Ending the Physician-Patient Relationship

Approved by Council: February 2000
Reviewed and Updated: June 2008, May 2017

Companion Resource: Advice to the Profession

Other Reference: "Ending the Physician-Patient Relationship," Dialogue, Issue 2, 2017

Policy

1. Physicians must comply with the expectations set out in this policy when ending the physician-patient relationship, except when discontinuation is due to the physician’s retirement, relocation, leave of absence, or as a result of disciplinary action by the College.¹
2. Physicians who provide specialist care must comply with the expectations set out in this policy when ending the physician-patient relationship prior to reaching the normal or expected conclusion of the patient’s care. When, in the normal course of providing care, involvement with a patient reaches its natural or expected conclusion (for example, because treatment has concluded), this policy does not apply.
3. Physicians must comply with the expectations set out in this policy except where, in the physician’s judgment, the patient poses a genuine risk of harm to the physician, the physician’s staff, or to other patients. In these circumstances, physicians are under no obligation to engage with the patient prior to ending the relationship.

General expectations

4. Prior to ending the physician-patient relationship, physicians must:
   1. apply good clinical judgment and compassion to determine the most appropriate course of action;
   2. bear in mind that ending the relationship may have significant consequences for the patient (for example, by limiting their access to care); and
   3. undertake reasonable efforts to resolve the situation in the best interest of the patient.

Situations which may lead a physician to end the physician-patient relationship

5. While the following examples include situations in which it may be appropriate to end the physician-patient relationship, physicians must consider each case independently, and in keeping with the expectations of this policy.

Where there has been a significant breakdown in the physician-patient relationship

Examples of situations that may lead to a significant breakdown include:

• prescription-related fraud;
• where a patient frequently misses appointments without appropriate cause or notice;
• as a result of behaviour which significantly disrupts the practice; and
• other forms of inappropriate behaviour, including abusive or threatening language.

6. In these circumstances, physicians must only end the physician-patient relationship after reasonable efforts have been made to resolve the situation in the best interest of the patient, including:
   1. proactively communicating expectations for patient conduct to all patients,²
   2. considering whether a problematic incident or behaviour is an isolated example or part of a larger pattern, and
   3. discussing with the patient the reasons affecting the physician’s ability to provide care.

Where the physician wishes to decrease their practice size

7. When reducing a practice size, physicians must:
   1. exercise professional judgment, consistent with this policy, to select which patients to remove from the practice;
   2. employ a method of selecting patients that is fair, transparent, and compassionate;
   3. take into account the medical needs of each patient; and
   4. consider any other relevant factors, including the patient’s vulnerability, and the patient’s ability to find alternative care in an appropriate timeframe.
8. Physicians must not selectively or disproportionately discharge difficult or complex patients.

Where a patient has been absent from the practice for an extended period of time

9. In these circumstances, physicians must:
   1. Make a good-faith effort to determine whether the patient would prefer to maintain the relationship. In doing so, physicians must, at minimum, send a letter of inquiry to the patient’s last known address. Where no response is received, or the patient indicates that care has been sought elsewhere, physicians may formally remove the patient from the practice.

When a patient has refused to pay an outstanding fee³

10. In circumstances where a patient has refused to pay an outstanding fee, or has accumulated a number of unpaid fees and provided no reasonable justification for nonpayment (such as evidence of financial hardship), physicians must:
    1. consider the financial burden that paying the fee will place on the patient;
    2. if appropriate, consider waiving or allowing for flexibility with respect to fees based on compassionate grounds;⁴,⁵ and
    3. undertake discontinuation in accordance with the general expectations of this policy, including that reasonable efforts be undertaken to resolve the situation in the best interest of the patient.

Where the patient has sought care outside of a rostered practice⁶

11. Where a patient has sought care outside of a rostered practice, physicians are advised to consider the factors that may have led the patient to do so (including the physician’s own availability).
12. When considering ending the physician-patient relationship, physicians mustfirst:
    1. provide the patient with clear information about their obligations within the rostered practice,
    2. provide the patient with an appropriate warning, and
    3. undertake reasonable efforts to resolve the situation in the best interest of the patient.
13. Physicians must only end the physician-patient relationship after these efforts have been undertaken, and after the patient has continued to wilfully seek care outside of the practice without appropriate justification.

Circumstances where physicians must not end the physician-patient relationship

14. Physicians must not end the physician patient relationship where doing so is prohibited by legislation.⁷
15. Physicians must respect patient autonomy with respect to lifestyle, healthcare goals, and treatment decisions,⁸and not end the physician-patient relationship solely because the patient:
    1. does not follow advice (for example, with respect to smoking cessation, drug or alcohol use, or the patient’s decision to refrain from being vaccinated or vaccinating his/her children);
    2. suffers from an addiction or dependence, or is on a high dose of a prescribed controlled drug and/or substance⁹; or
    3. seeks treatment to which the physician objects on the basis of conscience or religious beliefs.¹⁰

Expectations when ending the physician-patient relationship

Notifying the patient

16. Physicians must notify the patient of the decision to end the physician-patient relationship.
    1. Physicians are advised to notify each patient in person, whenever it is safe and possible to do so.¹¹
    2. In all cases, physicians must provide every patient with written notification that the relationship has been discontinued (see the accompanying Advice Document for a sample letter). Physicians must retain a copy of the notification and any confirmation of receipt in the patient’s medical record. Physicians must use a secure method to transmit the written notification, and ensure patient confidentiality.¹²
17. Physicians are advised to inform patients of the reasons why the relationship is being discontinued, unless there is a genuine risk of harm associated with communicating those reasons to the patient.

