Dear Dr. Mossman:
One of my patients, Ms. A, keeps calling in to refill her prescription, but will not come in for an appointment; she needs the medication, but I really shouldn’t keep prescribing it without seeing her. Another patient, Mr. B, has an open chart, but he stopped seeing me last year after I treated him for an acute depressive episode. May I “fire” these patients? If so, what should I do?—Submitted by “Dr. C”
All physicians occasionally encounter patients whom we’d like to stop treating, but because we feel devoted to those we treat, the idea of “firing” a patient makes us uncomfortable. Sometimes, however, ending a treatment relationship is the right choice for the doctor and patient.1
To know why, how, and when you may terminate your professional relationship with a patient, you need to:
- understand the legal and ethical status of a doctor-patient relationship
- know the proper way to end treatment relationships
- decide whether ending your care of the patient is the right medical and ethical choice.
After exploring these points, we’ll return to the cases of Ms. A and Mr. B and consider what Dr. C might do.
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Doctor-patient relationships
Legal and medical authorities characterize the treatment relationship as an implicit contract that imposes certain obligations on the doctor and the patient.2,3 Doctors are compelled to conduct themselves in accordance with the prevailing “standard of care.” Patients’ obligations include being honest and cooperating with care once they have agreed to a treatment plan (Table 1).3
Patients may stop seeing their doctors at any time, but a physician usually must continue to provide all necessary medical attention until either the treatment episode has concluded or both parties agree to end the doctor-patient relationship.2 If a physician wishes to withdraw from a case before the need for services has ended, the physician must either make arrangements for another competent physician to assume care or give the patient ample notice and opportunity to obtain treatment elsewhere.2 If a doctor fails to do this and harm to the patient results, the doctor is guilty of “abandonment,” legally defined as termination of the physician-patient relationship “at an unreasonable time or without affording the patient the opportunity to procure an equally qualified replacement.”2 Physician abandonment can lead to malpractice liability,4 complaints to state licensing authorities,5 and ethical condemnation.6
Table 1
A patient’s responsibilities
| Being truthful |
| Providing a complete medical history |
| Cooperating with agreed-upon treatment and keeping appointments |
| Meeting financial obligations for medical care |
| Health-enhancing behavior |
| Not participating in fraudulent health care |
| Source: Reference 3 |
Terminating without abandoning
Doctors commonly terminate care of their patients when they decide to move or close their practices. Accusations of abandonment may arise if such career decisions are executed improperly, but these matters are not as emotionally troubling for physicians as a decision to “fire” a patient because of the patient’s behavior. Common, legitimate reasons a doctor may consider unilateral termination appear in Table 2.7,8
Certain circumstances are not valid grounds for terminating a doctor-patient relationship. You cannot ethically decline to treat a patient whose problem lies within your areas of clinical competence solely because the patient is seropositive for human immunodeficiency virus,9 nor because of a patient’s race, religion, or other reasons that would constitute illegal discrimination.3 Doctors who practice in rural areas must be especially cautious about terminating care because their patients may have limited access to alternate care sources.10
Meeting with or verbally informing a patient of a termination may be reasonable in some cases, but appropriate unilateral termination of a patient usually requires providing written notification to the patient or person responsible for the patient’s care. Attorneys who specialize in risk management advise doctors to seek legal consultation when preparing a termination-of-care letter and to send it by certified mail. The letter should conform to any applicable rules or regulations where you practice. Typically, required content includes:
- notification that the physician-patient relationship is terminated
- a statement of willingness to provide emergency treatment and access to services for up to 30 days from the mailing date to allow the patient to arrange care from another provider
- an offer to transfer records to the new provider upon receiving the patient’s signed authorization to do so.11