Every physician faces caring for an uncooperative patient at one time or another. Failure to follow a prescribed plan of care, frequently missed appointments, open displays of hostility, and/or Doctor shopping can all be indicators of a potential litigant. The physician who feels he cannot provide good care because of the patient’s lack of cooperation is not legally obligated to continue to treat the patient as long as he makes proper arrangements to withdraw from the case. Further, allegations of patient abandonment can be effectively diffused if physicians take basic precautions, plus carefully document medical records and informational exchanges with the patients. It is important guidelines also apply in situations in which medical practice is destroyed, is terminated, or is purchased by a hospital or corporate entity, transfer of practice, death of a physician.

There are many troublesome situations in which a physician, or a physician=s office, could be alleged to have abandoned the patient. These include:

1. Unqualified refusal to further attend to the patient.

2. Leaving the patient unattended during or immediately after an operation while presence is necessary.

3. Refusal to treat at a certain time or at a certain location.

4. Premature discharge or dismissal of a patient.

5. Failure to give proper instructions before discharging a patient.

There are also many practical and valid reasons why physicians are withdrawing or discontinuing medical care. These may include;

1. Illness or death of the physician. This can excuse unilateral ending of the patient care relationship, but only with timely notification and the patient’s opportunity to get another physician. If immediate treatment is needed, the physician should arrange for a competent substitute.

2. Patient uncooperativeness. Liability can be avoided by following procedures under the next heading entitled “Important Guidelines.”

3. Substitution of another physician. This can pose problems if a patient isn’t given notice or doesn’t agree to the substitution. Ask for and get consent.

4. Unpaid medical bills. Courts generally have held this doesn’t justify unilaterally terminating the relationship when the patient still needs medical attention.

There is no question that the patient must absolutely be informed, in writing, of your intention to withdraw from the case. Send the letter by certified mail with a return receipt requested. Document any discussion with the patient and the issuance of the letter in the patient’s medical record. Your office staff should also document any contact they have had with the patient. If appropriate, and if the patient has given a consent of an individual to contact in an emergency, it may be appropriate to provide notification to a “significant other.” This letter should address the following issues:

13072. Advise the patient of your intention to withdraw and provide a sufficient period of time for the patient to obtain another physician.

13073. Refer the patient to a State or Local Medical Society (provide name, address and telephone number) to obtain a list of other physicians in the speciality required.

13074. State the reasons that led to the decision to withdraw from the care of the patient, failure to meet financial obligations, failure to cooperate in the established plan, illness or death of the physician, etc.

13075. State the reasons for termination in general terms, not specific. If the patient has urgent problems address it – mention a specific period of time in which the patient should be seen by a subsequent treating physician for the problem. State the urgent problem in general terms indicating the potential consequences.

13076. State your availability for emergency treatment if possible.

13077. Provide a deadline for withdrawing from the case, “After July 30, 1998, I will not see you as a patient.” If you do see the patient after this letter is issued, remember you must begin the entire process again.

13078. You may provide a copy of your office records or a summary of the care provided, to the new attending physician (with proper authorization from the patient). However, be certain not to breach confidentiality privileged by Statutes (e.g. psychiatrists or psychologist=s reports, drug and alcohol abuse). It may be best to contact legal counsel.

Unfortunately each letter must be tailored to the individual situation. A form letter will not work in situations in which there are efforts made to address any patient’s urgent problems. The following guidelines may be useful, but not necessarily totally effective in handling all situations. The advice of an attorney may be helpful in safeguarding against circumstances which pose additional or special risks:

Withdraw from care of uncooperative patients with written notification. Send letters by certified mail, requesting a return receipt (to verify delivery).

Specify reasons for withdrawing in tactful, general terms; allow adequate time for the patient to make other medical care arrangements; advise on ways those other arrangements could be made; offer to provide copies of medical records to a new physician; advise if patient should be seen by another physician within a specific period of time (to have an urgent problem handled); provide a general warning of consequences of leaving the problem untreated; indicate willingness and availability to treat emergency needs for a specified period of time; identify a specific date after which care will be discontinued.

Documentation is critical. Retain original hospital, laboratory or office records, along with copies of letters and certified mail return receipt.

Hospitalized patients require additional precautions. Be certain another competent physician has assumed full responsibility prior to discontinuing care. In teaching hospitals, remaining involved in a case because of “interest” after providing a consultation can be dangerous. Document all transfers of patients to other physicians, including the patient’s agreements to the transfers. A transferring physician should be certain the new physician acknowledges (in the record) acceptance of responsibility. At that point, the withdrawing physician should disassociate with the patient care management; a discharge/transfer summary should be dictated immediately ( a delay could implicate the withdrawing physician in subsequent problems).

Clearly define roles of attending physicians, consultants, one-time care-givers. Physicians with initial responsibility may be legally responsible and subject to abandonment charges.

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