Although healthcare delivery has changed drastically through the years, one element that has remained constant is the importance of trust between a patient and his or her physician. When events occur that weaken the bond between patient and physician and that trust is broken, the physician should take a good hard look at the relationship to determine whether the association should continue. If the relationship is no longer mutually beneficial, severing the doctor- patient association may be appropriate. If the physician decides to terminate the relationship— whether it be for noncompliance, communication difficulties, nonpayment of bills, or any other reason—he or she must advise the patient of this decision. The best approach is to have an open and honest discussion with the patient. The physician should explain the basis for the termination, then emphasize the importance of, and need for, continued medical treatment. Physicians must give patients a reasonable transition period in which to find a new healthcare provider. In general, what constitutes a reasonable period is based both on the patient’s healthcare needs and on the physician’s comfort level with having future visits with this patient. As a rule of thumb, the more specialized the care required or the more remote the area, the more time the patient should be given to seek another physician.

Guidelines
The following recommendations can help minimize a physician’s liability when terminating a relationship with a patient:

• Review the medical record for conditions that might require additional treatment or monitoring.
• Notify the patient of the termination. If possible, discuss the termination with the patient in person. If that’s not possible— and particularly if the patient is angry and refuses to meet—send a written notice of termination to the patient by registered mail and request a return receipt. Concurrently, send a back-up letter through regular mail. If the patient refuses to sign for the registered letter, keep the undelivered receipt and the letter in the patient’s medical record.
• If the patient is a member of a prepaid health plan, the plan must be notified of your intent to terminate the relationship prior to it taking place. The health plan should assist you with the termination process.
• Determine a reasonable time period for the patient to obtain another physician, if necessary. Indicate your willingness to be available for treatment of urgent or named conditions during that period.
• Indicate that upon written authorization or request, you will send copies of the clinical records to the new physician.

Physicians may want to consider the following two additional options when terminating the doctor-patient relationship:

• Avoid referring the patient to a specific physician. Instead, refer the patient to the local medical society or another referral source in the community.
• If the patient needs specialized or subspecialized care, make general care suggestions regarding specialists or subspecialists. (When doing so, take the geographical location of the patient into account.) Do not endorse or recommend specific physicians. If you recommend a certain physician and he or she commits malpractice, you may find yourself sued for negligent referral.

Make it clear to the patient that the choice of a new doctor should be based on his or her own evaluation of, and comfort level with, that physician.

Risky Situations
There are special circumstances in which terminating the doctorpatient relationship may be complex and even risky.

SAMPLE TERMINATION LETTER
FOR NONCOMPLIANCE
(send on office letterhead)

(Date)

(Mr. Tom Jones)
(222 Independent Ave.)
(Free Choice, USA 99999)

Dear (Mr. Jones):

I am concerned about your health. When we last spoke on (date), 
I recommended (therapy/treatment).

You have subsequently failed to follow the recommendations that I 
believe are important to your well-being. While I recognize your right 
to refuse this therapy/treatment, I believe that it is not in your best 
interest.

There appears to be a breakdown in the trust between us, and trust is 
the cornerstone of a good doctor-patient relationship. Accordingly, 
this letter is to advise you that I am terminating our relationship.

I will continue to see you for any urgent medical care needs for the 
next (number) days.

Since your condition does require monitoring and supervision, I strongly 
urge that you seek out and find another doctor whose advice you will follow 
in the management of your health. If you do not know of another physician, 
I would encourage you to contact the (local county medical society/association), 
a hospital referral hotline, or other source for a list of physicians from whom 
you can choose. Please do not delay in placing yourself under the care of another doctor.

Upon written request, I will be happy to forward a copy of your clinical 
information in my records to your new doctor.

