Definition/Introduction

Abandonment is considered a breach of duty and is defined as unilateral termination of the physician-patient relationship without providing adequate notice for the patient to obtain substitute medical care. The patient-physician relationship must have been established for abandonment to occur. This patient-physician relationship becomes established when a physician affirmatively acts in a patient’s care through the patient's diagnosis or treatment. This relationship is also established if the physician agrees to diagnose or treat the patient. A physician-patient relationship is often created when the “professional services of a physician are rendered to and accepted by another person for medical or surgical treatment,” which was further established by the Cygan v Kaleida Health court case in 2008.[1] There are certain circumstances in which a patient-physician relationship may be implied.

1. When a physician provides acute care in an emergency setting or provides care at the request of the patient’s regular physician.
2. When a physician provides medical care for a prisoner under a court order or a physician provides court-initiated treatment.
3. When a physician examines a patient in an independent medical examination context.[2]

Furthermore, there was a court case in 2015 where Pizzo-Juliano vs. Southside Hospital upheld that a physician-patient relationship can be implied between an on-call physician and patients whom the on-call physician has never met. In this particular case, a 2-year-old boy was bitten by a dog and was brought to the Southside Hospital emergency room. At this time, the hospital's on-call plastic surgeon was not available. The on-call plastic surgeon determined that a physician assistant would suture the young boy's facial laceration. This procedure led to the patient's facial scarring, pain, and suffering, and subsequently, this patient sued the plastic surgeon for malpractice. The plastic surgeon stated that a physician-patient relationship was not established because he never examined or treated him.[3]

To avoid these implied relationships, at the initial evaluation, a physician can provide a written statement to the patient stating that the initial visit does not guarantee entry into the physician's practice. The written statement may state that the visit is only for evaluation purposes and does not establish a physician-patient relationship. Additionally, when a physician works in limited examination settings such as community exercise events, health fairs, or websites (providing informal health advice), a physician can provide a disclaimer that an examination or the information provided does not establish a physician-patient relationship.[4]

Issues of Concern

Before dismissing a patient from practice, the clinician should evaluate whether all efforts have been made to ameliorate the relationship. For instance, when a patient is noncompliant with treatment and scheduled follow-up appointments, the physician can consider discussing the patient's needs and expectations. The physician and patient together may attempt to establish reasonable goals. If the patient has unrealistic expectations, the physician can attempt communication to reconcile differences. The physician should document all efforts made.[5]

According to American Medical Association (AMA) guidelines, a doctor may lawfully dismiss a patient for various reasons: Patient's repeated noncompliance with treatment and follow-up appointments that were previously agreed upon, disruptive or threatening behavior, unreasonable failure to pay for services, and a physician's closure of his/her practice or retirement. Other acceptable reasons or situations to dismiss a patient from a medical practice include when patients are misleading about their past medical history, chronic drug-seeking behaviors, displaying threatening or seductive behavior toward staff members or physicians, and a sentinel event such as violence, blatant sexual advances, theft, verbal threats or any criminal behaviors at the office. Such a sentinel event may require immediate intervention by security and law enforcement.[6]

Clinical Significance

Patient abandonment can be either intentional or inadvertent. An example of intentional abandonment is refusing to see a patient after failing to pay for the medical services received. Miscommunication regarding call coverage or negligence that occurs through errors in the scheduling system are examples of inadvertent abandonment. When patient injury or negligence results from a misunderstanding regarding the call schedule, the primary or covering provider may be liable for damages.

Suppose a physician is unavailable for long periods. In that case, a patient can be inadvertently abandoned, for example, if the physician takes an extended vacation or sabbatical without notifying the patient or arranging emergency coverage. Additionally, being unresponsive to patients' questions in an email or phone call, failure to follow up with a patient after surgery, or after the patient has started a new medication can be considered inadvertent abandonment.[7]

Nursing, Allied Health, and Interprofessional Team Interventions

The following are recommendations when health professionals terminate the patient-provider relationship.

1. Sending a termination letter to the patient by certified mail with a return receipt requested. Keep a copy of the termination letter and all communication documentation about the termination. If the physician works in a group, the termination letter should specify if the termination is between a specific provider or all the provider groups.
2. Providing the patient with an explanation for termination, however, providing a reason is not required and up to the provider's discretion, depending on what the reason may be. The AMA advises not to disclose the reason for dismissal. Another option is to include a vague phrase such as "the therapeutic benefit or alliance between patient and physician no longer exists."[8]
3. Agreeing to continue to provide treatment and medication refills for a reasonable period, such as thirty days since being notified, until the patient can secure care from another provider. Up to 90 days may be needed if no other providers are available within reasonable driving distance of the patient. For example, patients living in rural areas may need more time to obtain a new provider within a reasonable driving distance.[9]
4. Providing resources and recommendations to the patient about other physicians who may accept the patient and the patient's insurance.
5. Offering to transfer and promptly transferring records to the new provider upon signed patient authorization and being available to discuss the case to avoid patient care lapses.[10]

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References

1.

Farber NJ, Jordan ME, Silverstein J, Collier VU, Weiner J, Boyer EG. Primary care physicians' decisions about discharging patients from their practices. J Gen Intern Med. 2008 Mar;23(3):283-7. [PMC free article: PMC2359473] [PubMed: 18176852]

2.

Jerrold L. Patient abandonment. Am J Orthod Dentofacial Orthop. 2005 Feb;127(2):265-6. [PubMed: 15750549]

3.

Nicol GH. What is patient abandonment? Todays FDA. 2009 Jan;21(1):24-5, 27. [PubMed: 19402245]

4.

Blake V. When is a patient-physician relationship established? Virtual Mentor. 2012 May 01;14(5):403-6. [PubMed: 23351207]

5.

Bronshtein O, Katz V, Freud T, Peleg R. Techniques for terminating patient-physician encounters in primary care settings. Isr Med Assoc J. 2006 Apr;8(4):266-9. [PubMed: 16671364]

6.

Lippman H, Davenport J. Patient dismissal: the right way to do it. J Fam Pract. 2011 Mar;60(3):135-40. [PubMed: 21369554]

7.

McMullen L. Terminating the patient-physician relationship. Abandonment of the patient: what it means and how to avoid it. J Miss State Med Assoc. 2007 Sep;48(9):289. [PubMed: 19292120]

8.

Senderovitch H. The Ethical and Legal Dilemma in Terminating the Physician-Patient Relationship. Health Law Can. 2016 May;36(4):168-73. [PubMed: 27476245]

9.

Torres A, Wagner R, Proper S. Terminating the physician-patient relationship. J Dermatol Surg Oncol. 1994 Feb;20(2):144-7. [PubMed: 8113508]

10.

Gallagher TH, Levinson W. Physicians with multiple patient complaints: ending our silence. BMJ Qual Saf. 2013 Jul;22(7):521-4. [PubMed: 23576772]

Disclosure: Saendy Jung declares no relevant financial relationships with ineligible companies.

Disclosure: Rachel McDowell declares no relevant financial relationships with ineligible companies.