Terminating the Doctor-Patient Relationship

Question: Dr. X is a member of a rural group practice with no other doctor or doctor groups in the area. One of his patients has been noncompliant with medical advice and has refused to pay his bills on time. Additionally, there are style differences that have caused their interactions to be confrontational at times. Eventually, the doctor decided he’d had enough and unilaterally terminated the relationship. In a lawsuit that followed based on patient abandonment in this hypothetical, which of the following is incorrect?

A. One may terminate a doctor-patient relationship with patient consent.

B. One may unilaterally terminate a doctor-patient relationship without patient consent.

C. In terminating care, a doctor is required to give notice and forward all relevant records to the new provider.

D. The original doctor is still responsible for all care until the patient finds a new doctor.

E. Given the above fact situation, the entire group practice may terminate the relationship.

Answer: E. A doctor is permitted to terminate the professional relationship with a patient with or without his consent in situations such as irreconcilable disagreements over treatment plans, loss of rapport or trust, or patient refusal to pay the doctor’s bill. However, before terminating care, the doctor is required to give sufficient notice and arrange to transfer all medical records to the new treating doctor. In addition, the original physician must continue to provide ongoing care until the patient has established contact with the new doctor. In other words, it is the affirmative obligation of the physician to ensure that no interim harm comes to the patient.

A not uncommon scenario is where a group practice collectively refuses to treat a patient or group of patients. In Leach v. Drummond Medical Group, the plaintiffs complained to the State licensing board about some members in a group practice, and the entire group then attempted to terminate its professional relationship with those patients. The California appellate court held that whereas one member may decline to treat, the entire group may not exercise the same option, as there were no similar services within a hundred miles.

The American Medical Association’s Code of Medical Ethics (§8.115) emphasizes that physicians "have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured."

Merely making a referral may not be enough. In a dental malpractice case where the patient was simply referred to his family physician after oral surgery was complicated by an infection, an Illinois court held the dentist liable for the postop complications. Furthermore, civil rights laws prohibit discrimination based on race, gender, religion, or ethnic origin in places of public accommodation, which include a doctor’s office. Additionally, the Americans with Disabilities Act (ADA) prohibits discriminating against the disabled. Obviously, care for patients should not be terminated or refused for these reasons.

The tort of abandonment may be intentional or negligent. In the former instance, the deliberateness of the defendant’s action is a key element, and the aggrieved party may not need expert testimony to prevail. Still, in a 2007 Wisconsin case where a surgeon canceled an elective surgery after the patient had sued the employer surgical center, the appeals court overruled the trial court and held that expert testimony was required to prove the plaintiff’s case. However, negligent abandonment, for example, premature discharge of a patient from the hospital or emergency department, is simply a form of medical negligence, which will require expert testimony at trial to set the standard of care.

Rarely, the facts are so outrageous the courts have ruled that the health care providers owed no further duty to provide treatment. The best known case is that of Payton v. Weaver, where a physician and hospital refused to provide dialysis to a patient because of persistent uncooperative and antisocial behavior. In lamenting that "occasionally a case will challenge the ability of the law, and society, to cope effectively and sensitively with fundamental problems of human existence," the court affirmed the trial court’s judgment that the healthcare providers had no legal obligation to continue providing regular dialysis treatment.

The facts of the case are as vivid as they are tragic. Ms. Brenda Payton was a 35-year-old woman with end-stage-renal disease on dialysis. An active user of alcohol, heroin, and barbiturates, she was non-compliant with dialysis and medical therapy. She continued to buy barbiturates from pushers on the street at least twice a week, failed to restrict her diet, sometimes gaining 15 kg between dialysis, and frequently missed dialysis, resulting in 30 hospitalizations in the 11 months before trial. She would come to dialysis drugged or drunk, use profane and vulgar language, cuss at staff, and expose her genitals in a lewd fashion. At times, she would scream for dialysis to be terminated and pull the dialysis needle from the shunt causing blood to spew.

The court found her behavior to be "knowing and intentional" and described Dr. Weaver as "one of the most sensitive and honest physicians that I have been exposed to either in a courtroom or out of a courtroom." It held that "there exists no basis in law or in equity to saddle him with a continuing sole obligation for Brenda’s welfare."

In another refusal-to-treat case, an abusive and disruptive patient missed scheduled dialysis sessions, and threatened to kill his nephrologists, Dr. John Bower, and shoot the hospital administrator at the University of Mississippi Medical Center. The court ruled that to compel Dr. Bower to proffer dialysis was tantamount to involuntary servitude, and this would violate the 13th amendment which prohibits slavery. However, it ordered the medical center to continue to provide dialysis because there was no other facility in the region.

Dr. S. Y. Tan is an emeritus professor of medicine at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk." For additional information, readers may contact the author at [email protected].

