whether there is anything particularly sensitive that should not be disclosed to the patient, or should only be disclosed to them with someone present for support. 

Key take-out

While the treating relationship between psychiatrists and patients can be difficult, sometimes these difficulties are insurmountable and the relationship should be terminated, primarily because it is in the patient’s best interests. If this is done, the steps above should be followed ensuring the decision is clearly communicated with the patient, confirmed in writing, and that the patient receives continuity of their care.

Learn more

Read our Risk IQ Fact Sheet: Ending the doctor-patient relationship.

Complete our eLearning course: Boundary issues in mentally ill patients and obtain CPD points.