Although 30 days’ notice will be considered reasonable in most cases, ethical concerns can require a longer period. For example, physicians pledge to “do no harm” and also have an obligation to place patients’ welfare above their own interests.* Balancing patient and physician interests can get tricky when it will be difficult for the patient to find a new physician.
Case File
A family physician (FP), whose practice was located in a remote area, wanted to dismiss a long-term patient, but the FP’s practice was the only one within a 50-mile radius of the patient’s home. In order to obtain treatment from another provider, the patient, who could not drive and had no family support, would have to take a 50-mile bus ride. The patient had diabetes and was being seen monthly for blood sugar checks and appropriate chronic disease management care (e.g., foot care, eye exams, renal function, etc.).
The physician wanted to dismiss the patient because he was loud and obnoxious when he presented for treatment, and he generally bad-mouthed the practice around town. Additionally, he was non-compliant; for example, he would not give himself insulin injections, would not use an insulin pump and would not check and record his blood sugars.
Discussion
Just because a patient may have difficulty finding alternative medical care doesn’t mean a physician must continue a problematic physician-patient relationship. In this case, due to his non-compliance, the patient’s diabetes was not being appropriately treated. There comes a time with some patients when it may be better for them to seek care elsewhere. However, physicians in isolated or rural areas and specialists who are “the only game in town” need to be especially careful when dismissing patients. Even if a physician believes the patient has been given ample notice, the patient’s individual circumstances may preclude him or her from finding new care, and the notice interval may not be legally/ethically sufficient.
Because of the patient’s diabetes, delay of treatment caused by difficulties locating a physician willing to treat him could easily result in patient injury. Therefore, it would be important for the physician to make an attempt to rehabilitate the patient, and if that failed, to actively work with him to find an alternative source of care. Liability risk exposure would be high for this FP if he limited the termination process to sending a letter to this patient with a 30-day notice.
Medical Liability Risk Management Recommendations
Consider the following recommendations:
- Carefully weigh your ethical duty to treat the patient against your right to terminate treatment.
- Consider the seriousness of the patient’s condition.
- Seek guidance from a risk management specialist or your personal attorney if a patient’s circumstances will make it very difficult to obtain necessary treatment.
Reference
* Lippman H, MA, Davenport J. Patient dismissal: The right way to do it. J Fam Pract. 2011 Mar;60(3):135-40. (accessed 5/30/2017)
