Four Considerations Before Dismissing a Patient from Your Practice

Are you considering terminating a relationship with one of your patients? Maybe this patient is rude, doesn’t follow your recommendations, or is delinquent in paying his medical bills. Regardless, physicians should consider four aspects of the decision to terminate before they follow through.

The ethics
The AMA  notes in Opinion 8.115 of the Code of Medical Ethics 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.”

How to protect the patient
Termination of the patient-physician relationship should never threaten the patient’s health or access to care. All physicians are legally required to notify their patients in writing when they are no longer able to provide care for them.

So you should start by writing a formal discharge letter. This letter must identify a specific date - at least 30 days from when the letter is sent - after which you will no longer be able to provide care.

To help the patient secure the necessary care going forward, the letter should also include a description of her medical problems and contact information for another local physician or a physician referral service. Specialized rural practices should not terminate care if they know the patient will be unable to obtain similar care or services from other nearby healthcare providers.

How to protect yourself
Patient abandonment, which is defined as unreasonable discontinuation of healthcare treatment without the patient’s knowledge, is a tort that could make you legally vulnerable to a civil lawsuit.

To avoid liability, ensure that a patient won’t suffer foreseeable harm due to the discontinuation of your care by helping him secure a new healthcare provider.

Physicians could also be vulnerable to legal action if a former patient can prove that termination of the relationship took place for discriminatory reasons or in violation of the Americans with Disabilities Act. Make sure all communications with the patient are in writing so the reason for terminating the relationship isn’t left open to interpretation.

How to protect your practice
A 2004 study published in Family Practice found that “There were two distinct but overlapping types of patients who were most likely to become eligible for removal: ‘bad’ patients, who break the rules of the doctor-patient or practice-patient relationship, and ‘difficult’ patients, with whom the doctor-patient relationship is so strained that the doctors felt they can no longer care for them.”

Most of the removed patients studied felt that termination of the relationship was unjustified, and they blamed the physicians for breaking the rules of the relationship, describing the physicians as “rude, impersonal, uncaring, clinically incompetent,” and claiming that they lied to their patients. And while the physicians in this study described the end of the patient-physician relationship as a divorce, the patients viewed themselves as reluctant divorcées who’d been locked out of their marital homes.

When patients feel they have been wronged, they are more likely to lash out. They could pursue legal action, as mentioned above, or simply write a negative online review.

The best way to avoid getting negative reviews is to terminate a patient-physician relationship only as a last resort. Ideally the termination will be mutual, but that isn’t always possible. Therefore, you’ll want to minimize any ill will by providing sufficient support for the patient leading up to the termination date - even if that means going above and beyond to help a patient secure continuity of care.

The patient-physician relationship is a complicated one, and terminating the relationship comes with its own set of complications. Handle this decision wisely and cautiously by taking the necessary steps to uphold your ethical duty as a physician while still protecting the patient, your practice, and yourself.