1. Terminating a patient relationship When is it appropriate? According to the AMA's Code of Medical Ethics, Opinion 8.115, physicians have the option of terminating the patient-physician relationship, but they must give sufficient notice of withdrawal to allow another physician to be secured. Failure to follow the appropriate steps may lead to a claim of patient abandonment. Situations when termination is appropriate:  Treatment noncompliance  Follow-up noncompliance  Verbally abusive or disruptive behavior  Consistent dissatisfaction with the care provided  Non-payment of bills – repeated, with no attempt to set up a payment plan

2. Terminating a patient relationship When to think twice:  When the patient is in an acute phase of treatment, e.g.,  undergoing a diagnostic workup for a medical condition  immediate post-op phase  If the physician is the only provider or specialist within a reasonable driving distance, care may need to be continued until other arrangements can be made  The patient is in a protected class or has a disability. Termination is permitted, but careful documentation is needed to avoid claims of discrimination or violations of the ADA  Pregnant patients can be safely terminated during the first trimester of an uncomplicated pregnancy. Transfer of care to another provider is preferable

3. Terminating a patient relationship How to do it: The physician should inform the patient about the decision to discharge them from treatment. Begin with verbal communication - follow with written communication. A letter should be sent to the patient by certified mail and regular mail:  Briefly outline the reason for the termination; e.g., “Given (insert facts), I believe that you would be best served by establishing a relationship with another provider.”  Clearly communicate the end date of treatment, usually 30 working days from the date of the letter. Advise patients that they will be seen for any acute problems during this time frame  Provide clear instructions about how to handle medical emergencies after the 30 day period, e.g., “Any medical emergencies should be handled in a hospital ED.”

4. Terminating a patient relationship How to do it (cont’d):  Indicate that copies of medical records will be given to any subsequent providers – Enclose an authorization document with the letter  Provide suggestions for continued care through local referral services such as medical societies or insurers – Do not provide the name of a particular provider  Highlight any particular issues that need close follow-up and advise of any potential consequences of failure to do so  Review prescriptions and provide any necessary refills  Notify the patient’s other physicians that the patient is being transferred out of your care  Comply with requirements of third party payers for termination  Don’t forget to keep your office staff, particularly the scheduler, in the loop