Terminating the Therapeutic Relationship

Issues of Concern

Ethical Duties Relevant to Termination of the Therapeutic Relationship

Clinicians' ethical duties include the obligation to act in the best interest of patients; they have the imperative to foster public trust in the medical profession by upholding the highest standards of professional conduct. Healthcare professionals should strive to resolve clinician-patient conflicts with compassion and professionalism.[5] According to guidelines from the American College of Obstetricians and Gynecologists, attempts at conflict resolution should include an exploration of the reasons underlying the clinician-patient conflict and should set reasonable and clear expectations for the continued relationship. When conflict resolution efforts fail, clinicians should consider formal mediation by an ombudsperson, professional mediator, or hospital ethics committee. In intractable conflicts, when a clinician's safety, the safety of medical staff, or the clinician's professional judgment would be jeopardized by continuing to treat the patient, the clinician must end the therapeutic relationship respectfully and ensure continuity of patient care.[5] American Medical Association guidelines add that when considering ending a therapeutic relationship, a clinician should provide sufficient advance notice to the patient to allow the patient to find another clinician and facilitate the patient’s smooth transition of care if appropriate.[1] 

Reasons for Termination

Ethical guidelines provide limited examples of situations in which a clinician may rightfully dismiss a patient, such as when a patient engages in disruptive, violent, or threatening behavior or a clinician is retiring or closing a medical practice.[5] Empirical reasons for termination of care may differ from those in established ethical guidelines. A recent retrospective study of primary care practices analyzed 536 cases of formal termination; the results found that causes for termination included repetitive appointment “no-shows” (38%), disrespectful or disruptive behavior (22%), so-called “self-termination” (15%), violating an opioid contract with the clinician (4%), nonadherence with treatment plans (3%), and illegal behavior such as changing a written prescription or forging a clinician’s signature on a letter (2%).[6] The study results also reported that among patients who terminated and re-established care within the same health network, only 25% managed to secure a primary care visit within 6 months of termination, leading to concerns about potential discontinuities of care attributable to termination.[6] Race, age, and employment status all emerged as independent, statistically significant predictors of termination, suggesting that discrimination may frequently underlie termination decisions. The odds of being terminated were 1.77 times greater for Black patients than for white patients (P < .001), while Asian/Pacific Islander patients were 0.46 times less likely to be terminated than Caucasians (P < .001).[6]

Patient Abandonment

Legal duties to provide adequate notice and an opportunity to locate another clinician

While ethical guidelines broadly enjoin clinicians to resolve practitioner-patient conflicts with empathy and emphasize the importance of delaying or avoiding termination of the therapeutic relationship whenever possible, legal obligations toward patients are narrower. A negligence claim of patient abandonment is the most likely cause of action in cases where the underlying allegation is premature or unjust termination of the clinician-patient relationship. Some states have codified the tort of abandonment as an element of statutory law. Other states recognize this cause of action as a separate common-law tort or as a specific form of medical malpractice. Regardless of whether a negligence claim of abandonment arises under statutory or common law, states are broadly consistent in their approach to such cases.

The plaintiff in an abandonment claim must establish that the clinician unilaterally terminated the therapeutic relationship, that the clinician failed to provide reasonable notice to the patient before termination, or that the clinician failed to provide the patient with an adequate alternative clinician, and that the alleged abandonment occurred at a time when the patient required continued medical attention. In a negligence case based on allegations of patient abandonment, the plaintiff must prove that the clinician breached a duty to the patient by improperly terminating the therapeutic relationship and that the termination caused some injury or harm to the patient.[7] Although most legal cases involving abandonment will take the form of negligence claims, a patient could theoretically bring an abandonment case as a breach of contract claim, arguing that by improperly terminating the therapeutic relationship, the clinician violated the express or implied terms of the contractual agreement between patient and clinician.[7] 

Clinicians should understand that they need not expressly intend to terminate the therapeutic relationship to be held liable for patient abandonment. For example, inadvertent abandonment may occur if a healthcare professional fails to notify a patient or arrange emergency coverage during a prolonged vacation.[1] In contrast, a patient’s bothersome or antagonistic behavior does not result in inadvertent or implied termination of the therapeutic relationship. For example, patients who sue their clinician do not thereby implicitly terminate the therapeutic relationship. Although a clinician may understandably want to terminate the care of a patient who brings a medical malpractice claim, doing so might expose such a clinician to liability for abandonment.[8]

In Biby v Halstead Hospital, the United States District Court for the District of Kansas explicitly rejected the proposition that bringing suit against one’s clinician "absolves him or her of responsibility to give that patient due notice of withdrawal and ample opportunity to secure other medical care." Similarly, a clinician might feel tempted to terminate a patient who engages in excessive online health research, especially if such research fuels deep-seated health worries that give rise to unrestrained phone calls and emails to the office, criticism of clinician recommendations, or poor adherence to treatment plans. Results from a cross-sectional study of 2532 clinicians in Germany revealed that 20% of those surveyed had terminated at least 1 patient due to “uncontrolled online information behavior.”[9] Under these circumstances, termination without proper notice and opportunity to obtain replacement care could invite a malpractice suit.