Question: Dr. X is a member of a rural group practice with no other doctor or doctor groups in the area. One of his patients has been noncompliant with medical advice and has refused to pay his bills on time. Additionally, there are style differences that have caused their interactions to be confrontational at times. Eventually, the doctor decided he’d had enough and unilaterally terminated the relationship. In a lawsuit that followed based on patient abandonment in this hypothetical, which of the following is incorrect?

A. One may terminate a doctor-patient relationship with patient consent.

B. One may unilaterally terminate a doctor-patient relationship without patient consent.

C. In terminating care, a doctor is required to give notice and forward all relevant records to the new provider.

D. The original doctor is still responsible for all care until the patient finds a new doctor.

E. Given the above fact situation, the entire group practice may terminate the relationship.

Answer: E. A doctor is permitted to terminate the professional relationship with a patient with or without his consent in situations such as irreconcilable disagreements over treatment plans, loss of rapport or trust, or patient refusal to pay the doctor’s bill. However, before terminating care, the doctor is required to give sufficient notice and arrange to transfer all medical records to the new treating doctor. In addition, the original physician must continue to provide ongoing care until the patient has established contact with the new doctor. In other words, it is the affirmative obligation of the physician to ensure that no interim harm comes to the patient.

A not uncommon scenario is where a group practice collectively refuses to treat a patient or group of patients. In Leach v. Drummond Medical Group, the plaintiffs complained to the State licensing board about some members in a group practice, and the entire group then attempted to terminate its professional relationship with those patients. The California appellate court held that whereas one member may decline to treat, the entire group may not exercise the same option, as there were no similar services within a hundred miles.

The American Medical Association’s Code of Medical Ethics (§8.115) emphasizes that physicians "have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured."

Merely making a referral may not be enough. In a dental malpractice case where the patient was simply referred to his family physician after oral surgery was complicated by an infection, an Illinois court held the dentist liable for the postop complications. Furthermore, civil rights laws prohibit discrimination based on race, gender, religion, or ethnic origin in places of public accommodation, which include a doctor’s office. Additionally, the Americans with Disabilities Act (ADA) prohibits discriminating against the disabled. Obviously, care for patients should not be terminated or refused for these reasons.

The tort of abandonment may be intentional or negligent. In the former instance, the deliberateness of the defendant’s action is a key element, and the aggrieved party may not need expert testimony to prevail. Still, in a 2007 Wisconsin case where a surgeon canceled an elective surgery after the patient had sued the employer surgical center, the appeals court overruled the trial court and held that expert testimony was required to prove the plaintiff’s case. However, negligent abandonment, for example, premature discharge of a patient from the hospital or emergency department, is simply a form of medical negligence, which will require expert testimony at trial to set the standard of care.

Rarely, the facts are so outrageous the courts have ruled that the health care providers owed no further duty to provide treatment. The best known case is that of Payton v. Weaver, where a physician and hospital refused to provide dialysis to a patient because of persistent uncooperative and antisocial behavior. In lamenting that "occasionally a case will challenge the ability of the law, and society, to cope effectively and sensitively with fundamental problems of human existence," the court affirmed the trial court’s judgment that the healthcare providers had no legal obligation to continue providing regular dialysis treatment.

The facts of the case are as vivid as they are tragic. Ms. Brenda Payton was a 35-year-old woman with end-stage-renal disease on dialysis. An active user of alcohol, heroin, and barbiturates, she was non-compliant with dialysis and medical therapy. She continued to buy barbiturates from pushers on the street at least twice a week, failed to restrict her diet, sometimes gaining 15 kg between dialysis, and frequently missed dialysis, resulting in 30 hospitalizations in the 11 months before trial. She would come to dialysis drugged or drunk, use profane and vulgar language, cuss at staff, and expose her genitals in a lewd fashion. At times, she would scream for dialysis to be terminated and pull the dialysis needle from the shunt causing blood to spew.

The court found her behavior to be "knowing and intentional" and described Dr. Weaver as "one of the most sensitive and honest physicians that I have been exposed to either in a courtroom or out of a courtroom." It held that "there exists no basis in law or in equity to saddle him with a continuing sole obligation for Brenda’s welfare."

In another refusal-to-treat case, an abusive and disruptive patient missed scheduled dialysis sessions, and threatened to kill his nephrologists, Dr. John Bower, and shoot the hospital administrator at the University of Mississippi Medical Center. The court ruled that to compel Dr. Bower to proffer dialysis was tantamount to involuntary servitude, and this would violate the 13th amendment which prohibits slavery. However, it ordered the medical center to continue to provide dialysis because there was no other facility in the region.

Dr. S. Y. Tan is an emeritus professor of medicine at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk." For additional information, readers may contact the author at [email protected].

