Ending the Physician-Patient Relationship
Policy Number: #3-08
Policy Category: Practice
Approved by Council: February 2000
Reviewed and Updated: June 2008
Publication Date: September 2008
College Contact: Physician Advisory Service
Ending the Physician-Patient Relationship
This policy clarifies the expectations of physicians when ending the physician-patient relationship, and outlines the actions to be followed in doing so.
This policy covers situations where a physician ends the physician-patient relationship with one or more patients in circumstances other than the physician’s retirement, relocation, leave of absence or disciplinary action.1
- Physicians have a duty to act in the best interests of their patients.
- An effective doctor-patient relationship is necessary for the provision of quality health care.
- Patients are entitled to be treated with respect and without discrimination during all stages of the physician-patient relationship, even if the relationship faces termination.
The physician-patient relationship is of primary importance in the overall health care delivery model. It is a unique relationship which depends on trust and confidence between the parties for the provision of care. Physicians enter into the physician-patient relationship with a commitment to provide their patients with quality service. However, when circumstances affect the physician’s ability to achieve this, he or she may decide to end the physician-patient relationship. In some cases, it may be the patient who decides to end the physician-patient relationship.
Physicians are entitled to end the physician-patient relationship under certain circumstances. Each situation is ultimately fact-specific. Physicians are expected to apply good clinical judgment and compassion in each case to determine the most appropriate course of action.
Ending the physician-patient relationship will usually have significant consequences for the patient, as he or she will need to find another health care provider. The current shortage of health human resources in Ontario may make this especially difficult. Physicians should always carefully evaluate any decision to discontinue care and should use reasonable efforts to resolve any issues affecting the relationship with the patient prior to any final decision.
Reasonable efforts include discussing with the patient, when possible, the reasons affecting the physician’s ability to provide quality care and/or the elements that are necessary for an effective physician-patient relationship.
If physicians are uncertain whether or not it is professionally acceptable to end a physician-patient relationship, they are advised to contact the Physician Advisory Service at the College for further guidance and/or seek legal advice.
Situations which may result in a decision to end the physician-patient relationship
(i) Breakdown of trust and respect between the physician and the patient
Trust and respect are essential elements of an effective physician-patient relationship. Physicians may find in the course of providing services to a patient that these elements break down to the extent that the physician is no longer able to provide quality care to the patient.
This may occur when there has been:
- patient fraud, such as for the purpose of obtaining narcotics or other drugs;
- serious threat of harm to the physician, staff and/or other patients;
- other forms of inappropriate behaviour towards the physician, staff and/or other patients;2
- a conflict of interest that compromises the physician’s duty to put the interests of his/her patients first;3
- a communication breakdown that makes it impossible to provide quality care.
This list is not exhaustive.
(ii) The physician’s practice has become too large to manage
The College recognizes that Ontario is currently experiencing a shortage of health human resources, which places increasing pressure on both physicians and patients. As a result, physicians may find on occasion that their practice has become too large to manage and that they must decrease the number of patients to whom they provide services.
The College advises physicians in these situations to carefully consider the medical needs of their patients and to proceed in a manner that is fair, transparent and compassionate. Physicians should consider factors including: the vulnerability of the patient, the patient’s ability to find care in an appropriate timeframe and the consequences terminating the relationship may have on the health of the patient.
Physicians should also be careful that decisions to terminate the relationship comply with the Ontario Human Rights Code.4 Further information about the Human Rights Code appears below.
Situations where it is inappropriate for a physician to end the physician-patient relationship
(i) Prohibited by legislation
Physicians are prohibited from ending the physician-patient relationship because the patient chooses not to pay a block or annual fee.5
(ii) Prohibited by the Ontario Human Rights Code
The provision of medical services is subject to the Ontario Human Rights Code. Therefore,dismissing a patient based on any prohibited ground in the Human Rights Code (including race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex, sexual orientation, gender identity and expression, age, marital status, family status or disability) may lead to an allegation of discrimination, which could lead to a proceeding before the Human Rights Tribunal, as well as disciplinary action before the College.
