Private Patient Discharge Dilemma: Ethics and Hope

Why is discharging patients so difficult for therapists?

I dread discharging patients because I don't want to crush their dreams or squash their hope.

As therapists, our patients and their family members put so much faith and confidence in us and our skills. We are healers. There is often a tremendous amount of both pressure and responsibility (from patients/family and also that we place on ourselves) to help our patients make progress.

But when it becomes clear that the patient is no longer progressing, we are faced with a dilemma on patient discharge.

The "Plateau" Paradox

Having worked primarily in medical settings, I am constantly fighting the theory many doctors have that patients stop making progress after six months to one year after their injury. As a clinician, I know that while progress may slow after the first year, most patients continue to make progress for the rest of their lives.

The first thing I do when patients progress starts to slow is to try a different treatment approach. If that's not working, I'll try yet another treatment approach hoping that they might be able to progress in other ways.

At some point however, I will start to come to the conclusion that while this patient will continue to make progress, they are not making progress now and it's time to discuss discharge.

Ethical Dilemma: Do I Continue Private Therapy?

When you work in early intervention, a school or medical setting, how long you're able to see patients is governed by age, percentage of delay, IEP's, private insurance or Medicaid/Medicare. Both you (the therapist) and they (the payer or company) decides when the patient is no longer making progress and should be discharged.

When patients are paying out of pocket for services however, they are largely customers. They have hired you, the therapist, to help their loved one make progress towards their goals. If they don't feel that you're helping them or their loved one meet their goals, they may self-discharge.

Or they may ask you to continue services on private therapy.

But what if they make the decision to continue services, even if they are not making progress?

This is often a professionally sticky situation. Clinically, you may know that the person will not make progress beyond this point, no matter what you do or try. The patient or family member may decide that the person is used to working with you and wish to continue with you even if they are not seeing clinical benefits. You will feel guilty taking their money, feeling that you're not helping them. Consider if they are actually interested in continuing to pay you for the non-clinical benefits such as:

1. Socialization
    
2. Information/suggestions/tips
    
3. Hope

Now, if this was an insurance or Medicare situation, these are certainly unskilled services, but with private pay it's a different situation. You are exchanging a service for money, even if you tell them up front that you don't think the service is going to work for them, they may decide to keep you on.

So, do you continue to treat this patient?

You need to be honest with yourself and the family.

Do not be greedy.

Do not be lazy.

You need to make the ultimate decision, but consider the patient/families position.

Be upfront with the family. Tell them that you've been working with the patient for X amount of time and while XYZ gains were made early on,he or she is in a period where you're no longer seeing progress. You may comfort them with the fact that while they're not making progress not, it doesn't mean that they won't in the future. But you also don't want to lie.

If you are willing to keep trying, tell them that but make it clear that you're not expecting to see gains. You may want to set up another check in period say, one month from now, where you re-evaluate again. You or they may want to discontinue at that time.

If you want to stop services, tell them but be prepared for a variety of possible outcomes. They may:

• Beg you to continue
   
• Be upset but let you go
   
• Understand and part amicably
   
• Ask you for a referral to another clinician

Remember your clinical perspective on discharge is often clear cut - they haven't made progress in X number of sessions so I should discharge them. You leave their house, move on to the next patient and while you may miss them (personally and/or financially) you can move on.

For patients and families, discharge often means crushing dreams. Dreams of their child being "normal." Dreams of their father walking them down the aisle. Dreams of their wife talking again.

Handle each patient discharge with honesty, empathy... and hope.

How do you handle discharge situations with private patients especially those who don't want to be discharged?

FYI: This is a very gray area. Please feel free to share your stories without fear of criticism from others.

About the Author: Jena H. Casbon, MS CCC-SLP spends her days treating adults with cognitive-communication disorders and her nights helping fellow speech, occupational and physical therapy providers start and grow their own private practices. Her company, The Independent Clinician, seeks to provide information, community and a confidence boost to those who want to get started treating privately but don’t know how.

Jena’s first book is available now:The Independent Clinician Guide to Private Patients. She is also finishing her second (yet untitled) book for SLP/OT/PT therapists on building a web presence (websites, social media and more) to grow their private practices.

Click here to read more about Jena Casbon, MS-CCC-SLP