We open with some advice. Dismissing a patient is challenging. Sometimes arranging a graceful exit is best for both you and your patient. This article discusses general tips. Every case is different. When you do dismiss a patient, individualization is critical. Among other things, you must ensure continuity of care. If you are wondering when you can refuse to treat a patient, or terminate doctor-patient relationship, schedule a consultation with our Founder and CEO, Jeff Segal, MD, JD. Medical Justice has helped thousands of doctors address patient conflicts and a bevy of other medico-legal obstacles. We are ready to help.
As you have likely heard, the relationship between a doctor and a patient is a contract. The patient consents to be treated and the doctor consents to treat. In that purely legal sense, the doctor would therefore have an unfettered right to refuse their role.
Of course, that is not actually so. There are critical limitations on when a doctor may refuse to care for a patient.
The first issue is understanding whether the doctor is already in a therapeutic relationship with that patient. Under the common law “no duty” rule, unless the physician-patient relationship has formed, the doctor has no legal obligation to treat.
However, the converse is that if the relationship has formed there are strict limitations on ending it. So it is essential to understand what may create the physician-patient relationship.
When a patient makes and shows up for an appointment and the doctor examines and treats him the relationship has obviously formed. However, the relationship can form in ways other than these express acts.
Courts and medical boards will look to whether the claimed patient could have reasonably assumed that they were a patient of that doctor. This is based on the fact that the doctor is positioned to assert by his words or actions whether he agreed to take the patient on. The more “medical” the patient’s contact with the doctor’s office is – not just signing in but filling out a history form and having it accepted by a staff member or meeting with an MA, for example – the more the claimed patient can have relied on their being a patient of the practice even before they ever meet the doctor. There, the relationship is established through the office protocols the doctor set up and the individual’s interactions with the medical agents of the doctor.
The doctor may also be bound to a the physician-patient relationship by his interaction with third parties, either by contract or through providing consultation. The former occurs when the doctor is obligated, usually through their privileges agreement, to provide on-call services to an ER (which would also implicate duties under EMTALA) or to be an Officer of the Day for admissions in his specialty, or is part of a managed care entity that schedules patients for it (but just being on a panel). These arrangements pre-establish a relationship to all patients the doctor may encounter in those roles. The latter occurs when facilities or other practitioners request a consultation on a patient. When the doctor is consulted in a setting in which it is obvious that their opinion will be relied upon and can have harmful implications for the patient’s care if given negligently, the relationship will be held to have formed in an implied fashion, even if the doctor and the patient in question never meet.
If there is an existing physician-patient relationship then it must be terminated according to the statutory and common law requirements of the jurisdiction to avoid actionable abandonment. Abandonment occurs when a patient in need of ongoing care is terminated by the doctor without adequate notice to establish care elsewhere. In general, this can be avoided with a letter stating the termination and offering 30 days of emergency coverage. However, if the doctor is aware that that will be insufficient time or that there is no equivalent practitioner available due to issues like specialization or insurance coverage then that would constitute “constructive abandonment.” In that setting, the doctor may have to take additional steps, such as seeking an alternative for the patient or extending the emergency coverage period or, in rare cases, may not be able to terminate the patient at all.
A brief reminder – making these judgement calls can be challenging. Every case is different. But sometimes arranging a graceful exit is best for both you and your patient. If you are a doctor navigating the obstacles described in this piece, schedule a consultation with our Founder and CEO, Jeff Segal, MD, JD. Medical Justice has helped thousands of doctors address patient conflicts and a bevy of other medico-legal obstacles. And when you are finished reading this article, spend time with its companion piece: Perfecting the Patient Dismissal Letter. With that said, let’s return to the piece.
The next issue is, if the doctor wants to terminate the relationship, what reasons need underpin that termination.
The simple answer is that no reason is legally required unless the doctor is operating under a contract with a third party that requires a listed reason. Other than that, a doctor may refuse to see a patient for any reason or for no cited reason at all.
