Ask a Lawyer: Engaging with non-compliant patients and discontinuing nursing services

Question:

I am a nurse working in a community healthcare clinic. I am providing services to a patient who regularly fails to attend appointments, refuses to take prescribed medications as recommended, and has dismissed my proposed plan of care. I am concerned about their well-being and their compliance with clinic expectations regarding practitioner-patient communications. The patient does not appear receptive to hearing about these concerns and becomes increasingly agitated when we communicate. The patient has also been verbally abusive towards administrative staff. Our clinic is considering a discontinuation of our services. Is this appropriate?

Answer:

Once a nurse-patient relationship is established, there is an expectation that the nurse is required to provide the patient with quality services and care. However, a nurse may encounter challenging patient interactions that may lead them to re-examine the feasibility of continuing the relationship. Adapting the general standards of practice to a challenging situation may be difficult, and nurses may wonder how to best proceed. Below, we have provided some factors that would be prudent to consider if placed in this situation.

Collaborate and communicate

Prior to considering any withdrawal or discontinuation of nursing services, it is important to consider whether the patient’s health condition, may be contributing to the patient’s behaviour. In fact, certain medical or psychiatric conditions may cause “impaired judgment or an altered cognitive status.”¹ It is also important to consider the cultural, socio-economic, or other existing factors such as whether they are a patient from a vulnerable demographic. For instance, one regulatory college explains that conflicts between a nurse and a patient may escalate if a nurse judges or misunderstands a client, “has expectations based on incorrect perceptions of cultural or other differences” or does not respect a client’s needs or ethnocultural beliefs.²

Although documentation remains a key aspect of any nursing practice, there are specific considerations to document in the patient care record in instances where the nurse is working with a challenging situation, which will vary according to the clinical setting. This may include conversations about missed appointments or calls, declining proposed plans or care, any breaches of a behaviour agreement or office policies regarding treatment of staff, declined or missed referrals to specialized programs or clinics, and any conversations had about the reasons for discontinuation of services.

Manage expectations

Managing patient expectations is also an important aspect of providing nursing services. For example, the patient could request care that cannot be provided or treatments that are not typically recommended for their condition, or they may expect the nurse to respond to their concerns imminently, outside of a scheduled appointment. To mitigate this risk, it may be beneficial to discuss your role and responsibilities as their care provider or specialist at the outset of the therapeutic relationship, communicate the risks and benefits of treatment, and document all interactions with the patient regarding this issue.

Engage the employer or supervisor

If faced with a difficult situation, it may be beneficial to discuss the circumstances with your supervisor or employer prior to making a decision involving the patient’s care. If applicable, consult any dispute or conflict resolution policies that your employer may have.³ It may also be beneficial to consider arranging a meeting with the patient and the management of the establishment to try and resolve the issue prior to withdrawing nursing services. In any final correspondence or messaging to confirm the discontinuation of services, consider whether it would be more appropriate for the letter to come from the clinic rather than from the nurse individually.

Violent or aggressive behaviour

Despite the nurse’s best efforts, there are times where a patient or client may display violent or aggressive behaviour. Although nurses owe a duty of care to their patients, it is important to balance their personal safety with client needs in situations in which failing to provide care would pose a greater risk to the patient than to the nurse.⁴ This could be the case for a client with a condition that results in personality changes or forceful combative behaviour.⁵

Although it may be challenging, it is generally beneficial to stay calm and non-confrontational. Prior to choosing to withdraw care, try to communicate with the patient and verbalize that their behaviour is inappropriate. It is important to alert management of the situation, and to work with them to implement strategies to minimize the risk posed to you. If interventions cannot be carried out as requested, nurses should inform management, as well as the most responsible professional working with the patient.

On the other hand, should the behaviour result in assault or threat of assault to the nurse or other parties, it is best to remove yourself from the situation and contact the appropriate authorities.

Ending the nurse-client relationship

As a health care professional, terminating nursing services should be viewed as a last resort. Yet you may still be faced with a difficult situation where you feel it would be best for both you and the patient to discontinue the nursing services you are providing. This may include boundary violations, aggressive or threatening behaviour, or the patient’s lack of response. However, a nurse may wonder if they are discontinuing services for a suitable reason. If faced with this situation, it would be prudent to consult the nursing regulator’s guidelines and employer policies on patient abandonment and the duty to provide care in order to be fully informed about your rights and responsibilities.

Nurses have a professional and legal duty to provide clients with safe, competent and ethical care, while the client has a right to receive care.⁶ The CNA Code of Ethics and many nursing regulators explain that nurses should “respect the decisions a person makes, including choice of lifestyles or treatment that are not conducive to good health, and continue to provide care in a non-judgmental manner.” Nevertheless, this would not include putting yourself at an unacceptable level of risk.⁷

Generally, discontinuing professional services after you have accepted an assignment or established a therapeutic relationship with the client may be considered professional misconduct, unless:

1. The client requests the discontinuation,
2. Alternative or replacement services are arranged, or
3. The client or the nurse’s work provider is given reasonable opportunity to arrange alternative or replacement services.⁸

Refusing to care for a patient after accepting responsibility without transferring care to another provider or informing the appropriate supervisors so they can find a replacement could be considered a form of patient abandonment.⁹ You may also be required to negotiate with the patient or employer to “develop a mutually acceptable plan for withdrawal of service.”¹⁰

It is important to carefully document the factors that lead to the decision to terminate a client relationship, including all communication with the patient. In addition, if you choose to terminate the services, it would be prudent to ensure that the patient’s immediate follow up needs have been met. As such, you may wish to consider continuing to provide interim services until the patient has found a new care provider.

• For more information on ending the NP-client relationship, please consult Ask a Lawyer: Ending the NP-Client relationship.

Ending the nurse-client relationship can be complicated and may even result in consequences such as client accusations of abandonment to your nursing regulator. It is also important to remember your patients’ individual circumstances. It would be prudent to seek legal advice prior to making a decision that may result in a regulatory complaint and investigation. Please remember that the law expects a regulated health professional to adhere to the standards of the profession, practice ethically, and act reasonably and carefully in the circumstances, which requires exercising forethought for the benefit of the patient.

CNPS beneficiaries can contact CNPS at 1-800-267-3390 to speak with a member of CNPS legal counsel. All calls are confidential.

1. College of Nurses of Ontario, Conflict Prevention and Management, 2018.
2. Ibid
3. Certain regulators may also have guidelines on the topic. For instance, BCCNM: https://www.bccnm.ca/RPN/learning/professional/Pages/ResolvingProfessionalPracticeProblems.aspx
4. Nova Scotia College of Nursing, Abandonment Practice Guideline, July 2022.
5. Ibid
6. British Columbia College of Nurses and Midwives, Duty to Provide Care.
7. BCCNM, Defining client abandonment.
8. College of Nurses of Ontario, Discontinuing or Declining to Provide Care, 2024; BCCNM, Defining client abandonment; Nova Scotia College of Nursing, Abandonment Practice Guideline, July 2022.
9. Ibid
10. Nova Scotia College of Nursing, Abandonment Practice Guideline, July 2022.

October 2023

THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE.