PRINTER-FRIENDLY VERSION
Lessons from Litigation
Advanced Practice Registered Nurses
Facts of the Case
On October 29, 2015, Peter Strickholm saw a nurse practitioner (NP) for an “Establish New Patient” visit at a medical group practice to establish her as his primary-care provider. Peter’s blood pressure during the visit was 164/96 mmHg. On December 1, 2015, Peter returned to the practice for a “Comprehensive Care Visit,” and his blood pressure at this time was 176/94 mmHg at 8:05 a.m. and 179/100 mmHg at 8:25 a.m. The NP prescribed Lisinopril-HCTZ to Peter to control his high blood pressure and recommended that he return for a blood pressure check the next week. On December 8, 2015, Peter again returned to the practice for a “Nurse Check” to have his blood pressure checked. Although there is some dispute as to whether the NP was present that day, the blood pressure check was conducted by an LPN. Peter’s blood pressure was 140/110 mmHg. The LPN electronically conveyed the test result to a physician in the office. The physician responded electronically and stated, “systolic much improved but diastolic still high, would recheck in 1-2 weeks and if still elevated then increase lisinopril.” On December 11, 2015, at the latest, the NP electronically reviewed and approved the LPN’s report of the “Nurse Check” but did not recommend any further testing or treatment at the time.
On December 15, 2015, Peter arrived at the Bloomington Hospital emergency department with altered mental status. Peter was diagnosed with hyponatremia, among other things. Peter was admitted, and the next day he suffered cardiopulmonary arrest in the hospital’s intensive-care unit. Peter was revived, but he had suffered a hypoxic event which caused cognitive impairment.
Litigation
On December 4, 2017, the Strickholms filed their proposed complaint against the NP with the Indiana Department of Insurance (as required by Indiana tort reform laws). The Strickholms alleged medical negligence, specifically that the NP had breached the relevant standard of care in her treatment of Peter up to and through at least December 8, 2015. The NP defended on the grounds that she had not provided care to Peter after she prescribed the medication on December 1, 2015, which meant that the two-year statute of limitations ran on December 1, 2017, three days before the plaintiffs filed their suit. The trial court granted the NP’s motion to dismiss, but the Supreme Court of Indiana reversed and held that the suit was timely filed.
Commentary
This case says nothing about whether the NP was negligent in her care for Peter Strickholm or what she should have done differently. That will depend upon which expert witness the jury finds more credible.
However, it says a lot about the provider/patient relationship: how it is formed, how it is sustained and how it terminates. The familiar test for professional negligence includes the following four elements, all of which need to be shown by the plaintiff in order to win his case. These elements are: (1) a duty to act within the standard of care; (2) a breach of that duty; (3) an injury caused by the breach of the duty; and (4) damages as a result of the injury. The duty arises out of the provider/patient relationship and lasts for the duration of that duty. The relationship may last until it is actually or constructively terminated, or it may be clear through the passage of time that the relationship no longer exists. If the provider no longer wishes to provide care for the patient, she should terminate the relationship.
The relationship is formed by mutual assent: the provider agrees to provide care and the patient agrees to receive it. It continues during the time when the provider is responsible for the care of the patient. Terminating the relationship may require a written document that conveys this message to the patient.
Lessons Learned
Termination of the provider/patient relationship is not a step to be taken lightly. There should be no appearance of illegal discrimination. Care should be taken when terminating the “non-compliant patient: what is the reason for the non-compliance, and can it be rectified? It may be, for example, as simple as that the patient cannot afford the name brand medication, but there is a much cheaper generic substitute. Or, the patient does not appreciate the seriousness of her condition, but may be persuaded by additional education. In many cases, non-compliant patients are the patients who need the care the most. It is not in the patient’s best interests to terminate a salvageable relationship.
It is not technically necessary to terminate the relationship in writing, but it is easier to prove when and how the relationship was terminated if there is a written termination letter. It could also be documented in the medical record as a discussion with the patient. If a letter is used, it typically should contain the following:
- An unambiguous statement that the provider will no longer provide care for the patient;
- The effective date of the termination;
- A period of time (typically 30 days) in which the provider will provide care in an emergency; and
- A list of alternate providers who may be willing to provide care is optional, but recommended.
If the provider finds that the provider/patient relationship must be terminated, for whatever non-discriminatory reason, it should be done in an unequivocal manner.
