Termination of Patient–Physician Relationship
Termination of patient–physician relationship is a subject little discussed in pediatric literature. Termination of care is considered justified in situations that are: 1) potentially harmful to the healthcare provider or his/her practice (abusive and violent behavior, failure to pay bills, repeatedly missed appointments, overly demanding patients, etc.); or 2) harmful to the patient (nonadherence to medical advice, conflict of interest between physician and patient care, harmful behavior or practices, such as drug abuse, etc.). A related subject, whether parental refusal for child vaccination is grounds for termination of a patient–physician relationship, has recently received widespread attention and produced heated commentary in the pediatric community.11-13 As an officially sanctioned medical practice, such a decision remains on rather shaky ethical ground.12
In a case under consideration, the parent’s unacceptable behavior would qualify as grounds for termination of the patient–physician relationship. The parent’s behavior not only disrupts the clinic staff’s routine and sensibility, but it has a significant impact on the other children and families in the waiting area. Sometimes such behavior may escalate to threaten the safety of the office staff and other patients. Thus, termination of the patient–physician relationship could be considered justifiable even though, given the shortage of physicians with the required expertise, the health and well-being of the child may be at jeopardy. Due to important legal and professional constraints, it is a step not to be taken lightly.
The patient–physician relationship is based on the concept of “beneficence-fidelity.” This concept dictates: 1) a commitment to promote the health and well-being of the patient (beneficence); 2) a willingness to subordinate one’s own interest to the interest of the patient’s health; and 3) a commitment to earn and maintain the patient’s trust. This principle is endorsed by the American Medical Association, the American College of Physicians, and the General Medical Council of the United Kingdom.
A physician is free to choose whom to treat (in nonemergency situations), but once a patient–physician relationship has been established, the physician is obligated to provide the patient with consistent, ongoing care as needed.14 This relationship is expected to be one of mutual respect and collaboration, with patients sharing in the responsibility for their healthcare. Nonetheless, for a variety of reasons as discussed above, this relationship may irrevocably break down, necessitating a termination action. Central to decision making in such circumstances is the concept of nonabandonment. Nonabandonment requires that, after a decision to terminate care has been made, the physician remains obligated to provide care for the patient for a specific time sufficient to permit the parent/patient to find another medical provider.15
