An article for physicians by 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 some jurisdictions, a physician must have reasonable grounds or just cause to end the relationship, and some regulatory authorities (Colleges) require that those reasons are documented in the patient’s record.
You should also be aware of any College policies, human rights legislation, or codes of ethics that prohibit discrimination in the provision of medical services. Such policies may require reasonable grounds to discharge a patient, or 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, steals a prescription pad, or 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 the safety of their staff, and may wish to call the CMPA for advice on how to proceed.
Terminating the relationship
If reasonable attempts at resolution have been unsuccessful or you have decided that attempting to resolve the issues with the patient would not be appropriate in the circumstances, you may decide to terminate the relationship. You must then consider how to do so. Several Colleges have adopted guidelines or policies that govern the steps physicians should take; you should be familiar with the guidelines or policies in your province/territory. Being able to produce evidence that you followed such guidelines or policies 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 or your staff’s 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 to the patient. Check if your College has a preferred method for contacting patients for this purpose, such as by registered mail. Keep a copy of the letter in the patient's medical record.
- Whether you meet with the patient in person 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. When making this decision, you should take into consideration issues such as your personal safety and the patient's particular circumstances. You should also verify whether your College has any applicable requirements or advice.
- Provide the patient with reasonable notice of the date on which your 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.
- Inform the patient that you will provide only urgent or emergent care in the interim.
- 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 to obtain a new physician and, if possible, provide advice on this process.
- 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 physician is done promptly.
- Consider notifying other healthcare 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 your 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 that 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. In some jurisdictions, a physician must have reasonable grounds or just cause to end the relationship.
- Check to see if the College in your province/territory has a guideline or policy on when or how a doctor-patient relationship may be terminated. Retain evidence that you followed College guidance or requirements.
- 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; inform the patient you will provide only urgent or emergent care in the interim; with your patient's consent, have copies of the medical records transferred; 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 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 follow to efficiently transfer the patient's care to another physician.
- Act compassionately to help make the transfer of care as smooth as possible.