Professional standards and guidelines regarding: ending the physician-patient relationship and reducing the size of a medical practice

Preamble

This standard sets out the regulatory expectations of physicians when ending a physician-patient relationship within office-based community practice. It includes direction to physicians when reducing the size of their practice and with respect to dismissing inactive patients.

Physicians may end the physician-patient relationship (otherwise referred to discharging a patient) only in certain circumstances. When doing so, physicians must act in good faith, applying good clinical judgment and compassion.

Physicians must not abandon their patients. Abandonment is a unilateral dismissal of the patient from the physician-patient relationship, without due cause, and without providing adequate notice for the patient to obtain substitute medical care. Abandonment is recognized in law as a breach of the duty of care.

This standard does not apply to the circumstances of physician retirement, relocation, or leave of absence. For direction in those circumstances, please refer to Professional Standards Regarding Temporarily or Permanently Closing a Medical Practice.

Professional standards

Ending the physician-patient relationship

1. The College considers conflict resolution to be a professional responsibility. Before ending the physician-patient relationship, physicians must:
   1. Make reasonable attempts to resolve the situation;
   2. Consider the extent to which ending the relationship may have significant negative consequences for the patient;
   3. Consider the extent to which the patient’s personal, cultural, socio-economic, or medical circumstances may have contributed to the potential breakdown of the relationship; and
   4. Apply clinical judgement to determine the most appropriate course of action.
2. Physicians must not end the physician-patient relationship based on a prohibited ground of discrimination as identified in the Nova Scotia Human Rights Act.
   Prohibited ground of discrimination as identified in the Nova Scotia Human Rights Act are as follows: age, race, colour, religion, creed, sex, sexual orientation, gender identity, gender expression, physical or mental disability, an irrational fear of contraction an illness or disease, ethnic, national or aboriginal origin, family status, marital status, source of income, political belief, affiliation or activity, and an individual’s association with another individual or class of individuals having characteristics aforementioned.   Notwithstanding the above, the College accepts and recognizes the age mandate for the discipline of pediatrics and the IWK health authority.  
3. Physicians must have reasonable grounds to end a physician-patient relationship and must document their reasoning for doing so.
4. The following are NOT reasonable grounds to end the patient-physician relationship:
   1. Because a patient fails to keep appointments, unless the patient has been advised in advance that the physician-patient relationship will end for consistently missing appointments;
   2. Because a patient fails to pay outstanding fees for uninsured services, unless the patient has been advised in advance that failure to pay for outstanding fees will result in ending the physician-patient relationship; and
   3. Because a patient files a College or Health Authority complaint against a physician, unless the allegations cause irreparable damage to the overall therapeutic nature of the relationship.
5. When ending a physician-patient relationship patient, a physician must:
   1. Notify the patient of the reasons for ending the physician-patient relationship, unless this disclosure could be expected to:
      1. result in immediate and grave harm to the patient’s mental or physical health or safety,
      2. threaten the mental health and physical health or safety of another individual, or
      3. pose a threat to public safety;
         In situations set out in 5. a. i. – iii, the physician must document the reasons for not providing notice at the time.
   2. Ensure that all outstanding reports and work in progress (investigations, tests, and consultations) are reviewed and acted upon;
   3. Provide care, or arrange for another healthcare provider to provide care, up to the specified date the patient was notified the physician-patient relationship would end;
   4. Take reasonable steps to educate patients on accessing care going forward. Physicians are not expected to arrange transfer of care;
   5. Ensure there is a process for transfer of the patient’s medical information upon request; and
   6. Document the grounds for ending the physician-patient relationship and how this was communicated to the patient.
      Please refer to Appendix A for a sample letter to patients.

Reducing the size of a practice

6. When reducing the size of a medical practice, physicians must:
   1. Provide notice to affected patients of the criteria by which the size of their practice will be reduced and adhere to the criteria without exception;
      As with all cases of ending a patient relationship, the criteria used to reduce the size of the medical practice must not be discriminatory.  
   2. Provide notice to the health authority and the College of the criteria by which the size of their practice will be reduced and adhere to the criteria in all cases. Notice should be provided as soon as the physician has made this decision and/or within no less than three months;
   3. Notify the patients affected by the reduction of the practice no less than three months for ending the physician-patient relationship;
   4. Provide information to the patient on how to obtain and access resources which may include Virtual Care NS, 811 and information on how to register with Need a Family Practice Registry;
   5. Ensure that all outstanding reports and work in progress (investigations, tests and consultations) are reviewed and acted upon; and
   6. Provide necessary prescriptions to patients during the notice period and exercise professional judgment when prescribing medications beyond the notice period (when the physician will not be available for monitoring or review).

