Ending a doctor-patient relationship

For a number of reasons, a doctor-patient relationship may need to be brought to an end prematurely (that is, before its natural or expected end). Examples include:

• if the doctor wants to downsize, relocate or close their practice.
• If the patient is abusive, violent or poses a significant safety risk to the doctor or their colleagues.
• If the doctor-patient relationship breaks down.

The focus of MCNZ's guidance on ending a doctor-patient relationship is on the wellbeing and future care of patients. It requires doctors to put the patient first and emphasizes the importance of being fair and professional with the patient when ending a therapeutic relationship.

Whatever the circumstance then, if a doctor is considering bringing a therapeutic relationship to an end it is important that they do so carefully by following a proper process which includes communicating their concerns to the patient, considering the impact on the patient, and then if appropriate ending the relationship.

Considerations before ending a doctor-patient relationship

Doctors are expected to consider whether the decision to end the therapeutic relationship will impact negatively on the patient and their whanau, such as limiting the patients' options for, or access to, medical care. This may be particularly relevant in rural communities. Doctors should also pay particular attention to the impact on the patient where treatment may be incomplete, acute, or ongoing, and whether the treatment can be effectively transferred to another health professional.

Critically, doctors must ensure that the patient does not require urgent medical help. If the patient does require urgent care, then cessation of care should not proceed.

It is important too that the decision to bring the doctor-patient relationship to an end is not done abruptly. It is recommended that doctors consider first discussing their decision with a peer, colleague, or practice manager (while ensuring that the patient's dignity and privacy are protected). It is recommended too that you contact your medical indemnifier for guidance. It is a good idea to keep a written record of all such discussions.

An explanation should also be given to the patient of the doctor's concerns and the reasons they are considering ending the therapeutic relationship. It is important for doctors to first try and find a solution with the patient, taking into account their needs and circumstances, and any issues of safety whether to the patient, the doctor, or to the doctor's colleagues. Only when reasonable attempts to find an acceptable solution are unsuccessful should the doctor-patient relationship be brought to an end.

One situation which requires particular care is where there is or may be the risk of professional boundaries in the therapeutic relationship being blurred or crossed. In such circumstances it is likely that the therapeutic relationship should be brought to an end. Of course, the termination of the therapeutic relationship does not itself signal a green light to the commencement or continuation of a personal relationship with the patient. Typically, such situations are so fraught that the doctor should seek independent advice at the first opportunity.

If the decision is made to end the therapeutic relationship, doctors need to think about the most appropriate and culturally safe way to do this. MCNZ's guidance provides a six-step process for discontinuation of care.

Process for discontinuation of care

1. inform the patient (in person or in writing) that the doctor-patient relationship has ended and the reasons for this.
2. End the relationship in a respectful and professional manner so that it does not damage the patient's future engagement with other doctors or the health system.
3. Note the end of the doctor-patient relationship and the reasons for its termination, in the patient's records.
4. Give the patient sufficient notice to find another doctor or help them find one (if needed). If you are a specialist in secondary care, refer the patient back to their GP or another secondary care specialist.
5. Transfer the patients records to another doctor (although make sure that you have the patient's authority to do so, ideally in writing). This is important to facilitate continuity of care. Also ask the patient if they would like a copy of their records.
6. Unless there are extenuating circumstances, maintain a copy of the patient's records.

Until this process is complete the patient may require acute or ongoing care. If doctors are unable to provide that care, they will need to advise the patient of alternatives.

Ending a doctor-patient relationship can be stressful and not always straightforward. Where a doctor-patient relationship has broken down it can be particularly difficult not to rush the process in bringing the relationship to an end. It is important however that proper steps are taken, with each therapeutic relationship and patient being assessed carefully in light of the particular circumstances.

Should further guidance be required, check the MCNZ statement ending a doctor-patient relationship.

You may also care to seek advice from your indemnifier.

Updated 18 November 2022.