Terminating the Physician/Patient Relationship

According to the American Medical Association (AMA) Principles of Medical Ethics, Principle VI, “A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.” So, physicians do have the right to unilaterally terminate the physician-patient relationship, but the proper method is not as straightforward as it is for the patient, who does not need to give reason or notice of any kind.

A physician may decide to discontinue providing services to a patient for a number of reasons, including, but not limited to: 1) Behavior that is rude and verbally abusive; 2) Nonpayment; 3) Drug-seeking behavior; 4) Failure to follow the opioid agreement or other office policies; 5) Failure to show up for appointments; or 6) Noncompliance with the treatment plan. But patient safety dictates that there are guidelines for doing so. The AMA has addressed this issue in Termination of the Physician-Patient Relationship, Opinion 8.115, which provides that, “Physicians have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured.”

Of course, the purpose of reasonable notice is to prevent a physician from arbitrarily discontinuing treatment and leaving the patient without medical care. But what is “reasonable notice”? The AMA and many other professional organizations recommend 30 days, but several states allow for less notification. However, keep in mind that this recommendation is regarded as the minimum necessary time frame for the patient to find another qualified physician. In addition to observing the 30 day requirement, notice should be based on individual patients and their medical condition. Some patients ' depending on their disease process and physician needs ' may require more time to establish care with another provider, based on location and access to a specialist. In contrast, a relatively healthy individual in a large city requiring a primary care physician may have little difficulty acquiring another physician. In other words, the physician should review each situation on a case-by-case basis.

The Method

When a physician decides to discontinue the physician-patient relationship, it is highly recommended that these steps be taken to ensure patient safety and prevent abandonment:

Review the Record: Carefully consider the medical condition of the patient, which type of physician he or she will need for a replacement, the time it would take for the patient to get an appointment and the distance the patient would have to travel. Be extra cautious with patients in a critical stage of the treatment process.

• Document: Ensure that the medical record documentation is accurate and reflects the reason for the termination. Retain a copy of the termination letter in the medical record.
• Provide Written Notice: Send a letter to the patient by certified mail with return receipt requested. A copy of the letter should be placed in the medical record.
• Make Sure That Notice is Reasonable: Generally, 30 days of notice will suffice. Please see below for specific details. The letter should provide the exact day that the relationship will cease.
• Notify: Depending on the physician's specialty, call and/or send a copy of the termination letter to the patient's primary care physician. The physician should also inform the appointment desk that the patient is not to be scheduled for any appointments without prior approval.
• Include a Records Release: With the written notice letter, include a medical records release and inform the patient that, with their authorization, the terminating physician's office is prepared to forward the patient's medical records to their new physician.
• Provide Resources: Provide names or resources for the patient to select another physician.
• Continue Treatment: Ensure the patient's safety by continuing to see the patient until the termination date provided on the letter.
• Provide an Explanation for Termination: Although, depending on your jurisdiction, it may not be required to tell the patient the reason for the termination, a brief description is recommended, such as “failure to follow the plan of care” or “failure to make payment.”
• Inform Patient of Risks of Not Continuing Care: Consider listing the risks associated with the patient's not continuing medical care. The contents of this list will depend upon the patient's specific medical condition and serves to educate the patient as to the importance of further care.
• Don't Forget the Medical Board: Check with your state medical board for the specific requirements in your state.
• Inform the Patient's Health Plan: Contact the patient's insurance company to ensure that there are no additional requirements needed for the physician to meet contractual obligations with the health plan. (If physicians have any questions regarding this process, they should contact an individual in healthcare risk management, an attorney or the physician's state medical association.)

Avoid Abandonment

The AMA defines abandonment of an established patient as, “the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement.” Case law provides for similar components as the AMA, with the addition of harm to the patient that occurs as a result of the abandonment. Therefore, in general, to prove abandonment, the following elements must be shown: 1) The termination was unilaterally performed by the physician; 2) The patient was not given reasonable notice or a replacement physician; 3) The termination occurred at a critical stage of the treatment process or when the need for continued care was present; and 4) As a direct result, the patient suffered harm.

In addition to any harm that may come to the patient, there are other after-effects of patient abandonment. Since abandonment is considered a breach of the physician's duty, a patient may file a claim against the physician for medical negligence. Also, due to reporting requirements or patient complaint, the physician's state medical board may investigate and/or take action.

Conclusion

Physicians have an ethical and legal duty to provide continued care to their patients. Although it is legally permissible for a physician to unilaterally terminate services to a patient if certain steps are followed, if the physician fails to follow these steps, and the patient suffers harm, the physician may be liable for abandonment. While the general principles of abandonment are the same, each state may have additional requirements. Therefore, it is important to check with the medical board in the terminating physician's state for the specific requirements to prevent abandonment.

Kimberly Danebrock, RN, JD, is a senior risk management and patient safety specialist for the Cooperative of American Physicians.

At some point in their careers, physicians may be faced with terminating services to patients. In general, terminating the physician-patient relationship is allowed as long as the physician provides reasonable notice to the patient ' giving him or her the opportunity to obtain another qualified physician to manage his or her care. If this requirement is not met, and the patient suffers injury, the physician may have breached a duty to the patient and may be found liable for medical negligence (malpractice) under the theory of abandonment. How do we terminate the physician-patient relationship while also preventing abandonment?