The following guidelines are provided as non-binding guidance to the profession, to be considered when interpreting the professional standards above.

Guidelines

1. A physician may immediately end the physician-patient relationship when:
   1. There are reasonable grounds to believe a patient poses a safety risk to the physician, office staff, or other patients;
   2. The patient is found to be deceptive with the physician or staff, such as for the purpose of obtaining controlled medications; and
   3. The patient is found to have exerted undue influence, withheld relevant information, or provided false or misleading statements, especially for the purpose of gaining inappropriate access to services.
      Examples of this are many and diverse, including exercising influence in order to queue jump or falsely claiming Indigeneity to wrongfully access designated services that are protected under human rights law. 

This list is not exhaustive.

2. After making reasonable attempts to resolve an issue, physicians may end the physician-patient relationship when the patient:
   1. Is consistently non-adherent with medical advice, thereby rendering the relationship non-therapeutic. Physicians are reminded that non-adherence can be a function of social determinants of health and of health conditions;
   2. Is verbally or otherwise abusive to the physician, staff, or other healthcare providers;
   3. Is no longer a permanent resident of the province;
   4. Is no longer able to present to the physician for an in-person appointment where the physician feels in-person care may be necessary. Exceptions would include house bound patients for whom the physician has historically provided care; and/or
   5. Has not been seen by the physician for 10 years. In this situation, before ending the physician-patient relationship, it is suggested that the physician should attempt to communicate with the patient to determine if the patient wishes to remain under their care. If unsuccessful, the physician should document the attempt.
3. A physician may end the physician-patient relationship if the physician is changing scope of practice, such that the patient would no longer fits within the new scope.
4. Physicians who are ending the physician-patient relationship should provide patients with notice (no less than three months), and notification should be documented in the chart. Such notice should include information on where patients can obtain urgent care and how patients can obtain information from their medical records. It is acceptable to have patient notification done by a designate of the physician.​Acceptable methods of notification are:
   1. During a scheduled appointment;
   2. Written letter from physician;
   3. Telephone call from physician or designate;
   4. Email notification; and/or
   5. E-messaging.
5. Physicians should make every effort to ensure that patients requiring ongoing or chronic care, or requiring post-operative follow-up will continue to receive the necessary care.

Appendix A: Sample letter

The following is a sample letter for physicians notifying patients that the physician-patient relationship has ended. Specifically, this letter applies to when there has been a significant and irremediable breakdown in the physician-patient relationship.

Physicians can customize this letter to fit the specific circumstances of each case, and to help ensure that the letter is written in a way that the patient can understand.

Dear [patient’s name]:

As we discussed at your appointment on [insert date], my first obligation as a medical doctor is to provide quality care to all of my patients. In order to do this, you and I must cooperatively and respectfully work together towards your health and well-being.

It has become clear that because of [if appropriate, indicate reason], our physician-patient relationship has broken down, and this has made it difficult for me to continue providing quality care to you.

Despite taking the following steps to resolve the situation [if appropriate, list the steps undertaken to resolve the situation in advance of ending the relationship], I therefore regret to inform you that I will not be in a position to provide you with further services after [enter the date -- this time will vary from community to community, but you should give sufficient notice].

I urge you to obtain another health-care provider as soon as possible. With your consent, I will be pleased to provide them with a copy or summary of your medical records. I will also ensure appropriate follow-up on all laboratory and test results still outstanding.

For assistance in locating another physician, you may wish to contact Virtual Care NS, 811 and Need a Family Practice Registry, who assists Nova Scotians who are looking for a primary care provider. You may also wish to contact your local hospital to see whether any physicians on staff are accepting new patients. Lastly, some physicians, including those who are new to an area or who are beginning to establish a practice, will advertise that they are accepting new patients.

Yours truly,

[Signature of physician]

Resources

College of Physicians and Surgeons of Nova Scotia

• Professional Standards Regarding the Management of Medical Records

Canadian Medical Protective Association

• Informed Discharge
• Closing or leaving a practice: Tips for physicians
• How to manage your medical records: Retention, access, security, storage, disposal, and transfer
• Ending the Doctor Patient Relationship

 Government of Nova Scotia

• Nova Scotia Personal Health Information Act
• Nova Scotia Human Rights Act

Canadian Medical Association

• CMA Code of Ethics and Professionalism 2018

Acknowledgements

The development of this College standard was informed by the College of Physicians and Surgeons of Ontario’s policy Ending the Physician-Patient Relationship.

Document history