What to do when either the patient or physician chooses to end the doctor-patient relationship
Patients and physicians alike may decide to end a doctor-patient relationship. Patients are free to leave their current physician’s practice at any time and seek care from another provider. Physicians, meanwhile, may end a doctor-patient relationship provided certain conditions are met.
Regardless of who initiates it, terminating a therapeutic relationship in an orderly manner helps to safeguard the patient’s well-being, ensures compliance with the physician’s professional obligations, and reduces the stress for both parties.
Permitted conditions
While patients may end the doctor-patient relationship at any time and for any reason, physicians may terminate the relationship only under certain circumstances.
Most medical regulatory authorities (Colleges) generally permit physicians to terminate the doctor-patient relationship owing to a significant breakdown in trust, retirement, relocation, a leave of absence, or to reduce their practice size, among other possible reasons. In these circumstances, physicians must comply with expectations specified by their College. The expectations may vary depending on the reason for the termination. For example, there are generally no expectations where the relationship reaches its natural or expected conclusion (e.g. specialist care).
Unless there is a real risk of harm to you, your staff or other patients, prior to ending the doctor-patient relationship all Colleges generally require that, at a minimum:
- the patient does not need urgent or emergent care; and
- you have given the patient adequate notice to find another healthcare provider.
Colleges also generally expect a physician to have reasonable grounds or just cause to end the relationship. Be aware of any College policies, human rights legislation, or codes of ethics that prohibit discrimination in the provision of medical services and that may affect your ability to terminate the doctor-patient relationship.
When the decision to end a doctor-patient relationship arises from the behaviour of the patient—for example, if the patient fraudulently obtains narcotics from you or threatens or is abusive to you or your staff—you may be concerned for your safety and the safety of your staff. Contact the CMPA for advice on how to proceed.
Where possible, you should make reasonable efforts prior to ending the relationship to attempt to resolve the situation with the patient by communicating your expectations as these pertain to their behaviour, and how their behaviour is affecting your ability to provide care.
Steps in terminating the relationship
If you have determined that it is appropriate to proceed with terminating the relationship, you must then consider how to do so. Several Colleges have adopted guidelines or policies that govern the steps physicians should take; you should be familiar with the guidelines or policies in your province/territory. Being able to produce evidence that you followed such guidelines or policies will help you defend yourself against a College complaint or civil action arising from the termination. The CMPA generally assists with College complaints or civil actions in these circumstances.
Making the decision to end the doctor-patient relationship is all the more challenging when physician shortages exist across Canada and patients may have few alternatives to receive medical care from another physician. To avoid a claim of abandonment or a College complaint by a patient, consider taking the following steps:
- Consider the circumstances, and if you think it is appropriate, inform the patient in person or virtually (including telephone and videoconferencing) of the decision to terminate. There may be circumstances, such as when you are concerned for your or your staff’s safety, where such a meeting would not be advisable. If you do have a discussion with the patient, you should clearly document it in the patient's medical record and send a confirming letter, if your College requires it.
- If you do not think a face-to-face meeting is advisable, send a letter to the patient. Check if your College has a preferred method for contacting patients for this purpose, such as by registered mail. Keep a copy of the letter in the patient's medical record.
- Whether you meet with the patient in person or send a letter, you will want to:
- Notify the patient clearly of your decision to end the doctor-patient relationship or confirm you understanding of the patient’s wishes to do so. You also need to decide what, if anything, you will tell the patient about the reasons for the termination. When making this decision, you should take into consideration issues such as your personal safety and the patient's particular circumstances. You should also verify whether your College has any applicable requirements or advice.
- Provide the patient with reasonable notice of the date on which your medical services will terminate. Adjust the notice period to each situation, taking into consideration such things as the patient's circumstances, including the need for ongoing medical care or follow-up, the availability of alternative physician resources in the community, and whether the patient poses any threat.
- Inform the patient that you will provide only urgent or emergent care in the interim.
- Advise the patient to obtain a new physician and, if possible, provide advice on this process.
- Provide the patient with information or instructions concerning their medical condition (e.g. information about outstanding laboratory results and where they will be sent, information about renewal of prescriptions, or other specific medical advice) to ensure the continuity of care in the circumstances.
- Inform your staff members about the termination and instruct them on how to transfer copies of the medical records with appropriate consent. You should be as helpful as possible in ensuring the transfer to the new physician is done promptly.
- Consider notifying other healthcare providers involved in the patient's care of the transfer of medical responsibility, to ensure there is no interruption in the continuity of care. Privacy legislation may provide patients with the right to restrict what information you can communicate in these circumstances, so be aware of any such limitations in your specific case and seek advice from the CMPA or your College on how to proceed.
It is important to obtain appropriate authorization from the patient before transferring any copies of medical records. You and your staff should also ensure the original records are retained, in the event that there is some question at a later time about the care you provided to the patient, or in the event of a College complaint or legal action surrounding the care or the termination.
Ending the doctor-patient relationship can be difficult and stressful for you as well as your patient. If the decision was the patient’s, you might want to discuss their reasons with them: for example, they could be moving away, or perhaps they were dissatisfied with some aspect of your practice. Whatever the stated reasons, it may be beneficial to leverage this experience as an opportunity for learning and potentially making improvements.
The bottom line
Patients can choose to end an existing doctor-patient relationship at any time, and the decision to do so is theirs. Physicians are permitted to end a doctor-patient relationship, provided they comply with College requirements, which include ensuring the patient has access to urgent or emergent care, and has been provided reasonable notice to find another healthcare provider. If the decision was the physician’s:
- Consult the applicable College policies and guidelines in your province/territory.
- Determine which is the most appropriate way to inform the patient of the decision to terminate — in person or by letter or both. If you are informing the patient in person, send a confirming letter, if your College requires it. In either case, give reasonable notice you are ending the relationship; advise the patient to find a new physician; inform the patient you will provide only urgent or emergent care in the interim; with your patient's consent, have copies of the medical records transferred; and provide specific information concerning the patient's particular medical condition to ensure continuity of care.
- Inform your staff members about the termination.
- If appropriate, consider notifying other involved healthcare professionals that the relationship has ended.
- Document the rationale for terminating the relationship in the patient's record, and note any conversations you have with the patient in the medical record or keep a copy of the termination letter. Keep records of the steps you follow to efficiently transfer the patient's care to another physician.
- Act compassionately to help make the transfer of care as smooth as possible.
