A general practitioner member recently contacted MIGA for advice in relation to their attempts to end a long-standing therapeutic relationship with a patient. The patient was refusing to follow our member’s recommendation that they see another general practitioner. Our member was particularly concerned by the patient’s allegation that he was duty bound to continue to see the patient so that the patient was not denied their right to access health care.
The Claims and Legal Services team at MIGA receives many queries from members in relation to this area, mainly in situations where there has been a breakdown in the relationship between a medical practitioner and a patient.
In this case, we advised our member that, as a general rule, there is no legal obligation on a doctor to consult a patient unless in the context of a patient requiring emergency medical treatment (which creates an ethical rather than legal obligation). Therefore, we were of the view that he was not restricting the patient’s right to access health care by choosing to end the therapeutic relationship. However, we further advised that a doctor cannot refuse to consult a patient based on unlawful discrimination (for example, refusing to treat a patient based on reasons of sex, race, marital status, religion or disability).
There are a number of reasons why a doctor may choose to end the doctor/patient relationship, including a loss of mutual trust, a patient becoming violent or aggressive, boundary violations, repeated failure by the patient to attend appointments or non-compliance with treatment recommendations. In many situations, doctors have tried various strategies and have ultimately reached the conclusion that it is no longer practicable to continue the therapeutic relationship.
The Medical Board’s Good Medical Practice: A Code of Conduct for Doctors in Australia specifically discusses the obligations a doctor has to a patient when ending a professional relationship. Section 3.13 states:
In some circumstances, the relationship between a doctor and patient may become ineffective or compromised, and you may need to end it. Good medical practice involves ensuring that the patient is adequately informed of your decision and facilitating arrangements for the continuing care of the patient, including passing on relevant clinical information.
We recommend a number of steps be followed in the event that a doctor decides to end the therapeutic relationship with a patient, including:
- Good communication is vital. Do not assume that a patient will pick up on hints or suggestions to see another practitioner. Be clear in communicating that you need to end the doctor/patient relationship.
- Document any patient non-compliance. Do not expect to be able to defend the termination of the relationship based on memory. All events of non-compliance should be recorded at the time the doctor becomes aware of the non-compliance.
- Do not delegate to staff. This is not a time to delegate to staff the message of ending a doctor/patient relationship. The best way to ensure that the termination process is done correctly is for the doctor to do it directly.
- Write a letter to the patient. Inform the patient of the decision to end the relationship but do so in a non-accusatory manner, using language that reflects concern about the patient’s wellbeing.
- Be careful about referral. As a general rule, it is best to refer the patient to an appropriate medical college, professional association or the Yellow Pages for a list of practising doctors.
- Consider informing other parties. In some situations, it may be appropriate for a doctor to inform other parties (such as the patient’s referring doctor or specialist) that they are no longer involved in the patient’s ongoing care and treatment. The doctor should also inform their own practice partners, practice manager and support staff of the decision to end the relationship.
The letter to the patient should be short and courteous and include the following details as a minimum:
- The reason(s) for ending the relationship
- The effective date of termination
- Suggestions for continued care through local medical groups, nearby hospitals or community resources
- An offer to transfer a copy of the patient’s medical record by enclosing an authorisation document with the letter to be returned to the practice with the patient’s signature. It may be appropriate to do so at no cost, if a fee is normally incurred
- A reminder to the patient about what follow up or ongoing medical care is required and say that this is now the patient’s responsibility and that both should be pursued.
The doctor should document that a letter has been sent to the patient and keep a copy of the letter in the patient’s file.
The Claims and Legal Services team at MIGA is always here to assist you and we encourage you to contact us for advice if you have any queries in relation to this area.