There are different situations that will result in terminating your relationship with a patient:
- They die, or you do.
- The patient chooses to end it.
- The treatment plan has been completed.
- The practitioner chooses to withdraw services.
This first one is easy – it’s over. The second one raises the question of why the patient doen’t want to come back. True professionals try to find out the answer to this and document the reasons on file. The final two situations involve formally discharging a patient from care.
Withdrawal of care requires that you inform the patient. You may do this orally when appropriate, but you must also put it in writing. (If you anticipate any contentious issues, make sure to send the notice of withdrawal from care by registered mail. You will want to have proof that they got your letter.)
When a patient has been returned to their pre-injury condition and/or reached optimal function you will generally discharge them. This is particularly true when a third party is paying for the treatment.
If another professional referred the patient to you, you need to send a copy of the discharge letter to them. If the patient has only managed to reach a certain level of recovery, your letter should make reference to any pain or limitations that are expected to persist and affect their ability to work or perform the activities of daily living.
If you have to unilaterally discharge a patient who you no longer wish to see, it will be for one of three reasons
- They are not following your advice
- They are behaving in ways you are uncomfortable with, or they are threatening or abusive
- You have decided to focus on certain types of cases, say maternity care, and no longer want to handle sports injury cases and geriatric care. If one of your patients is an 80 year old man with heel spurs and bad knees, it is perfectly acceptable to discharge him from your care, as long as you make every effort to find him someone else who can help him.
This letter will, as is appropriate:
- Outline the reasons for terminating the therapeutic relationship
- Describe the instructions given that were not followed
- Describe specific behaviours and any discussions of the consequences of non-compliance
- Specify the date that treatment will end and give them enough notice that they can find another practitioner with no gaps in their care
- Identify the patient’s need for continued care and offer to transfer their records to a new practitioner.
Drawing from the College of Chiropractors of B.C.’s, professional conduct handbook’s sample letter, after addressing the patient, the chiropractor can immediately outline the purpose of the letter and provide a short explanation why. Chiropractors can then suggest another practitioner, agree to treat them (if they so choose) for a “reasonable period of time” after receipt of the letter, and confirm with them to secure their consent for you to provide case history and information regarding the treatment you had provided them.1
You need to give enough notice so they have time to find another healthcare provider. If you live in a populated area this should be relatively easy, but in rural or remote communities it may take longer.
“It’s important to note that if the healthcare provider feels threatened or harassed by the patient, they may withdraw from treatment without giving advance notice to the patient,” according to the CCBC handbook. It also states that “depending on the particular circumstances, further communication with the patient by a confirming letter may or may not be advisable.”2
A patient does not need to give any notice to their healthcare provider to terminate the relationship. However, in some circumstances it may be prudent to confirm the patient’s termination of the relationship in writing to avoid a claim of abandonment.
Remember, in all cases of discharged patients you will need to keep the file for 16 years, but the patient has a right to the information the file contains.
Breaking up with a patient need not be hard – or permanent. Having a clear strategy and the right paperwork in place to properly discharge patients is an essential component of all healthcare practices.
Resources
- CCBC Professional Conduct Handbook (2017) Appendix A: Withdrawing from patient care
- CCBC Professional Conduct Handbook (2017) Appendix A – Schedule 1
DR. DAWN ARMSTRONG is a graduate of CMCC and has been in practice for over 30 years. She is currently focused on promoting life-long learning and professional development and has created a continuing education course – Clinical Record Keeping: A Hands-On Approach. Learn more at auroraeducationservices.ca.
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