Question: Dr. X is a member of a rural group practice with no other doctor or doctor groups in the area. One of his patients has been noncompliant with medical advice and has refused to pay his bills on time. Additionally, there are style differences that have caused their interactions to be confrontational at times. Eventually, the doctor decided he’d had enough and unilaterally terminated the relationship. In a lawsuit that followed based on patient abandonment in this hypothetical, which of the following is incorrect?

A. One may terminate a doctor-patient relationship with patient consent.

B. One may unilaterally terminate a doctor-patient relationship without patient consent.

C. In terminating care, a doctor is required to give notice and forward all relevant records to the new provider.

D. The original doctor is still responsible for all care until the patient finds a new doctor.

E. Given the above fact situation, the entire group practice may terminate the relationship.

Answer: E. A doctor is permitted to terminate the professional relationship with a patient with or without his consent in situations such as irreconcilable disagreements over treatment plans, loss of rapport or trust, or patient refusal to pay the doctor’s bill. However, before terminating care, the doctor is required to give sufficient notice and arrange to transfer all medical records to the new treating doctor. In addition, the original physician must continue to provide ongoing care until the patient has established contact with the new doctor. In other words, it is the affirmative obligation of the physician to ensure that no interim harm comes to the patient.

A not uncommon scenario is where a group practice collectively refuses to treat a patient or group of patients. In Leach v. Drummond Medical Group, the plaintiffs complained to the State licensing board about some members in a group practice, and the entire group then attempted to terminate its professional relationship with those patients. The California appellate court held that whereas one member may decline to treat, the entire group may not exercise the same option, as there were no similar services within a hundred miles.

The American Medical Association’s Code of Medical Ethics (§8.115) emphasizes that physicians "have an obligation to support continuity of care for their patients. While physicians have the option of withdrawing from a case, they cannot do so without giving notice to the patient, the relatives, or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured."

Merely making a referral may not be enough. In a dental malpractice case where the patient was simply referred to his family physician after oral surgery was complicated by an infection, an Illinois court held the dentist liable for the postop complications. Furthermore, civil rights laws prohibit discrimination based on race, gender, religion, or ethnic origin in places of public accommodation, which include a doctor’s office. Additionally, the Americans with Disabilities Act (ADA) prohibits discriminating against the disabled. Obviously, care for patients should not be terminated or refused for these reasons.

The tort of abandonment may be intentional or negligent. In the former instance, the deliberateness of the defendant’s action is a key element, and the aggrieved party may not need expert testimony to prevail. Still, in a 2007 Wisconsin case where a surgeon canceled an elective surgery after the patient had sued the employer surgical center, the appeals court overruled the trial court and held that expert testimony was required to prove the plaintiff’s case. However, negligent abandonment, for example, premature discharge of a patient from the hospital or emergency department, is simply a form of medical negligence, which will require expert testimony at trial to set the standard of care.

Rarely, the facts are so outrageous the courts have ruled that the health care providers owed no further duty to provide treatment. The best known case is that of Payton v. Weaver, where a physician and hospital refused to provide dialysis to a patient because of persistent uncooperative and antisocial behavior. In lamenting that "occasionally a case will challenge the ability of the law, and society, to cope effectively and sensitively with fundamental problems of human existence," the court affirmed the trial court’s judgment that the healthcare providers had no legal obligation to continue providing regular dialysis treatment.

The facts of the case are as vivid as they are tragic. Ms. Brenda Payton was a 35-year-old woman with end-stage-renal disease on dialysis. An active user of alcohol, heroin, and barbiturates, she was non-compliant with dialysis and medical therapy. She continued to buy barbiturates from pushers on the street at least twice a week, failed to restrict her diet, sometimes gaining 15 kg between dialysis, and frequently missed dialysis, resulting in 30 hospitalizations in the 11 months before trial. She would come to dialysis drugged or drunk, use profane and vulgar language, cuss at staff, and expose her genitals in a lewd fashion. At times, she would scream for dialysis to be terminated and pull the dialysis needle from the shunt causing blood to spew.

The court found her behavior to be "knowing and intentional" and described Dr. Weaver as "one of the most sensitive and honest physicians that I have been exposed to either in a courtroom or out of a courtroom." It held that "there exists no basis in law or in equity to saddle him with a continuing sole obligation for Brenda’s welfare."

In another refusal-to-treat case, an abusive and disruptive patient missed scheduled dialysis sessions, and threatened to kill his nephrologists, Dr. John Bower, and shoot the hospital administrator at the University of Mississippi Medical Center. The court ruled that to compel Dr. Bower to proffer dialysis was tantamount to involuntary servitude, and this would violate the 13th amendment which prohibits slavery. However, it ordered the medical center to continue to provide dialysis because there was no other facility in the region.

Dr. S. Y. Tan is an emeritus professor of medicine at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk." For additional information, readers may contact the author at [email protected].