(iii) As outlined in the regulation on professional misconduct
Under the regulations of the Medicine Act, 1991, certain activities can give rise to allegations of professional misconduct. Discontinuing required services constitutes professional misconduct unless:
- the patient requests the discontinuation;
- alternative services are arranged, or
- the patient is given a reasonable opportunity to arrange alternative services.6
(iv) The patient chooses not to follow the physician’s treatment advice
Patients are entitled to make decisions about their health care. In general, they can make their own decisions about treatment and lifestyle, even if the physician does not agree with those decisions. In general, a physician should not end the physician-patient relationship because the patient chooses not to follow the physician’s advice.
Under the Health Care Consent Act, physicians are prohibited from administering treatment unless they have obtained consent from the patient or the patient’s representative, even if the treatment is beneficial. Patients are entitled to withhold consent to any proposed or ongoing treatment. If this occurs, it should be noted in the patient’s medical record, particularly if the recommended treatment is supported by evidence based practice or generally accepted standards of practice.
(v) The patient requires urgent or emergency services not otherwise available
Where care is needed on an urgent or emergency basis and there are no other services available, such as a walk-in clinic or local emergency room, physicians should provide the needed care.
Communicating a decision to terminate
Decisions to terminate the physician-patient relationship are difficult for both physicians and patients. In all circumstances, physicians must have a transparent and bona fide rationale for ending the physician-patient relationship. This should be shared with the patient when appropriate, and documented in the patient’s medical record.
In most cases, it is appropriate and useful for the patient to understand the reasons why medical services are being discontinued. However, physicians may use their discretion in situations where there is a genuine risk of serious harm associated with communicating those reasons to the patient.7
The decision to terminate must always be communicated to the patient in writing (see Appendix for sample letter). Ideally, physicians should also communicate the decision in person, but rare situations (such as where there is a genuine risk of serious harm) may warrant written communication only.
Actions to be taken when ending the physician-patient relationship
Ending the physician-patient relationship should always be done in a professional manner. When ending the physician-patient relationship, the College expects physicians to take the following actions:
- Notify the patient of your decision to end the physician-patient relationship by letter sent by registered mail (see Appendix for sample letter). Physicians may also discuss this decision with the patient, if appropriate.
- Place a copy of the notification letter (with the registered postal receipt) in the patient’s chart. Also, document if the matter was discussed with the patient.
- Document in the patient’s chart the reasons for ending the professional relationship.
- Clearly convey to the patient that he or she should seek ongoing care.
- Be as helpful as possible to the patient in finding a new physicianor other primary care provider and provide him or her with a reasonable amount of time for doing so.
Ensure the provision of necessary medical services in the interim.8 This includes:
- What is considered “a reasonable amount of time” depends on the circumstances of each case.
- This period can be defined as the amount of time it would take a person using reasonable effort to find a new physician.
- This time may vary from community to community and may be complicated by physician shortages.
- Sometimes it may be impossible for a patient to find a new physician. In such circumstances, the College would not expect the physician to continue to provide care indefinitely, but would expect that he or she would provide emergency services that would otherwise be unavailable to the patient.
Ensure the timely transfer of a copy or summary of the patient’s medical records upon the patient’s request.10 Notify appropriate staff (e.g., office receptionist) that you are no longer providing care to the patient. Notify the patient’s other health care providers that you are no longer providing care to the patient, if such notification is necessary for the purposes of the patient’s care and if the patient has not expressly restricted you from providing information to other health care providers.11
- renewing prescriptions, where medically appropriate (and where feasible without the need for ongoing monitoring), for a reasonable length of time given the needs of the patient, the time required to find a new physician, and the nature of the medication;9 and
- ensuring access for patients to laboratory or test results and that all abnormal results receive required review and follow-up. Patients should be given necessary contact information for obtaining their test results.