Sincerely,
(Doctor’s signature)
(John Doe MD)

These situations are listed below, along with recommended courses of action:

• In cases where the patient is noncompliant or denies illness, warn him or her—both verbally and in writing—that the medical conditions require monitoring and cannot go unsupervised without potential harm.
• When patients refuse recommended therapies, warn them in the termination letter that, in your opinion, failure to follow the recommended treatments can be detrimental to their health.
• The above circumstances—along with any other health considerations— will affect the amount of time in which you can reasonably expect a patient to find other medical care. Such circumstances, which are entirely patient-specific, will also determine the set time period during which you provide “transitional” care.
• When a relationship with a high-risk patient is being terminated on an adversarial note amid complaints about the quality of services or care rendered, contact a SCPIE Risk Manager for additional recommendations or courses of action.

Conclusion
Physicians should use care when terminating doctor-patient relationships. Following these recommended guidelines and procedures can minimize the potentially negative implications associated with discontinuing a difficult relationship.

For additional information about terminating a doctor-patient relationship, contact a SCPIE Risk Manager at 800/585-7799.

SAMPLE TERMINATION LETTER FOR
NONCOMPLIANCE—Managed Care Patient
(send on office letterhead)

(Date)
(Mr. Tom Jones)
(222 Independent Ave.)
(Free Choice, USA 99999)

Dear (Mr. Jones):

I am concerned about your health. When we last spoke on (date), 
I recommended (therapy/treatment).

You have subsequently failed to follow the recommendations that I 
believe are important to your well-being. While I recognize your right 
to refuse this therapy/treatment, I believe it is not in your best interest 
and can be detrimental to your health.

There appears to be a breakdown in the trust between us, and trust is 
the cornerstone of a good doctor-patient relationship. Accordingly, 
this letter is to advise you that I am terminating our relationship. 
I will continue to see you for any urgent medical care needs for the 
next (number) days.

Since your condition does require monitoring and supervision, 
I strongly urge that you seek out and find another doctor whose advice 
you will follow in the management of your health. If you do not know 
of another physician, I would encourage you to contact your health 
plan’s membership services representative, (Jane Smith at 800/555-
1212). Note: Doctor, provide the rep’s name and phone number, which 
should have been given to you in discussion with the managed care organization 
prior to termination. You may also contact the (local county medical 
society/association), a hospital referral hotline, or other source 
for a list of physicians from whom you can choose. Please do not delay 
in placing yourself under the care of another doctor.

Upon written request, I will be happy to forward a copy of your 
clinical information in my records to your new doctor.

Sincerely,
(Doctor’s signature)
(John Doe MD)

SAMPLE TERMINATION LETTER FOR
COMMUNICATION DIFFICULTIES
(send on office letterhead)

(Date)

(Mr. Tom Jones)
(222 Independent Ave.)
(Free Choice, USA 99999)

Dear (Mr. Jones):

I am concerned about your health. When we last spoke on (date), 
I recommended (treatment/therapy). From a communication aspect, 
there appears to be a breakdown in the trust between us, and trust 
is the cornerstone of a good doctor-patient relationship.

Accordingly, this letter is to advise you that I am terminating our relationship.

I will continue to see you for any urgent medical care needs for the next (number) days.

Since your condition does require monitoring and supervision, I strongly urge that 
you seek out and find another doctor whose advice you will follow in the management 
of your health. If you do not know of another physician, I would encourage you to 
contact the (local county medical society/association), a hospital referral hotline, 
or other source for a list of physicians from whom you can choose. Please do not 
delay in placing yourself under the care of another doctor.

Upon written request, I will be happy to forward a copy of your clinical 
information in my records to your new doctor.

Sincerely,
(Doctor’s signature)
(John Doe MD)

SAMPLE TERMINATION LETTER FOR
NONPAYMENT OF BILLS
(send on office letterhead)

Same as Sample Termination Letter for Communication Difficulties, except replace the first paragraph with the following:

I am concerned about your health. There appears to be a breakdown in the trust between us, and trust is the cornerstone of a good doctor-patient relationship.

Additionally, our records indicate that your account is delinquent.