Termination of Care
An important element of appropriate patient care is an ongoing, consistent, stable relationship between patient and physician. Because of the value of this relationship, and the significant harm that can follow to patients when alternate care is not available, the decision to terminate care to a patient should be a difficult one. Unless alternate care can be immediately arranged, such a decision should only be made in unusual circumstances and for the best of reasons. Otherwise, the physician could be subject to a complaint of abandonment.
It should first be noted that there are only a few circumstances where such a decision to terminate care could be made without advance notice to the patient. These would be generally limited to cases involving illegal activity or fraud, usually for the purpose of improperly obtaining controlled drugs or substances.
In contrast, there are also situations which should rarely, if at all, be considered as sufficient grounds to terminate care. These would be situations where a patient was asserting their rights to have the physician meet ethical obligations. Patients have the right to information, to ask questions, to insist on informed consent, and to make reasonable requests for second opinions. They also have the right to accept or reject any intervention or treatment offered by the physician. It is only when such a decision adversely affects the doctor/patient relationship in a fundamental way that the physician may consider the option of asking the patient to find care elsewhere.
Difficulties can arise in situations between these extremes. In those circumstances, the physician is obligated to communicate the nature of the problem directly to the patient, making it clear that there is a potential for the patient to be discharged from the practice. It is only if the situation does not resolve after such notice that the physician can formally advise the patient that the relationship is being concluded.
The physician may consider terminating care in the following cases:
- prescription or related fraud
- patient repeatedly misses appointments without cause or excuse
- patient displays inappropriate behaviour
- the physician is aware that another physician has assumed ongoing care of the patient
The patient’s care must not be terminated if:
- medical care is likely to become too complex
- the patient requires the physician to complete documentation
- the patient requires more time than is required for other patients
- the patient makes unhealthy lifestyle choices
- the patient repeatedly questions the member’s medical advice
- the physician will be required to participate in legal proceedings
If a physician is reducing the size of the practice, they must exercise professional judgment and do so in a way which does not appear to be discriminatory. It is not appropriate to selectively or disproportionately discharge difficult or complex patients.
If a patient refuses to pay outstanding fees, the physician must consider such in context of the financial burden, consider the possibility of flexibility in the invoice, and only undertake discontinuation in line with this guideline, making a reasonable effort to pursue a resolution.
When such a final decision has been made, it should be communicated directly to the patient, preferably by registered mail. The patient should be advised that ongoing care will be provided for a reasonable period of time to allow them to make alternate arrangements. In some circumstances, a period of two to three months is considered appropriate. The patient should also be advised that relevant records will be forwarded to a new physician on request.
11/02, 11/20