Patient non-compliance or bad conduct that impedes the doctor’s ability to render proper care, or a patient’s demand that the doctor engage in care that the doctor believes is fruitless or harmful or exceeds the doctor’s own expertise are all valid bases to refuse to treat. The underlying issue is that the doctor is required to adhere to the Standard of Care and so may refuse involvement in care that falls below that due to patient actions / requests.
A refusal to treat may also be stated from the start, either by closing to new patients because the practice is at maximum or by pre-limiting the scope of the care, as when a surgeon contracts with the patient for only the operation and the post-operative visits.
However, there are also limits that must be borne in mind.
Unless there is a state law to the contrary, although non-payment is a valid reason to terminate a patient, a patient cannot be refused care while still in the practice because they have not yet paid. This would actually constitute “internal abandonment.”
A doctor may also refuse to engage in care that he feels violates their religious beliefs, such as performing an abortion. The set-off, though, is that they likely need to refer to another practitioner and must, if the case is an emergency and there is no available alternative, provide the care himself.
Finally, the Americans with Disabilities Act precludes a refusal to treat a patient based on their disability unless the individual poses a direct threat or significant risk to the health and safety of others that cannot be eliminated by adequate precautions or reasonable modification of policies, practices or procedures.
In summary, the right of a doctor to refuse to care for a patient is actually quite broad. That refusal encompasses objective issues that limit the ability of the doctor to treat properly. It also encompasses purely subjective matters that impede the smooth functioning of the therapeutic relationship. Refusal to treat is subject to the requirements that patients may not be discriminated against, either directly or through a pretext, and that a patient who is already established must not be abandoned, issues that all doctors should bear in mind when denying or ending care.
[Medical Justice notes: If a patient terminates the relationship on his own, the doctor does not need to give 30 days’ notice. The patient, free to choose what type of care he wants, has already moved on. If the patient has made such a move, document in your record.]
“Finally, the Americans with Disabilities Act precludes a refusal to treat a patient based on their disability unless the individual poses a direct threat or significant risk to the health and safety of others that cannot be eliminated by adequate precautions or reasonable Actually…no.modification of policies, practices or procedures. ”
Actually…no. If a physician feels that he cannot safely treat a patient, then once the referral to the next physician is made, he’s at least largely off the hook. It’s pretty hard to imagine a jury agreeing with a plaintiff’s lawyer that the doctor really could have done a great job, but just didn’t want to be bothered. Lots of luck to the PL with that approach.
If a doctor feels that a patient is engaging in high-risk behavior and is setting himself [the patient] for complications to arise, this technique has a lot going for it. When I was doing neurointerventional surgery, the last thing I wanted were patients with serious complications. If they were smokers–who seemed empirically to have odds ratios of 10-100X for complications for treating intracranial aneurysms, I flat out declined to treat them electively until and unless they both stopped smoking (which I could measure) and promised they wouldn’t start up again (which I obviously couldn’t).
I always provided them with the alternative that I’d be more than happy to refer them to colleagues who didn’t seem to are whether they were smokers; amazingly enough, not a single patient took me up on that-even if they didn’t stop smoking. Which tells me that no small number of patients have both hardware and software problems.
But I digress.
Bottom line is that it could be easily argued that I had not yet established a doctor-patient relationship, so the issue was moot for me in case. Perhaps that’s actually true. But perhaps it was not: if I sat down and explained everything about the patient’s problem, proposed surgical (interventional) solution, risks, etc., did that constitute formation of a doctor-patient relationship? If so, did my refusal to treat them until they modified their behaviors to be less risky constitute abandonment? I (obviously) argue in the negative.
What says out legal brethren?
If you believed the standard of care required a patient to stop smoking, then you did not have to treat your patient. You do not have to treat a non-compliant patient. You gave him an option. Stop smoking and I will do the case. Or, I will send you to someone else who may have looser restrictions. But, my recommendation is stop smoking.
As long as the standard of care is what others would support, then I do not see you abandoned the patient.
I would argue that loosening your standards to accommodate a patient’s budget or ability to comply is a greater risk to you in the courtroom.
