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POLICY: Ending a Patient-Physician Relationship

 
Preamble

The patient-physician relationship is a unique relationship based on trust, honesty, respect and a mutual desire to improve health outcomes.  There must be a mutual and collaborative understanding of the patient's needs and expectations, and the physician's capacity to respond. Relationships based on openness, trust and good communication will enable the physician in partnership with the patient, to address the patient's individual needs.

The fundamental responsibilities of physicians in the Patient-Physician Relationship are described in the College’s Code of Ethics and Code of Conduct.

It is necessary for both parties in the patient-physician relationship to be honest, considerate and polite, and treat each other with dignity, respect and as individuals. 

It is important for the physician to respect patients’ privacy, autonomy and right to confidentiality, to support patients in caring for themselves to improve and maintain their health, and to encourage patients who have knowledge about their condition to use this when making decisions about their care.

It is equally necessary for the patient to be honest and open in providing pertinent communication to enhance the value of the interaction.  As well, the patient should be mindful of the advice or treatment recommendations provided by the physician.

The College's Position

Occasionally there will be some patient-physician relationships that for one reason or another do not work.  Either party may decide to terminate the relationship.  A physician may ethically decide not to continue to see a patient, as long as there are valid reasons and the patient is not in immediate need of medical care.

When ending a patient-physician relationship, the College expects the following:

1. The decision to end the relationship should be clearly communicated to the patient. The initial decision may be communicated verbally if appropriate. A follow-up letter sent by registered mail is recommended. Be as compassionate and supportive as possible. State the reason(s) for the decision. Document any discussion and save a copy of the letter in the patient's file.

    

2. Give the patient a “reasonable” time to find another physician. A notice of one month is minimally acceptable under usual circumstances. A longer or shorter time might sometimes be needed to accommodate patient needs, physician safety, or due to geographic location and access to other physicians.

    

3. State that you will give or arrange for care until that date, and that you will respond to a request for care in an emergency situation. If ongoing care is needed, ensure that the patient (or their proxy) is aware of this.

    

4. Be helpful to the patient in finding a new physician and transferring records (see guideline on Transfer of Patient Records) and ensure that there are appropriate arrangements in place to ensure that there is follow up of outstanding investigations and consultations. If considered safe to do so, provide enough prescription renewals to last till another provider can assume care.

    

5. Circumstances may arise when a consulting physician perceives that conflict between themselves and a referred patient (or proxy) is sufficiently problematic that the physician is no longer able or willing to persist in care delivery. In such circumstances careful re-evaluation is suggested to ensure that the relationship is not salvageable. In such cases where the consultant physician deems it preferable to have the patient cared for by another provider, the physician may direct care back to the referring physician only in circumstances where the care being sought is considered non-urgent and the patient will not come to any immediate harm while waiting for referral to, and consultation with, another care provider.If the patient is likely to come to harm during the re-referral timeframe, the consultant must arrange for direct transfer to the care of another consultant able to provide the care required.

    

6. In circumstances where a physician is ending the patient-physician relationship by transferring care to another physician, it is essential that the transfer be facilitated by providing all necessary information and records to accepting physician.

A physician must not discharge a patient:

1. Based on a prohibited ground of discrimination including age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or economic status.

    

2. Because a patient makes poor lifestyle choices.

    

3. Because a patient fails to keep appointments or pay outstanding fees unless advance notice has been given to the patient and the patient has been provided with the opportunity to address the concerns.

    

4. Because the patient refuses to follow medical advice unless the patient is repeatedly non-adherent despite reasonable attempts by the physician to address the non-adherence.

    

5. Because the physician relocates his/her practice to a new location/setting to which current patients could be reasonably expected to follow.

    

6. Because the patient asks for a service or requests access to services that the physician has a conscientious objection to.

    

7. If discharge significantly hampers access to a physician due to remoteness or lack of local physician resources in the community. For example, only one physician or one clinic in the community.

    

8. If a patient, due to a medical condition, becomes unable to travel (for example exclusively relying on Home Care or personal care providers for Medical Services) and/or is unable to independently find an alternate care provider (for example Long Term Care (LTC) placement, whether into Special Care Homes (SCH), Personal Care Homes (PCH) or assisted living, until the patient’s care has been accepted by and transferred to an alternate care provider.

Physicians are not obligated to provide health services to which they conscientiously object, however they must comply with the CPSS Policy “Conscientious Objection” and/or CPSS Policy “Medical Assistance in Dying: Patient’s Death is Not Reasonably Foreseeable” and/or CPSS Policy “Medical Assistance in Dying: Patient’s Death is Reasonably Foreseeable” with respect to providing or arranging access to care in such circumstances. 

For suggested wording for a letter from a physician ending the patient-relationship refer to the CPSS website section on Advice to the Profession or the CMPA document “Ending the doctor-patient relationship.”

Additional Resources

CPSS Regulatory Bylaw 7.1 – The Code of Ethics

CPSS Regulatory Bylaw 7.2 – Code of Conduct

CPSS Policy “Standards for Primary Care”

CPSS Policy “Conscientious Objection”

CPSS Policy “Medical Assistance in Dying: Patient’s Death is Not Reasonably Foreseeable”

CPSS Policy “Medical Assistance in Dying: Patient’s Death is Reasonably Foreseeable”

CMPA – Ending the doctor-patient relationship

CMPA – When physicians feel bullied or threatened