Appendix: Sample Notification Letter
The College expects physicians to communicate decisions to terminate the physician-patient relationship in writing in all cases and in person when appropriate. The following template contains possible wording for a notification letter when a physician-patient relationship is ending due to a breakdown of trust and respect between the physician and patient. The College expects the physician to customize his or her letter to fit the particular circumstances. The letter should explicitly state the reason for termination, and should be written in a way that the patient can understand.
Dear [patient’s name]:
As we discussed at your appointment on [insert date],12 my first obligation as a medical doctor is to provide quality care to all of my patients. In order to do this, you and I must willingly work together towards your health and well-being.
It has become clear that because of [if appropriate, indicate reason] there has been a breakdown of trust in our doctor-patient relationship. This has made it difficult for me to continue providing quality care to you.
In these circumstances, I do not believe that it is in your best interest for me to continue as your doctor. I therefore regret to inform you that I will not be in a position to provide you with further medical services after [enter the date -- this time will vary from community to community, but you should give sufficient notice].
I urge you to obtain another physician or primary health care provider as soon as possible. With your consent, I will be pleased to provide them with a copy or summary of your medical records. You are also able to obtain the results of any outstanding medical tests by contacting [enter contact information].
For assistance in locating another physician, you may wish to call Health Care Connect, a Ministry of Health and Long-Term Care program which helps Ontarians without a family health care provider find one. To register for the Health Care Connect program, call 1-800-445-1822. Other options include contacting your local hospital to see whether any physicians on staff are accepting new patients, or your Community Health Centre, an organization that provides primary health care and prevention programs through physicians and a variety of other health professionals. A list of community health centres in Ontario is available on the Ontario Ministry of Health and Long-Term Care website. Lastly, some physicians, including those who are new to an area or who are beginning to establish a practice, will advertise in the local newspaper that they are accepting new patients.
[Signature of physician]
1Expectations of physicians in instances of retirement, relocation, leave of absence or disciplinary action are included in the CPSO policy Practice Management Considerations for Physicians Who Cease to Practice, Take an Extended Leave of Absence or Close their Practice Due to Relocation.
2Inappropriate behaviour can include foul language, rudeness, argumentativeness, etc. If the office has a policy regarding inappropriate behaviour, all patients should be made aware of this (it may be useful to have a printed version of the policy readily available in the office). Otherwise, before ending the physician-patient relationship for reasons of inappropriate behaviour, the physician should carefully consider whether the behaviour is an isolated occurrence.
3For more information about possible conflicts, see the CPSO’s Conflict of Interest policy.
4The Ontario Human Rights Code, R.S.O. 1990, c. H 19 is provincial legislation that protects people in Ontario against discrimination in services such as health care. The Human Rights Code is enforced by the Ontario Human Rights Commission.
5Section 18(2) of the Commitment to the Future of Medicare Act, 2004, S.O. 2004, c. 5. Also see the CPSO’s Block Fees and Universal Services policy.
6Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s. 1(1)7.
7For example, if the patient is volatile, aggressive, threatening, etc.
8Unless (i) the patient requests discontinuation; (ii) alternative services are arranged; or (iii) the patient is given a reasonable opportunity to arrange alternative services (O. Reg. 856/93 s.1(1)7).
9It is not expected that prescriptions will be renewed indefinitely.
10For further information, refer to the CPSO policy on Medical Records.
11Under the Personal Health Information Protection Act, 2004, a health care provider can provide personal health information about a patient to another health care provider for the purposes of providing health care or assisting in the provision of health care to the patient. Despite this provision, the Act also gives patients the right to expressly restrict his/her physician from providing another health care provider with his/her personal health information, including whether the physician is providing the patient with services. In cases where a physician is asked by another health care provider for information about a patient that is reasonably necessary for the provision of health care or assisting in the provision of health care to the patient, the physician must notify the other health care provider if they have been restricted from disclosing information about the patient and they may wish to advise the other health care provider to direct any inquiry to the patient him/herself for a response.
12This wording may be deleted if a physician has not previously discussed termination of the relationship with the patient.