If you knew the outcome related to noncompliance was dismal, and that outcome was foreseeable and preventable, and you still treated the patient, then a legal case might be made arguing you should not have abandoned your protocol.
“Which tells me that no small number of patients have both hardware and software problems.”
Together with the fact that this is a quite dated posting, I am a retired physician and stand at the crossroads of your perspective quoted above in that throughout all my years of experience in practice I amassed increasing intolerance of medical professionals who in no short supply likewise possessed both hardware and software problems. For the medical professional, their choice to treat is one based upon predictive value drawn from hard data and the choice by patients of the most suitable medical professional merely likened to the statistical odds of the average lottery since complications can and sometimes do arise even under the most favorable circumstances.
Your argument seems, at best, an attempt to illustrate the conflict in accepting risk despite the fact that no altogether trustworthy assurances exist. For surgeons then, the only path to proceed within an already risk-laden profession, is to exclude smokers from access to your services and act to prevent it prior to any legal establishment of a physician-patient relationship. Problem solved unless you feel that you would be unable to financially exist upon the plethora of non-smokers who require surgery within your realm of expertise.
I, myself, came to deny a physician-patient relationship wherein evidence existed of any lifestyle preferences that were counterproductive to my efforts in providing quality medical care. It is not that I saw them as patients with hardware and software problems but rather merely a subset of the population beyond the reach of the all too apparent limitations of medical practice where variable degrees of success are requisite to obtain an acceptable measure of success. Even from the most modest point of my academic journey to achieve a license to practice medicine I was well aware that I lacked any realistic ability to positively influence the lifestyle habits of the patient population, for their perspective is collectively one that merely elucidates one of the frailties of being human. Any admonitions by a health professional are poorly matched against the power of personal fable, one the puts far too much distance between such persons and any consequence arising from poor habits.
Thus, I aimed my practice strictly toward that portion of the patient population that demonstrated favor in the odds of successful treatment and maintenance of their healthcare needs. The definition of my role was not the attempt to rescue those engaging in health risks but rather the focus upon patients who utilized their interface with the healthcare community as an adjunct to positive health practices. While some healthcare needs indeed lie beyond any patient’s influence and must nevertheless be addressed, attempting to illustrate the fundamental premise of right and wrong is demonstrably pointless.
If you’re confident enough that you believe yourself capable of producing a completely genuine physician-patient relationship by withholding your offer to engage your services only upon first realizing evidence of compliance by the patient, then I find it entirely unnecessary to point out that both winners and losers exist in every game of poker for a reason.
Interesting piece. The corollary is also true in the ever more prevalent “peer reviews” once such peer reviewer enters the stage (“physician-patient relationship by his interaction with third parties”). More than once have I been able to void such a peer review by pointing out in writing that the patient in question would now be the sole responsibility of the peer reviewing physician and his agents, and they would carry any and all liability.
Strong move!
I did something similar once upon a time at the U where I was working. The chairman and the main counsel called me to meeting where they insisted that I either stop traveling to do cases or give them a hefty cut of my collections. Very imperious. They were gonna show me. [Not. I was a tenured full professor at the time, so the best they could do was posture, and they know it.]
I pointed out to them that I was willing to give them 3-5%; they wanted 50%. I told them no. But I also questioned the wisdom of them getting anything at all. After all, if they got a cut, then they were the deep pockets in case of a lawsuit–I’m just a little old doc. Did they really want that? [imagine blank stares, then:] How much are you bringing in each year? Oh, only a few thousand bucks. Well!! It’s a de minimis situation anyway. We’re through here.
Total turkeys. Never even asked me to show them a tax return–which would actually have verified what I was telling them. But after pointing out their potential liability, they wanted to get away from that meeting like I had ebola, and was sneezing.
Gotta love it.
