How to end the doctor-patient relationship

• You can end the doctor–patient relationship if you consider it to be in the patient’s best interests or if the therapeutic relationship has become untenable.
• If possible, end the relationship in person and follow up the conversation with a letter restating your position.
• You have a continuing professional obligation to treat the patient in an emergency.

The doctor-patient relationship is fundamental to your ability to provide clinical care. The nature of this relationship may vary, but the core elements are openness, trust and good communication. 

The doctor-patient relationship comes to a natural end when the patient moves location or no longer requires your care. Sometimes though, you will want to end the relationship and this can be quite challenging.

In general terms, if you are unwilling to continue treating a private patient you are not compelled to do so. However, before telling the patient you should consider their best interests and explore reasonable alternatives. If you work in a public hospital, you should also refer to your hospital's policy.

It is important to be able to recognise when it’s appropriate to cease treating a patient and to know how to do so without breaching your legal and professional obligations. If you believe you do not have the expertise to continue to assist a patient, then in the patient’s best interests you should transfer care.

Avoid ending the relationship simply because a patient is challenging to deal with. You cannot refuse to treat a patient for a discriminatory reason such as on the grounds of gender, race, marital status, religion or disability.

Before ending a relationship with a patient, check that you do not have a contractual obligation to see certain patients at your workplace. Some workplaces will also have a policy on how these matters should be handled.

Difficult situations

Difficult situations may include a patient’s conduct towards you, drug-seeking behaviour, repeatedly missed appointments or non-compliance with medical advice. To address your concerns and set clear boundaries, you could warn the patient that you may have to end the relationship because of their behaviour or enter into a written agreement with them about their behaviour.

Measures such as these can avoid taking a patient by surprise if you do end the relationship and be evidence of your efforts if a complaint is made against you. Make sure you document any warnings provided.

Single significant event 

In some instances, you may choose to end the relationship immediately after a single significant event. This may be a physical threat, sexual advance, deceptive behaviour (such as falsifying a medical certificate) or stealing from the practice.

Patient complaint

Patients have the right to complain about their care and this, in itself, may not be a reason to end the relationship. In some states and territories, it is unlawful to subject a patient to any detriment because they intend to make or have made a complaint.

The regulator encourages practitioners and practices to maintain the therapeutic relationship after a complaint if possible. This can be difficult if trust and confidence has broken down and it may be in the patient’s best interests to have their care transferred to another practitioner. Always consider whether the therapeutic relationship can be maintained or improved with resolution of the complaint.

If you decide to end the relationship in the patient’s best interests, make it clear to the patient that this is because of a breakdown in trust, rather than directly because of the complaint.

Before taking action 

It can be useful to discuss the situation with senior colleagues or Avant before officially ending the relationship.

Remember, the responsibility for ending the doctor–patient relationship rests with you, the doctor. Do not delegate it to another staff member.

If there has been a serious breakdown in the doctor–patient relationship, consider whether an incident report should be forwarded to Avant in case a complaint or claim is made.

Communicate openly 

When ending the relationship, aim to communicate in person with the patient. You should ensure the patient is adequately informed and understands your decision. Be honest, while still being sensitive to the patient’s feelings.

Try to ensure the patient does not interpret the ending of the relationship as a personal rejection. You should explain that the doctor–patient relationship relies on mutual trust.  When this has broken down, it can compromise patient care, so it is in the patient’s best interests to transfer to another practitioner.

Remember to remain calm and polite during all interactions.

Follow up

Follow your discussion with an email or letter to the patient ensuring you have clearly communicated your decision (see sample letter). If the patient requires a review of their condition or medication within a certain timeframe, highlight this in the letter. Where the patient has not complied with treatment, explain the consequences should they continue to go without appropriate treatment.

You may want Avant to review the letter before you send it to the patient.

Write to other practitioners involved in the patient’s care to inform them you are no longer treating the patient. Be careful with your explanation to avoid prejudicing the patient’s relationship with ongoing and future treatment providers.

The transition

Give the patient a reasonable timeframe to find a new doctor. You may need to assist vulnerable patients such as those with complicated medical issues or restricted mobility, or patients in a regional setting with limited options. In these situations, you may wish to seek advice from Avant.

Reassure the patient that you will, within the agreed timeframe, provide care for any medical problems that arise. Advise them to attend the local emergency department or urgent care centre for immediate care needs.

Transfer the files to the new doctor or practice 

To ensure continuity of care, advise the patient that you will provide a copy of their medical records to their new practitioner after receiving the patient’s consent (it may be unwise to charge the patient for this service).

Advise all practice staff 

Advise your practice staff that your relationship with the patient has ended and they should not make further appointments for the patient after a specified date.

Make sure all staff at the practice, including other doctors, are clear about what the termination means for the practice. There may be other doctors in the practice who are happy to treat the patient, or it may mean that no doctors in the practice will see the patient.

It’s a good idea to place an alert on the patient file to ensure all staff members, including new staff unfamiliar with the patient, are aware of the situation.

Be careful during an acute illness or emergency situation 

If the patient is experiencing an acute illness, ending the therapeutic relationship and failing to provide continuity of care could compromise the patient's health. Carefully consider whether you can continue to treat the patient until any health crisis is over before broaching the subject of ending the therapeutic relationship with the patient. If it is not possible to continue their care, take steps to ensure their care is appropriately handed over before ending the therapeutic relationship.

In an emergency you have an ethical and legal duty to provide assistance. This duty exists even if the person was not previously a patient or if you have recently ended the therapeutic relationship.

Reflect on what caused the therapeutic relationship to break down and consider if there is anything you could have done to stop the situation escalating or to prevent the relationship ending. There may be learning opportunities from the situation.

Consider using the following letter template 

Optional paragraphs depending on circumstances

Where the patient has misplaced expectations or is not following clinical advice

You have failed to follow the advice and recommended treatment I believe are important for your wellbeing. While I acknowledge your right to refuse advice and treatment, I believe it is not in your best interest to do so. If you continue to not follow advice, [there is a risk that/it is likely that] your [condition] will [consequences].

Bad behaviour or complaints that cannot be resolved

The events of [date(s)] lead me to believe that you have lost faith in my care. As trust is the cornerstone of an effective doctor–patient relationship, I believe I can no longer treat you effectively.

Inappropriate advances

Doctors are required by Good medical practice: a code of conduct for doctors in Australia and the Medical Boards Guidelines: Sexual boundaries in the doctor–patient relationship to only have a professional relationship with their patients. Your personal feelings expressed on [date] mean I can no longer see you except in the case of a genuine emergency.

[After the sentence ‘I will continue to provide ongoing care until you identify your new doctor’ you may want to include ‘but only with another person present during the consultation’].

Patient requiring review within a certain timeframe

Please be aware that you require a review of [condition or medication] by [date].

Medical Board of Australia - Good Medical Practice: A Code of Conduct for Doctors in Australia 

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