Health care practitioners often find themselves in situations where they wish to cease their treatment of non-cooperative or non-paying patients. As unpleasant as these situations may be, unfortunately the solution is not as easy as merely turning these patients away and shutting the doors on them. There is much more to consider before a practitioner can terminate the doctor-patient relationship.
Section 27 of the Constitution of the Republic of South Africa 1996, affords everyone a right to health care services and guarantees that no one may be refused the right to emergency health care services. Once a medical practitioner accepts a patient for treatment, both an ethical and a legal duty of care arise. It is for this reason that practitioners must take the necessary precautions when terminating the doctor-patient relationship, to ensure that they have discharged their duty of care in such a manner that the patient has continuity of care and will not be regarded as abandoned. Failure to discharge these obligations properly could lead to a complaint to the Health Professions Council of South Africa (HPCSA) or even a civil claim against the practitioner.
A practitioner needs to have sufficient reason to terminate the doctor-patient relationship. According to the HPCSA's Guidelines for Good Practice in the Health Care Profession, booklet 1 of 2016 (the Guidelines), a practitioner must always act in the best interest of the patient, even if such interests contradict their own. The guidelines are there to protect patients from prejudice arising from a practitioner’s personal beliefs and to protect patients from possible discrimination.
Before a practitioner terminates a doctor-patient relationship, they must evaluate the individual circumstances of that patient and make use of ethical reasoning to ensure that the termination is just and fair. They should consider all possible alternatives and measures which might remedy the situation and enable them to continue to care for the patient. Some situations will be easier to assess than others, where it will be clear that there is no solution but to terminate the doctor-patient relationship.
Once it is established that no possible alternative or remedy exists, and most importantly, that a continuation of treatment will prejudice the level of care given to the patient, a practitioner may terminate the doctor-patient relationship.
The following are possible situations, where termination of the doctor-patient relationship could be justifiable:
- Aggressive or violent patients: Practitioners also enjoy the constitutional right to security and a safe environment. If a patient is abusive, either verbally, physically or sexually, the practitioner can terminate the doctor-patient relationship for their own safety and wellbeing.
- Non-payment of fees: Practitioners cannot be expected to work free of charge. If a patient is unable to pay the practitioner’s professional fees, even when offered payment plans and/or discounts, the practitioner may refer the patient to a colleague who charges less, or to a state facility, for further treatment, unless the patient requires emergency treatment.
- Improper relationships: The HPCSA Guidelines advise practitioners against improper relationships with their patients. Examples of an improper relationship, as per the Guidelines, include a sexual or quasi-sexual relationship, or an exploitative financial relationship. If a practitioner and patient’s relationship develops into a sexual or romantic relationship, or when the doctor-patient relationship is being misconceived or misinterpreted by either the doctor or the patient, the practitioner may terminate the doctor-patient relationship. The improper relationship must either cause strain on the doctor-patient relationship resulting in breakdown of the relationship, or alternatively, must affect the decision-making capacity of the practitioner to render effective treatment.
- Non-compliant patients: A practitioner is at risk of a complaint regarding defective treatment when a patient is non-compliant. Practitioners must therefore document every incident of non-compliance and weigh the effects of such non-compliance against the potential detriment to the patient. Practitioners must always inform the patient of the risks associated with non-compliance and warn the patient that if the non-compliance continues, they will not be able to treat the patient further without placing themselves at risk. If the patient remains non-compliant, despite such warnings, the practitioner would then be justified in terminating treatment, should the risk of such non-compliance be material.
- Religious or embedded beliefs: Although the HPCSA Guidelines preclude a practitioner from refusing to treat a patient as a result of religious beliefs or differences, the practitioner’s constitutional right to their religious beliefs must also be upheld. If rendering treatment to a patient will result in a practitioner having to perform an act is that contrary to his or her beliefs, such as performing an abortion or participating in end of life treatment, the practitioner may object to providing such treatment personally. Practitioners must however be careful not to judge patients or object to providing treatment merely because of a difference in beliefs. The act of treatment itself must be contrary to the practitioner’s belief and such belief must be deeply rooted. The Guidelines indicate that in such a case, the practitioner must inform the patient of their objection and advise the patient of their right to see another health care practitioner.
Once it has been established that there is sufficient reason to terminate the doctor-patient relationship and that no alternative or remedial action exists which might fix the situation, the hard task of terminating the relationship begins. To do this, the practitioner must ensure that they do not alienate or abandon the patient. The termination must be documented in the patient file and the patient must understand that the relationship with that practitioner has been terminated. Most importantly, the patient must receive continued treatment.
It is recommended that a practitioner, from the onset, document all incidents which led to the termination of the relationship in the patient file, including the remedial measures or efforts attempted to salvage the relationship. The practitioner can then either write to the patient or arrange a meeting with them. The practitioner must explain to the patient, in a calm and respectful manner, that he or she cannot continue treating the patient and the circumstances that have led to the necessity for termination. The communication must be clear and comprehensible to avoid any misunderstanding by the patient which might lead them to expect continued treatment. This conversation or written correspondence must also be documented in the patient file.
The practitioner must recommend other doctors which the patient may consult and must assist the patient, where possible, to secure further treatment. This can be done by writing a report or referral letter to the patient’s next or recommended doctor. The practitioner can also provide the patient with a copy of their patient file so that the next treating practitioner will have access to the patient’s treatment history.
From the above, it is clear that practitioners cannot just close their doors to existing patients. Each patient’s circumstances must be evaluated carefully and appropriate steps must be taken to terminate the doctor-patient relationship, where this is indicated. The circumstances of some patients may be unique and some will be more difficult to handle than others. In case of doubt, a practitioner should always consult a senior colleague or seek legal advice.
