Ending the doctor-patient relationship An article for physicians by physicians
Originally published March 2006 / Revised July 2008 IS0659-E
Considerations for ending the doctor-patient relationship.
Of interest to all physicians
For many physicians, deciding when it is appropriate or necessary to end a doctor-patient relationship can be difficult. Once the decision is made, the next question is how to carry it out.
Making the decision
As a physician, you are ethically permitted to end a doctor-patient relationship for reasons other than your own retirement, relocation or leave of absence provided the patient does not need urgent or emergent care, and provided you have given the patient adequate notice to find another physician. In Québec, a physician is also required to have reasonable and just cause to end the relationship.
You should also be aware of any human rights legislation, regulatory authority (College) policies, and/or codes of ethics that prohibit discrimination in the provision of medical services or that may otherwise affect your ability to terminate the doctor-patient relationship.
The circumstances leading to your decision to end a therapeutic relationship may vary but the decision usually occurs when there is an irreconcilable breakdown in the doctor-patient relationship. On other occasions the behaviour of the patient may warrant termination of the relationship as for example, when the patient fraudulently obtains narcotics from you or steals a prescription pad, or when the patient threatens or is abusive to you or your staff. Physicians who wish to end a doctor-patient relationship in these instances are frequently concerned for their own safety and/or the safety of their staff and may wish to call the CMPA for advice on how to proceed.
Terminating the relationship
If you have decided that attempting to resolve the issues with the patient would not be appropriate in the circumstances or reasonable attempts at resolution have been unsuccessful, you may decide to terminate the relationship. You must then consider how to do so. Several Colleges have adopted guidelines advising physicians on the steps to take; you should be familiar with the guidelines in your province/territory. Being able to produce evidence you followed such guidelines will help you defend yourself against a College complaint or civil action arising from the termination.
Making the decision to end the doctor-patient relationship is all the more challenging when physician shortages exist across Canada and patients may have few alternatives to receive medical care from another physician. To avoid a claim of abandonment or a College complaint by a patient, you might consider taking the following steps:
Consider the circumstances, and if you think it is appropriate, inform the patient in person of the decision to terminate. There may be circumstances, such as when you are concerned for your safety, where such a meeting would not be advisable. If you do have a discussion with the patient, you should clearly document it in the patient's medical record and send a confirming letter, if your College requires it.
If you do not think a face-to-face meeting is advisable, send a letter (your College may require that it be registered) to the patient. Keep a copy of the letter in the patient's medical record.
Whether you meet with the patient in person and/or send a letter, you will want to:
Notify the patient clearly of your decision to end the doctor-patient relationship. You also need to decide what, if anything, you will tell the patient about the reasons for the termination. The Colleges appear to differ on the best course of action. When making this decision, you should take into consideration issues such as your personal safety and the patient's particular circumstances.
Provide the patient with reasonable notice of the date on which medical services will terminate. Tailor the notice period to each situation taking into consideration such things as the patient's circumstances, the availability of alternative physician resources in the community, and whether the patient poses any threat.
Advise the patient to obtain a new physician and, if possible, provide advice to the patient on possible steps to do so.
Advise the patient of the need to transfer copies of medical records to the new physician. You should also request the necessary consent to make the transfer. Consider any Privacy Commission or College guidelines that might apply to the transfer of patient records.
Inform the patient you will provide only urgent or emergent care in the interim.
Provide any specific information or instructions concerning the patient's particular medical condition (e.g., information about outstanding laboratory results and where they will be sent, information about renewal of prescriptions, or other specific medical advice) to ensure the continuity of care in the circumstances.
Inform your staff members about the termination and instruct them on how to transfer copies of the medical records. You should be as helpful as possible in ensuring the transfer to the new treating physician is done promptly.
Consider notifying other health care providers involved in the patient's care of the transfer of medical responsibility to ensure there is no interruption in the continuity of care. Privacy legislation may provide patients with the right to restrict what information you can communicate in these circumstances, so be aware of any such limitations in your specific case and seek advice from the CMPA or College on how to proceed.
It is important to obtain appropriate authorization from the patient before transferring any copies of medical records. You and your staff should also ensure the original records are retained in the event there is some question at a later time about the care you provided to the patient, or in the event of a College complaint or legal action surrounding the care or the termination.
Ending the doctor-patient relationship can be difficult and stressful for you as well as your patient. Keep careful records of the reasons for the termination and the steps you followed to ensure care was efficiently transferred to another physician. Acting in a compassionate manner that recognizes the inconvenience to the patient, while also informing the patient of how they might go about finding a new physician, will go a long way in making the transfer of care as smooth as possible.
The bottom line
As a physician, you are ethically permitted to end a doctor-patient relationship provided the patient does not need urgent or emergent care, and provided you have given the patient reasonable notice to find another physician. Under Québec's Code of Ethics of Physicians, a physician may end a therapeutic relationship when there is reasonable and just cause to do so.
Check to see if the College in your province/territory has guidelines on when or how a doctor-patient relationship may be terminated. Retain evidence you followed such guidelines.
Determine which is the most appropriate way to inform the patient of the decision to terminate — in person or by letter. If you are informing the patient in person, send a confirming letter, if your College requires it. In either case, give reasonable notice you are ending the relationship; advise the patient to find a new physician; with your patient's consent, have copies of the medical records transferred; inform the patient you will provide only urgent or emergent care in the interim; and provide specific information concerning the patient's particular medical condition to ensure continuity of care. Document the rationale for terminating the relationship in the patient’s record and note any conversation you have with the patient in the patient's medical record or keep a copy of the letter.
Inform your staff members about the termination.
If appropriate, consider notifying other involved health care professionals that the relationship has ended.
Keep careful records of the steps you followed to efficiently transfer the patient's care to another physician.
Act compassionately to help make the transfer of care as smooth as possible.
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