Selected Commentary

In response to feedback requested from physicians, Council wishes to confirm that there has been no policy change regarding physicians’ ethical obligations, should they wish to terminate the care provided to a patient.  Physicians retain the right to decide to provide no further treatment to a patient provided the patient is not in need of immediate care. 

Council notes that the decision to terminate care is, and should be, a difficult one.  Council also acknowledges additional pressures that the lack of alternatives can create for physicians and patients. 

Under these circumstances, Council encourages members to consider the gravity of any such decisions.  There are, indeed, some circumstances which clearly warrant the termination of care.  This includes fraud for purposes of obtaining narcotics and other drugs, violent or aggressive behaviour, and double doctoring.  (Members should note that “double doctoring” has a very specific meaning under the Controlled Drugs and Substances Act.  It refers to attempting to obtain a narcotic or controlled drug without disclosing that such had been prescribed by another physician within the previous thirty days.)

There are other circumstances where Council feels physicians should use significant caution.  The Code of Ethics advises physicians to respect the right of patients to make reasonable requests for second opinions, consultations, or simple information.  Council also notes that physicians should judge each circumstance according to the particular patient.  If one member of a family voluntarily or involuntarily leaves a practice, it may be inappropriate to discharge other members as a consequence.

In any case, Council does note that there is no evidence that this is a significant problem in terms of patient access.  The majority of patients without physicians are obviously in that situation for other reasons.

Some years ago, the College published a guideline from the College of Physicians and Surgeons of Ontario.  While it is not completely appropriate to the New Brunswick situation, it is reproduced here to assist members.

(From the College of Physicians and Surgeons of Ontario)

As far back as anyone can remember, the ethics of the profession have defined the physician/patient relationship as an ongoing one in which the doctor accepts responsibility for the patient’s care and will not end the relationship with a patient without good reason, proper notice and an opportunity to obtain another doctor’s services.  The Canadian Medical Association Code of Ethics prohibits discontinuing necessary medical services unless the patient requests the discontinuance, alternative services are arranged or the patient is given a reasonable opportunity to arrange for those alternative services.

Here are some suggestions for ways to proceed when your judgement tells you that it will be in the patient’s best interest to terminate your physician/patient relationship. 

  1. Communicate your decision to the patient as compassionately, as supportively, but as clearly as possible.
  1. Give the patient a reasonable amount of time to find a new physician.  This time would be that which it would take a reasonable person, using reasonable effort, to find a new doctor.  This time may vary from community to community.  [In New Brunswick there will usually be considerable delay in a patient finding another physician.  In these circumstances, it is generally considered reasonable that the original physician continue to provide service to the patient for a period of two to three months.  When alternate care can be arranged directly, then the patient can be transferred immediately.]
  1. Be helpful to the patient in finding a new doctor and transferring records.
  1. Document the process you choose to use.  In some cases, you may wish to consider sending a registered letter with a return receipt requested.  Place a copy of the letter with the postal receipt in the patient’s chart along with the termination entry recording your actions.
  1. Be sure your staff is aware of your decision so that further calls from the patient may be responded to appropriately.
  1. Where the patient has ongoing dealings with other health care providers, (e.g., pharmacists, hospitals, physiotherapists) let those providers know that you are no longer caring for the patient. 
  1. If you are of the opinion that ongoing care is necessary, make sure you convey this clearly to the patient. 

The following is a sample of a letter you might wish to consider in conveying your decision to patients.  This letter, must, of course, be customized to fit your particular circumstances.  The need to terminate your relationship with a patient can be most comfortable for you and the patient if a caring and rational explanation is given. 

Dear (Patient’s name) 

For the reasons we discussed recently, I do not believe that it will be in your interest for me to continue as your physician.  I regret to inform you that I will not be in a position to provide you with medical services after (fill in the date, which will vary with your circumstances). 

I urge you to obtain the services of another physician satisfactory to you. 

When you have had an opportunity to see your new physician, please ask him or her to contact me and I will be pleased to provide a full summary of my care while you have been my patient and to transfer a copy of your medical record. 

Yours very truly,

(your name and signature) 

11/02

General Information

Address all correspondence to

Dr. Ed Schollenberg, Registrar
College of Physicians and Surgeons of New Brunswick
One Hampton Road, Suite 300
Rothesay, NB E2E 5K8 

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