Vol 9 No 2
April 1998

by Susan Moebius Henderson
Assistant Attorney General for the Board

Once a physician undertakes treatment of a patient, he or she has a continuing legal duty to treat that patient until the need for his or her services is at an end or until the physician-patient relationship is terminated lawfully. Physicians who improperly terminate a physician-patient relationship risk both civil lawsuits and charges of unprofessional conduct for patient abandonment.

A physician must exercise reasonable and ordinary care in determining when the physician’s services are no longer needed. Generally speaking, a physician must continue to provide services as long as the case requires it.

Unlike a patient, who may lawfully terminate the physician-patient relationship at any time, a physician may withdraw before the need for his or her services is at an end only after giving the patient prior notice. That notice must afford the patient ample opportunity to secure another equally competent physician prior to the withdrawal.

A patient who sues a physician for abandonment must prove that the abandonment caused the injury for which damages are being sought. For example, a physician incurred no liability for refusing to treat a patient some 16 days following initial treatment for a severely cut finger. After the finger became infected and was amputated, the patient sued the physician for abandonment. The court exonerated the physician because the refusal to treat occurred after the critical, initial period when immediate treatment necessary to save the finger was provided.

Abandonment has been justified in certain limited circumstances, such as where the patient has failed to cooperate in his or her treatment (e.g., failing to keep or reschedule appointments). One court held that a nephrologist had no legal obligation to continue dialysis treatment for an uncooperative patient where the patient was given sufficient notice that his treatment was being terminated and was provided with a list of other dialysis providers in the area.

Rural providers whose patients may have difficulty locating an equally competent replacement should be especially cautious when “firing” a patient. At least one rural physician has been forced to defend himself against potential violations of anti-trust law by denying healthcare services to a patient in an underserved area.

Courts traditionally have held that a patient’s failure to pay for services will not justify abandonment if the patient still is in need of medical treatment. For example, one physician was held liable for refusing to continue the treatment of a patient being prepared for emergency hand surgery until after the patient satisfied his outstanding account balance.

In a more recent case from Iowa, a physician was found not to have abandoned his patient by refusing to treat abscesses occurring subsequent to a gastric bypass. The surgeon’s bookkeeper “fired” the patient for her failure to pay the bill for her surgery and follow up visits. The Iowa court found that the surgeon, who had seen the patient 11 times post-operatively and had previously advised her on treatment of the abscesses, was not liable because he did not abandon the patient during a critical stage of treatment.

From these cases, it appears that where a physician has successfully treated a patient’s illness and has not been paid, he or she arguably may condition renewal of the physician-patient relationship on receipt of payment if the patient presents with a different illness that does not require immediate treatment.

Terminating a physician-patient relationship can be complicated further if the patient has a disability protected by the Americans with Disabilities Act (ADA) or the Federal Rehabilitation Act of 1973. The ADA prohibits places of public accommodation, such as physician offices, from discriminating against disabled individuals in the provision of goods and services.

In a recent case, a deaf patient successfully sued his physician for discrimination under the ADA after being discharged as a patient. The discharge occurred because the physician lost the only employee in his office who could communicate with the patient in sign language. The court held that instead of firing the patient, the physician should have made a reasonable effort to accommodate him by furnishing him written materials or using other methods to facilitate communication.

Before “firing” a patient, a physician should weigh carefully the potential risk for malpractice or discrimination lawsuits against the perceived benefits of firing a particular patient. If a decision is made to proceed, the physician should take the least amount of affirmative action possible to sever the relationship in order to avoid needlessly incurring the patient’s ill will.

For example, one surgeon effectively terminated the physician-patient relationship while the patient was hospitalized awaiting a surgical procedure. After the patient refused to sign the proffered surgical consent form, the surgeon supplied the patient with a list of appropriate replacement surgeons. The court held that furnishing the list of substitute surgeons was a reasonable means of severing the physician-patient relationship where the patient’s condition did not warrant immediate medical attention.

The following are some practical tips to consider when”firing” a patient:

• When the patient calls to schedule his or her next routine appointment, determine if the patient is in need of immediate care and if the physician is presently involved in treating the patient for an ongoing illness. If these questions are answered in the negative, politely advise the patient that the physician no longer wishes to continue the relationship. Provide the patient with the telephone number of a referral service so that the patient may locate another appropriate physician. Document this conversation in the patient’s file.
• Use caution in sending written letters to terminate the physician-patient relationship. Ignore the natural urge to defend your decision or to provide too much information that might generate feelings of rancor in a patient. Letters may be useful to document unacceptable patient behavior, however, especially where warnings are given about the physician’s intention to terminate the relationship if the unacceptable behavior continues. Be sure to include in the letter a referral to another competent physician or appropriate referral service.
• Do not volunteer reasons for the physician’s decision to sever the relationship. If asked, explain the circumstances without making accusations against the patient. Possible examples to consider are:
• “To reduce the doctor’s heavy case load, he had to make some difficult decisions about which patients he could continue to see.”
• “The doctor felt that you did not cooperate fully with her treatment during your prior illness and that you should see another physician.”
• “The doctor has decided that he cannot keep you as a patient because of your unwillingness to pay promptly for his services.”

Always remember that an ounce of prevention is worth a pound of cure. Before ending a troublesome physician-patient relationship, consider all possible adverse consequences and then take prudent steps to diffuse potential future complaints by handling the situation with common sense and diplomacy.