Providing interim care

18. Physicians must ensure the provision of necessary medical services while the patient seeks a new physician.¹³ This may include, for example, renewing prescriptions, where medically appropriate and for a reasonable length of time, and ensuring appropriate follow-up on all laboratory and test results ordered.¹⁴ 
19. Physicians must be as helpful¹⁵ as possible to the patient in finding a new physician or other primary care provider, and provide them with a reasonable¹⁶ amount of time for doing so.¹⁷  The College does not require physicians to continue to provide care indefinitely, but physicians must provide care in an emergency, where it is necessary to prevent imminent harm.
20. Physicians must seek to accommodate patients with special needs or disabilities that may make seeking new care challenging.

Additional requirements

21. When ending the physician-patient relationship, physicians must:
    1. document in the patient’s medical record the reasons for the discontinuation and all steps undertaken to resolve the issue(s);
    2. clearly convey to the patient that they should seek ongoing care;
    3. inform the patient that they are entitled to a copy of their medical records, and provide an estimate of any fees associated with providing copies of, and/or transferring, medical records;¹⁸
    4. ensure the timely transfer of a copy or summary of the patient’s medical records upon the patient’s request;¹⁹
    5. notify appropriate staff (e.g., office receptionist) that care is no longer being provided to the patient;²⁰ and
    6. notify the patient’s other health care providers that care is no longer being provided if such notification is necessary for the purposes of the patient’s care, and if the patient has not expressly restricted the physician from providing information to other health care providers.²¹

Endnotes

^1. Expectations for physicians in instances of retirement, relocation, leave of absence, or disciplinary action are included in the CPSO policy Closing a Medical Practice.

^2. For example, physicians can fulfil this expectation by establishing office policies and posting them in a prominent location.

^3. In the course of providing care, physicians may sometimes charge patients for services that are not covered by the Ontario Health Insurance Plan (OHIP). Physicians are entitled to pursue and receive payment for uninsured services.

^4. The Canadian Medical Association Code of Ethics #16 states that “in determining professional fees to patients for non-insured services, consider both the nature of the service provided and the ability of the patient to pay, and be prepared to discuss the fee with the patient”.

^5. For further expectations related to fees for uninsured services please see the College’s policies on Uninsured Services: Billing and Block Fees, Medical Records Management, and Third Party Medical Reports. Physicians are further reminded that, in accordance with the College’s Third Party Medical Reports policy, they are encouraged to refrain from requiring prepayment for uninsured services on compassionate grounds, when the patient or examinee is responsible for payment directly, and the report relates to basic income and health benefits.

^6. Rostered practices impose specific commitments on both family physicians and their patients: physicians commit to provide comprehensive and timely care, and patients commit to seek treatment only from their enrolling physician or group except in specified circumstances. When patients seek care outside of a rostered practice, except in these specific circumstances, there is a risk that the physician’s trust and the patient’s continuity of care may be undermined.

^7. Physicians must ensure that any decision to end the physician-patient relationship is compliant with relevant legislation. This legislation includes The Commitment to the Future of Medicare Act, 2004, which prohibits physicians from ending the physician-patient relationship because the patient chooses not to pay a block or annual fee; the Ontario Human Rights Code, which prohibits ending the physician-patient relationship due to one of the protected grounds set out in the Code; & the professional misconduct regulations under the Medicine Act, 1991.

^8. Health Care Consent Act, 1996.

^9. Controlled Drugs and Substances are defined in the Controlled Drugs and Substances Act, 1996.

^10. The College’s expectations for physicians who limit care due to conscience or religious beliefs can be found in the Human Rights in the Provision of Health Services policy.

^11. In most cases, it is appropriate and useful for the patient to be advised of the reasons why the relationship is being discontinued; however, physicians may use their discretion in situations where there is a genuine risk of harm associated with communicating those reasons to the patient.

^12. Acceptable methods of transmission include, among others: hand delivery to the patient during an appointment, registered mail, and courier.

^13. Discontinuing professional services that are needed may constitute professional misconduct unless alternative services are arranged, or the patient is given a reasonable opportunity to arrange alternative services (O. Reg. 856/93 s.1(1)7).

^14. For further information on appropriate follow-up, refer to the CPSO policy on Managing Tests.

^15. The help that a physician is able to provide will ultimately be case-specific; however, examples include referring the patient to an organization that may be able to assist him/her in finding another healthcare provider, such as a Community Health Centre, local hospital or emergency room, or other organization. Alternatively, physicians may wish to refer the patient to a colleague who may be accepting new patients.

^16. A reasonable amount of time’ may vary from community to community, depending on the availability of alternative healthcare providers.

^17. What is ‘reasonable’ will depend on a variety of factors. These will include the circumstances of each case, including the patient’s specific health-care needs.

^18. In accordance with the College’s Medical Records Management policy, physicians are able to charge a reasonable fee for copying and transferring medical records.

^19. For further information, refer to the CPSO’s Medical Records Management policy.

^20. Such notification must only be provided when the patient has not withheld or withdrawn consent to the collection, use or disclosure of their personal health information by the member of the physician's staff to whom the notification would otherwise be provided.

^21. Under the Personal Health Information Protection Act, 2004, a health care provider may provide personal health information about a patient to another health care provider for the purposes of providing health care or assisting in the provision of health care to the patient. Despite this provision, the Act also gives patients the right to expressly restrict his/her physician from providing another health care provider with his/her personal health information, including whether the physician is providing the patient with services. In cases where a physician is asked by another health care provider for information about a patient that is reasonably necessary for the provision of health care or assisting in the provision of health care to the patient, the physician must notify the other health care provider if they have been restricted from disclosing information about the patient and they may wish to advise the other health care provider to direct any inquiry to the patient him/herself for a response.