Sometimes it may be appropriate to stop being someone’s doctor. When you decide to end the relationship with your patient, it is often perceived in a negative way by the patient. If you have any doubt on whether the reason to terminate the relationship is justifiable, seek advice and guidance from your professional indemnity insurer.

Thus, withdrawing care for a patient should be done in an ethical way. Consider the following request that was submitted by a doctor asking for advice:

I have this patient, with a chronic condition, and has been non-compliant with my prescribed treatment, he has missed a few scheduled appointments. I am afraid that his consistent non-compliance is putting me at a medicolegal risk. I do not want to see this patient anymore. Please advise: Can I terminate my relationship with this patient? If so, how do I go about doing it?

This request highlights the complex nature of a doctor-patient relationship where there is a need to strike a balance between patient autonomy and treatment requirements.  

The doctor-patient relationship is one of the core elements in the ethical principles of medicine.

When a patient consults a doctor, a contractual relationship begins. This contract takes the form of an implied agreement that the doctor owes the patient a duty of care. The doctor is required to provide a certain standard of skill and care to the patient equal to a standard of a reasonable doctor. The duty of care comprises several elements such as, consulting, diagnosing, treating, instructing and referral of the patient if or when indicated.  

An expectation is that a doctor-patient relationship will continue until the patient is cured, requires no further treatment, the patient is referred to another doctor or death of the patient. However, there may be occasions where the doctor would like to terminate the doctor-patient relationship.

A decision to terminate a relationship with the patient is always difficult for the doctor and must always be justifiable such as:

• When there is an irretrievable trust breakdown, this could be in a situation where the patient has taken legal action against the doctor
• When the patient is rude and/or abusive to the doctor or the practice employees
• When the patient coerces the doctor into providing unlawful treatment or the patient engages in unlawful or criminal act such as forging the doctor’s prescription
• When the patient is violent or threatening violence to the doctor or the practice employees
•     When the patient sexually harasses the doctor or the practice employees
• When the doctor has a conscientious objection – like, refusing to perform termination of pregnancy based on your constitutional right to conscience, religion, thought and opinion
• When the doctor is closing or relocating the practice
• When the patient refuses or does not comply to prescribed treatment

Non-compliance to prescribed treatment, as in the request above, is indeed a legally valid basis to terminate a doctor-patient relationship. However, this shouldn’t be taken lightly and should be a measure of last resort.

• When terminating the relationship, the patient must be handed over to another competent practitioner or hospital. Failure to do so can be deemed as patient abandonment
• Even after termination, the doctor still has an obligation to treat the patient in an emergency, as prescribed by Section 27(3) of The Constitution and Section 5 of the National Health Act.  

It is important to inform the patient of the decision to terminate and the reasons for termination which must be clear, so the patient no longer has any expectations of ongoing care.

The doctor is obliged to record the decision to terminate the relationship in the patient medical record and hand the patient a letter confirming the doctor’s decision. Information recorded in the patient’s records relating to the decision must be factual and objective, and should not include anything that could unfairly prejudice the patient’s future treatment

Naturally, the referring doctor must facilitate the handover of care promptly and forward relevant clinical information to the receiving practitioner or hospital without delay. The referral letter should be clinical, relevant and objective.

Steps to follow

1. Seek advice and guidance from your professional indemnity insurer
2. Inform the patient of your decision and reasons for termination and where possible give the patient a termination letter.
3. Record your decision to end the relationship in the patient records
4. Refer the patient to another doctor
5. Inform your practice staff that the relationship has been terminated
6. If the decision to terminate is based on any violence or unlawful conduct on the part of the patient, consider reporting this to the relevant authorities.

Key take-outs

• As with any relationship, things are not always straightforward and there is no easy way to call an end.
• You must be prepared to explain and justify your decision and actions, carefully consider the reasoning and possible consequences in deciding to part ways.
• A proper termination letter to the patient and a referral letter to another practitioner who has indicated a willingness to take over the management of the patient is advisable. That way, if the patient absconds or does not pick up with the new practitioner, you cannot be faulted especially since patient abandonment may attract sanction from the HPCSA.
• As always, when in doubt seek advice from us.

Any guidance is intended as general guidance and does not constitute legal or medical advice. Practice proper clinical decision making regarding individual circumstances and exercise your own independent skill or judgment. If you need specific advice relating to your own circumstances, please contact one of our advisers. Information is current at the date published.