I was sent to a neurologist last January by the ER after I started having frequent tonic clonic seizures out of nowhere. I also was in an unstable living situation which I informed them of. Having moved three times since May 2021. Finally in a stable environment I called in December to schedule an appointment. Since you can never reach anyone by phone I left a vm. Someone called me back a few mins later “I’ll ask the doctor and call you back”. No one did so I called 4 days ago. Only be told by someone else that I was terminated who also told me I could not get a refill of Keppra which I’ve been taking the last year. Which I knew nothing about. Since they sent a letter to an address I haven’t lived at since May. The person I spoke to in December knew this and neglected to tell me this. When I could have already have seen a new neurologist in that time. After that call I immediately scheduled a new appointment with another neurologist that isn’t until the 22nd. Neurologist refused to approve a for a prescription for my Keppra until I could see the new neurologist. Which resulted in me running out of medication and hoping the emergency room can provide a temporary script until I can see the new neurologist next month. Being placed into a life threatening situation from the lack of ethics from this particular clinic is unreal.
Joint and several liability was removed in Pennsylvania at the request of the Pennsylvania Medical Society in conjunction with the Hospital association of Pennsylvania. Now the deep pockets don’t have any more than the percentage of liability and deep pockets mean nothing, only percentage liability.
I called the neurologist my disabled adult son sees for seizures. I asked if they take Humana Medicare Advantage and they said yes. They also said his primary doctor needed to do a referral. His primary doctor did the referral. The neurologist office gave my son an appointment. They called his primary doctor back and said they don’t accept Medicaid. She explained that his health insurance was Humana Medicare Advantage. He only gets waiver services through Medicaid. The office manager said they would not see him even though they accept Humana Medicare Advantage because he receives waiver services through Medicaid. I don’t understand why that should matter to them. Is this unusual behavior for a doctor’s office?It seems discrimanatory behavior to me.
This is not discrimination on the part of the neurologists office. It is ignorance. And the staff is too lazy to call Humana and ask for clarification
I have been seeing a psychiatrist for five years for complex trauma. Her husband, a psychologist, acting in an administrative capacity sent a letter abruptly terminating my care. I had contact with my doctor 3-4x/wk for most of the five years whether it be in session, email, or a quick phone check. The reason for the termination was a misinterpretation of an email that he felt implied I was making a threat of legal action. I wasn’t. In fact, in an email a month prior, I explained my intent ie looking for a third party review (anonymous) of a medical prescribing issue that arose three years earlier which he could not be neutral in evaluating nor, as a non medical provider (not my doctor at any time), was not qualified to evaluate. Despite the ongoing disagreement about the one issue, the relationship I had with my doctor was good.
So, on Christmas morning, 12 hours after I arrived on vacation across the country, I received a letter from my doctor’s husband terminating all care effective immediately and that I would not be allowed any communication with my doctor whatsoever. He noted that there was no one in out town that was qualified for my care and the two recommendations for care he made would require I quit my job and move either to another city for one, or out of state for another. He made it clear no further care would be provided to me.
I paid cash for services at the rate of $225/45 minutes. My doctor allowed me to write/journal to her daily for five years. I waited over forty years to finally disclose my trauma history. I trusted her. I have multiple emails from her explicitly stating she would not abandon me. I counted on that.
I stayed in the community where the office was after graduation just to continue treatment at great financial cost.
I can really use some help right now because I can’t get through the wall he’s created. I have not been able to keep up at work. I’ve taken days off. I can’t sleep. I can’t breathe. Nothing about this situation is right.
And to clarify, I have no history of violence nor was there ever a threat of violence ever made. The only perceived threat was one of legal action and I swear that was not the intent at all. I wanted to continue working with my doctor. We had a special relationship. She came to my graduation. She bought me a bracelet as a gift for graduation that I wear every single day for three years now. I wouldn’t do anything to risk that. I wouldn’t do anything to cause harm.
Please help. If you can’t help, please direct me to someone who can.
Thank you
My kidney doctor refuse to put me on the list for a kidney transplant. Simply because I had stated to him in stead of having tubes coming out of my arms I would like to get on the list for a transplant he said that it might take a year for that I told him that I can wait he refused to place me on the list what rights do I have it really bothered me I told him that I’m going through a stressful moment with my wife and he refused to continue to see me because I asked him to place me on the list for a transplant . I don’t drink or see mike neither do any drugs only the meds prescribed