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When a physician–patient relationship must be terminated, the physician must
carefully document the circumstances in the patient’s medical record. This
termination note should review the patient’s previous medical treatment and the
current state of the patient’s health. If the termination will not affect the patient’s
health, this should be stated and explained. If the patient is in need of continuing
care, the note must explain how the physician has ensured that the termination will
not compromise the patient’s health. For patients in need of continuing care, there
must be documentation of the arrangements made for the patient’s subsequent care.
If no arrangements have been made, there needs to be a detailed discussion of why
the relationship is being terminated and why it was not possible to make follow-up
arrangements.
There are several acceptable reasons for terminating the relationship with a patient
who is still in need of medical care for an acute problem. One is that the patient has
refused to follow the physician’s advice to the extent that it becomes impossible to
care for the patient in a professional manner. [Payton v. Weaver, 131 Cal. App. 3d
38, 182 Cal. Rptr. 225 (Cal. App. 1 Dist. 1982).] For example, a severely
hypertensive patient may refuse to take medication. Assuming this refusal is not
based on a reasonable concern with the side effects of the medicine, the physician is
not bound to try to continue treating a patient who refuses what the physician
believes to be essential therapy. The case of Bouvia v. Superior Ct., [Bouvia v.
Superior Ct., 179 Cal. App. 3d 1127, 225 Cal. Rptr. 297 (Cal. App. 2 Dist. 1986).] in
which a person with cerebral palsy sought the legal right to force a hospital to starve
her to death, is an extreme example of this problem.
Physicians may also terminate the physician– patient relationship when changing
circumstances in a physician’s practice may make it difficult to care for a patient in a
professional manner. The physician may be changing the nature of the practice (such
as working part time), moving to a different geographic area, or joining a corporate
practice that will make it difficult to continue treating former patients.
H. Documenting the Termination
When the relationship between a physician and patient is terminated, the exact
circumstances of the termination must be documented. The patient’s condition should
be summarized in the same manner as a discharge note in a hospital record. For each
ongoing medical problem that is identified, there should be evidence that the patient
was notified of the problem and the need for further care. If the physician knows who
the patient is transferring to, this should be recorded in the termination note.
A physician who terminates the physician–patient relationship must document that the
patient was properly notified. The physician should write a termination note in the
patient’s chart documenting that the patient was contacted and told of the physician’s
decision, its medical implications, and where to obtain further care, if needed. This
information should also be put in a letter to the patient. If possible, the patient should
sign a copy of this letter during a visit with the physician. The physician should give
the patient the original letter, keeping the signed copy for the files. If this is not
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