Ethical guidelines offer equivocal advice on what clinicians should do when patients are unable or unwilling to pay for medical services. The American College of Obstetricians and Gynecologists opines that although clinicians “may ethically discharge patients for financial reasons,” they should also remain “mindful of their responsibility to mitigate health inequities for patients from under-resourced communities.”[5] Many clinicians may believe that failure to pay for medical services permits them to dismiss a patient so long as they provide reasonable notice and an opportunity to find another clinician. However, certain situations may require clinicians to extend treatment even without payment to avoid liability for abandonment.

For example, the Supreme Court of New Jersey held in Marshall v Klebanov that a psychiatrist whose depressed patient completed suicide 3 weeks after he allegedly refused to see her due to her inability to pay for services could be held liable for patient abandonment. The court opined that when there is a “foreseeable risk” of self-injury due to a patient's mental health condition, a psychiatrist who knew or should have known about this risk may be liable for abandonment if termination of the therapeutic relationship prevents the psychiatrist from taking appropriate suicide precautions. The court’s conclusion is consistent with other abandonment cases, which collectively affirm the responsibility to continue caring for patients who are in a critical stage of illness, regardless of ability to pay.

Clinical Significance

To avoid liability for patient abandonment, practitioners must give patients adequate notice and a reasonable opportunity to locate replacement medical care before termination. In emergencies or when a patient is critically ill, a clinician is required to delay the termination of the therapeutic relationship until the patient becomes medically stable.[10] In medical emergencies, the federal Emergency Medical Treatment and Active Labor Act (EMTALA), also known as the “anti-dumping law,” prevents emergency departments from involuntarily transferring patients to a different hospital due to their inability to pay for services.[11] A full discussion of EMTALA is outside the scope of this general discussion on the termination of the therapeutic relationship. However, emergency department clinicians should be aware that this federal statute governs their ability to terminate therapeutic relationships in the emergency context. The remainder of this learning activity will set forth best practices for a smoother termination process, including alternatives to termination, notification procedures, and when to involve additional parties, such as insurers. 

Attempt conflict management techniques before termination

Labeling certain patients as “difficult” may hamper a clinician's ability to hear their sincere concerns about their medical care. Patients’ frustration with healthcare experiences often stems from their perception that clinicians do not care enough or are too busy to listen. Inviting patients to voice strongly felt emotions and listening actively to these expressions without judgment or defensiveness may go a long way toward defusing the situation and repairing strained clinician-patient relationships. Clinicians should be mindful of their own challenging emotions that may arise when dealing with certain patients. Paying attention to and exploring these emotions can help clinicians identify their cognitive distortions and prevent negative emotions from interfering with empathetic patient care. When a clinician-patient disagreement has escalated to outright conflict, a clinician’s sincere apology for any perceived rudeness may help to defuse the situation. Any apology should be limited to how the clinician handled the conversation with the patient so that it is not misconstrued to encompass any perceived medical error.[2] In the interest of accurate and complete record-keeping, clinicians should briefly document clinician-patient conflicts in their clinical notes, including the apology. This will create a written record of the interaction that is available to refresh the clinician’s recollection in advance of future encounters.

If a clinician’s conflict-resolution efforts are unavailing, additional conflict-resolution efforts via third-party mediation or a formal ethics consultation may be worthwhile. Despite best efforts to employ sequential conflict resolution strategies, certain clinician-patient conflicts may be intractable. In such cases, clinicians can minimize liability risk by following standard notification procedures and affording patients sufficient time to obtain follow-up care commensurate with the care received from the terminating provider.

Utilize standardized notification procedures

Judicial opinions on patient abandonment stress the importance of providing reasonable notice in advance of termination. How much notice is considered reasonable to avoid liability? Clinicians should consult state statutes, state departments of health, or state medical boards for specific regulations on how many days are required between a patient receiving a termination notice and cessation of medical services. Often, 30 days is considered a reasonable amount of time. However, the amount of time that is reasonable may be longer in rural locations where replacement care may be more difficult to obtain. Clinicians should always provide notices of termination of care in writing. Many states require that such notices be sent via certified mail, return receipt requested, to the patient’s most recent address on file. Clinicians should maintain the certified mail return receipt and a copy of the termination notice in the patient’s medical record.[12] At least 1 state now endorses using Health Insurance Portability and Accountability Act-compliant electronic messages sent via patient portals that notify the sending practitioner regarding whether the message has been viewed. This may become the preferred notification method, but certified mail is currently the preferred means of sending termination notices. Clinicians may wonder what they should do if a patient fails to sign the certified letter’s return receipt and then subsequently contacts the clinician or appears in person at the Healthcare professional's clinic after the amount of time specified in the letter has elapsed. In this situation, the patient should be given a copy of the letter or informed via phone that a letter was mailed and should politely be told that care was terminated as of the date in the letter.[12]

