Case Study: The Violent Pediatric Patient

While most healthcare providers do not often have to deal with violent patients, such situations present moral, ethical, and legal questions that every pediatric practice should be prepared to address. Providers not only have to consider the rights and needs of the patient, but also the rights of staff and the needs of the parents. The following is intended to provide guidance to a pediatric practice when a violent pediatric patient presents to the office.

The Case

A 12-year-old male pediatric patient presented to a pediatric practice in North Carolina with a history of behavioral issues, a diagnosis of autism, and a history of upper respiratory symptoms including cough, runny nose, painful ears, and fever for the past seven days. Normal protocols were followed, and the patient was checked in and seen first by an advanced practice provider (APP). The child did not want to have his ears checked or open his mouth for a throat evaluation. When the APP attempted to look in the patient’s ear with her otoscope, the patient swung his arm at her, catching her arm and knocking the otoscope out of her hand. The patient remained clearly agitated, and there was concern that any further efforts to examine the patient would have resulted in further physical outbursts.

The Patient Has Rights

The North Carolina Medical Board Position Statement on the Physician-Patient Relationship states, “A physician’s first responsibility is to his or her patients…. It is the Board’s position that it is unethical for a physician to allow financial incentives or other interests to adversely affect or influence his or her medical judgment or patient care. Patient advocacy is a fundamental element of the patient-physician relationship…All physicians should exercise their best professional judgment when making patient care decisions.”

If a violent patient has a disability, the healthcare provider risks a claim that the practice is refusing to treat the patient in violation of the Americans with Disabilities Act (ADA). While the ADA is clear that healthcare facilities are places of public accommodation that must make themselves physically accessible to patients with disabilities, the ADA is less clear about accommodations for patients who are disruptive in the healthcare setting. What is clear is that if a patient were to claim he or she was discriminated against because of a disability, the healthcare provider has an affirmative defense under the ADA known as the “direct threat” defense: If a patient poses a direct threat to the health and safety of others, then the healthcare provider has a defense to the claim. The threat must be objective and must pose a significant risk of substantial harm. The factual scenario above likely would not qualify for such a defense.

The Healthcare Provider Has Rights

Both federal and state laws require employers to make reasonable efforts to provide a safe workplace for their employees. These laws do not only apply to construction sites and chemical plants, but may be interpreted to apply to healthcare practices, particularly those with patients who may present a risk of harm to its employees. Some of the practices particularly at risk for patient violence include pediatric practices caring for patients like the one described above (also consider the potential for violence from a parent reacting to this scenario), medical practices dispensing opioids, and emergency rooms.

Where Is the Balance?

In a scenario like the one described above, the APP should seek the assistance of his or her supervising physician. The supervising physician needs to ensure that the APP is not injured, and then needs to engage the parent(s) of the child. Can the parent get the child to cooperate with a physical examination? Does the office have the capacity to restrain the child? Does the level of illness require restraints? Should the patient be sent to the emergency department for further evaluation? If the parent cannot get the child to cooperate, this office is not set up to restrain the child, and the extent of the illness is not clear, then the child needs to be sent to the emergency department for further evaluation.

As discussed above, if a patient poses a direct threat to the health and safety of a healthcare provider that can be demonstrated by objective evidence, the healthcare provider can take reasonable steps to protect his or her safety even if that means terminating the patient from the practice.

Termination of the Patient

The scenario above likely does not require termination of the patient from the practice. However, repeated episodes of violence, more extreme episodes of violence, and lack of cooperation from the parents to assist with the control of the patient’s violent outbursts may lead the practice to terminate the patient.

Members can visit Curi’s Risk Management Handbooks for state-specific information on the steps needed to terminate a patient from a practice.

Risk Management Takeaways

• Have a policy in place for what your employees are to do when presented with a violent patient and provide annual training on the policy.
• Consider having a single provider in charge of assessing each circumstance of patient violence for consistent application of decisions on how to approach the patient, the parents, and decisions about termination.
• Document each instance of violence in the patient’s chart to establish objective evidence to support termination and prove a “direct threat.”
• Apply all policies related to the violent patient equally to patients with and without disabilities.
• Have a letter template for termination of a patient from your practice that includes the specifics required by your state’s medical board. Medical Mutual’s Risk Management Handbooks provide letter templates for a variety of scenarios by state. The selected template should be customized for each patient who receives the letter.
• If you are not sure how to approach a specific factual scenario, or would like more information about how to handle such situations, contact Curi’s Risk Management department at 800-662-7917.