Terminating the Physician-Patient Relationship - Crozer-Keystone Health System - PA

Terminating the Physician-Patient Relationship

The relationship between a physician and patient is based on trust. This trust gives rise to the physicians’ ethical obligations to place a patient’s welfare above their own self interest and above obligations to others.   

The AMA Code of Ethics recognizes that the physician-patient relationship works best when it is a mutually respectful alliance. In most cases, the relationship exists in that respectful environment. However, adverse events or interactions can occur which damage the physician-patient relationship beyond hope of reestablishing or maintaining a therapeutic relationship. In those cases, a patient has the option of ending the relationship by simply walking away. The physician cannot walk away. He/she could be labeled as abandoning the patient, which carries negative legal and ethical ramifications for the practitioner. The physician must follow specific procedural steps to ensure that the relationship is ended in the appropriate legal and ethical way.  

Termination of the physician –patient relationship is a two step process. First, identify the behaviors or patterns of behavior that trigger termination. Then provide the appropriate notice of termination to the patient.  

Behaviors that Trigger Termination

Overall, where the patient’s negative actions or behaviors make it impossible to maintain a therapeutic relationship, the physician is justified in discontinuing that relationship.   

The first step is to determine what behavior or pattern of behaviors, actions or omissions by the patient can trigger termination. It may be one incident, such as; forging prescriptions, a violent, aggressive, physically or verbally abusive outburst directed at the physician and/or the office staff. It may be a pattern of negative behavior such as missed appointments without excuse, non-compliance with treatment, failing to honor their financial commitments, drug seeking behaviors or an irreconcilable difference in treatment philosophy that triggers the termination.  The underlying element in each of these triggers is a breach of trust in the relationship.  

The physician needs to document in the patient’s medical record the patient’s action, pattern of behavior or non-compliance that triggers the termination. The steps taken by the physician to address the negative behavior, such as telephone calls, letters and or conversations with the patient should also be well documented.

Notice of Termination

Proper termination of the physician–patient relationship requires proper notice to the patient. The following steps need to be done: 

  1. Notify the patient in writing that the care will be terminated.  It should be a certified letter, return receipt requested. A copy of the letter should also be sent via regular mail. In some cases, you may want to contact the patient directly to notify them of the termination. In those cases, you must document the conversation and written notice must still be sent to the patient as follow up. 
  2. The termination letter should set out a reasonable time period in which you will continue to provide urgent or emergent care until a new provider can be obtained. The usual time is 30 days but a final date certain should be stated, ex)”…our office will continue to provide urgent care for 30 days but no later than (specific date).” Advise the patient that if a new provider has not been found by the date certain given in the letter then they are to seek treatment at the hospital/ emergency department near them. This thirty day window is not a legal standard.  Use common sense. If the reason for termination is threatening, physically or verbally abusive behavior by the patient, then your safety and that of your staff comes first. You do not have to invite the patient back in to the office. Refer them directly to the Emergency Department should they require emergent care. 
  3. At a minimum, give the patient’s insurance carrier’s contact number as a reference for seeking a new care provider. 
  4. Offer to send the patient’s medical records to the new provider and include a medical record release form with the termination letter. Sending a Medical Release Form is not only convenient for the patient but if the reason for termination was a troubling situation, it allows the process to move forward without the need for further direct contact with the patient. 
  5. Keep a copy of the termination letter in your files. If the certified letter was returned, keep the unopened letter in the file as well.   

Once you have taken the proper steps to terminate the relationship and the treatment window you gave the patient has expired, do not provide care or advice to the patient. By treating or providing treatment advice to the patient after the time frame specified in the letter, it can be perceived as reestablishing the physician-patient relationship. Any subsequent attempt to terminate the relationship must follow the same procedural steps and can extend the timeframe of treatment.      

Terminating the Physician-Patient Relationship  Questions/Answers

Terminating the Physician-Patient Relationship  Questions and Answers

 

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