The Duty

Although there is generally no written contract to establish the physician-patient relationship, one can be created by a physician treating the patient in the office or hospital, through call obligation or via contract with the health plan. Once the relationship has been created, the physician has an ethical and legal duty to provide services to the patient until the relationship has been terminated. This relationship can be ended when the patient and physician both agree to do so; the patient no longer wants or requires the physician's services; or the physician unilaterally terminates the relationship, provided the patient is given reasonable notice to allow time to find another physician.

According to the American Medical Association (AMA) Principles of Medical Ethics, Principle VI, “A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.” So, physicians do have the right to unilaterally terminate the physician-patient relationship, but the proper method is not as straightforward as it is for the patient, who does not need to give reason or notice of any kind.

A physician may decide to discontinue providing services to a patient for a number of reasons, including, but not limited to: 1) Behavior that is rude and verbally abusive; 2) Nonpayment; 3) Drug-seeking behavior; 4) Failure to follow the opioid agreement or other office policies; 5) Failure to show up for appointments; or 6) Noncompliance with the treatment plan. But patient safety dictates that there are guidelines for doing so. The AMA has addressed this issue in Termination of the Physician-Patient Relationship, Opinion 8.115, which provides that, “Physicians have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured.”

Of course, the purpose of reasonable notice is to prevent a physician from arbitrarily discontinuing treatment and leaving the patient without medical care. But what is “reasonable notice”? The AMA and many other professional organizations recommend 30 days, but several states allow for less notification. However, keep in mind that this recommendation is regarded as the minimum necessary time frame for the patient to find another qualified physician. In addition to observing the 30 day requirement, notice should be based on individual patients and their medical condition. Some patients ' depending on their disease process and physician needs ' may require more time to establish care with another provider, based on location and access to a specialist. In contrast, a relatively healthy individual in a large city requiring a primary care physician may have little difficulty acquiring another physician. In other words, the physician should review each situation on a case-by-case basis.

The Method

When a physician decides to discontinue the physician-patient relationship, it is highly recommended that these steps be taken to ensure patient safety and prevent abandonment:

Review the Record: Carefully consider the medical condition of the patient, which type of physician he or she will need for a replacement, the time it would take for the patient to get an appointment and the distance the patient would have to travel. Be extra cautious with patients in a critical stage of the treatment process.

• Document: Ensure that the medical record documentation is accurate and reflects the reason for the termination. Retain a copy of the termination letter in the medical record.
• Provide Written Notice: Send a letter to the patient by certified mail with return receipt requested. A copy of the letter should be placed in the medical record.
• Make Sure That Notice is Reasonable: Generally, 30 days of notice will suffice. Please see below for specific details. The letter should provide the exact day that the relationship will cease.
• Notify: Depending on the physician's specialty, call and/or send a copy of the termination letter to the patient's primary care physician. The physician should also inform the appointment desk that the patient is not to be scheduled for any appointments without prior approval.
• Include a Records Release: With the written notice letter, include a medical records release and inform the patient that, with their authorization, the terminating physician's office is prepared to forward the patient's medical records to their new physician.
• Provide Resources: Provide names or resources for the patient to select another physician.
• Continue Treatment: Ensure the patient's safety by continuing to see the patient until the termination date provided on the letter.
• Provide an Explanation for Termination: Although, depending on your jurisdiction, it may not be required to tell the patient the reason for the termination, a brief description is recommended, such as “failure to follow the plan of care” or “failure to make payment.”
• Inform Patient of Risks of Not Continuing Care: Consider listing the risks associated with the patient's not continuing medical care. The contents of this list will depend upon the patient's specific medical condition and serves to educate the patient as to the importance of further care.
• Don't Forget the Medical Board: Check with your state medical board for the specific requirements in your state.
• Inform the Patient's Health Plan: Contact the patient's insurance company to ensure that there are no additional requirements needed for the physician to meet contractual obligations with the health plan. (If physicians have any questions regarding this process, they should contact an individual in healthcare risk management, an attorney or the physician's state medical association.)

Avoid Abandonment

The AMA defines abandonment of an established patient as, “the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement.” Case law provides for similar components as the AMA, with the addition of harm to the patient that occurs as a result of the abandonment. Therefore, in general, to prove abandonment, the following elements must be shown: 1) The termination was unilaterally performed by the physician; 2) The patient was not given reasonable notice or a replacement physician; 3) The termination occurred at a critical stage of the treatment process or when the need for continued care was present; and 4) As a direct result, the patient suffered harm.

In addition to any harm that may come to the patient, there are other after-effects of patient abandonment. Since abandonment is considered a breach of the physician's duty, a patient may file a claim against the physician for medical negligence. Also, due to reporting requirements or patient complaint, the physician's state medical board may investigate and/or take action.

Conclusion

Physicians have an ethical and legal duty to provide continued care to their patients. Although it is legally permissible for a physician to unilaterally terminate services to a patient if certain steps are followed, if the physician fails to follow these steps, and the patient suffers harm, the physician may be liable for abandonment. While the general principles of abandonment are the same, each state may have additional requirements. Therefore, it is important to check with the medical board in the terminating physician's state for the specific requirements to prevent abandonment.

Kimberly Danebrock, RN, JD, is a senior risk management and patient safety specialist for the Cooperative of American Physicians.