Termination letters should contain the following elements:

1. The letter must state the date on which the clinician-patient relationship will end.
2. The letter should state that the clinician will remain available to provide medical care and medication refills until that time.
3. The letter should note emergency resources such as local crisis centers.
4. The clinician must offer to make the patient’s medical records available to a new clinician as soon as the patient authorizes the release and include a release of information form.[13] 
5. Although clinicians are not usually legally obligated to offer any reason for the termination, they may choose to do so if they feel it is appropriate under the circumstances.[1] Authors disagree about providing a general statement that the clinician-patient relationship would no longer be therapeutically beneficial or a specific statement explaining the clinician's reasons for termination.[7][14]
6. The letter should emphasize the importance of obtaining continuing medical care. Authors disagree on whether it is advisable to suggest specific names of colleagues for follow-up care.[12][15] However, some state medical boards may require that a clinician include the names of other potential healthcare professionals or the contact information for a referral service associated with a local medical society. Consider directing the patient to their healthcare insurer for resources, including finding a new clinician who accepts their insurance.

If the patient has terminated the practitioner-patient relationship, the physician is not required to send a termination notice. However, physicians would be wise to send a letter confirming the patient’s choice in writing to avoid ambiguity and reduce the risk of legal liability. Clinicians terminating patient relationships due to the closure or relocation of a medical practice are not immune to lawsuits for abandonment. They are required to give patients reasonable notice that medical services will no longer be available from the practice and time to find another clinician. Some states require clinicians closing a practice to publish an advertisement to that effect in a local newspaper. Clinicians should always verify state requirements for closing or relocating a practice and ensure compliance.

Involve appropriate third parties

Clinicians may be able to manage the termination process on their own, but it may be necessary or desirable to seek assistance from third parties in certain situations. For example, if a clinician seeks to terminate care because a patient has engaged in violence, threats of violence, or other illegal activity, it is important to contact local law enforcement for purposes of documenting the events leading to termination and to reduce the risk that the patient’s violent or illegal behavior harms others.[12] In addition, if the patient is in a managed care organization in which the clinician participates, the clinician should first contact the insurer to determine whether the insurer has placed any restrictions on termination options. For example, contracts between clinicians and third-party payers often include verbiage restricting clinicians’ ability to refer patients to those who do not participate in that managed care network. Some insurers require that a 30-day notice be sent to the insurer, in addition to the patient, in advance of termination.[12] If the patient is insured by Medicare or Medicaid, the clinician should be aware that government payers often have stricter policies than private insurers concerning termination of care, especially if it involves being disenrolled from a government health coverage plan.[12] 

Review consequences for abandonment

Before making a final decision to terminate a patient, clinicians should consider proactively retaining legal counsel for assistance in drafting a termination letter that complies with all relevant state laws and regulations regarding termination. Clinicians should be aware that in addition to legal risks, including civil damages, a hasty or poorly executed termination, if reported, could lead to consequences such as disciplinary action by state licensing boards.

Enhancing Healthcare Team Outcomes

In addition to consultation to obtain ethical and legal guidance before termination, it is also essential for healthcare team members to maintain a consistent approach when termination of the therapeutic relationship becomes a likelihood. Consistent messaging takes on heightened importance when there is a rift in the therapeutic relationship. Once a final decision has been made to terminate the therapeutic relationship, all healthcare team members should be notified of the date on which the termination is effective and of their continued responsibilities toward the patient before this date. Clinicians should encourage office staff to work with the patient to facilitate the release of the patient's medical records; they should remind staff that discussing the reasons for termination with the patient can lead to confusion. Clinicians, social workers, nurses, medical assistants, and other healthcare team members should collaborate to streamline the termination process and ensure that all legal and ethical responsibilities toward the patient are fulfilled. 

Ensuring that the events leading up to the termination of the therapeutic relationship do not result in emotional or physical harm to members of the healthcare team is essential. In cases where patients have behaved inappropriately toward team members, formal debriefing may be necessary. If violence or threats of violence have occurred, clinicians should report this to local law enforcement agencies, do everything possible to maintain a safe environment and ensure that affected healthcare team members have access to counseling services to prevent and address any adverse mental health consequences of such events. 

A smooth termination process requires collaboration among the members of the healthcare team. Clinicians should emphasize open communication between team members to address any questions or concerns about their responsibilities toward a patient who has terminated care. During the termination process, team members should encourage one another to maintain professionalism and continue to treat patients and each other with compassion, respect, and attentiveness to the safety of patients and staff.