Physicians are obliged to suggest treatment that, in their best medical judgment, is appropriate for the individual patient. However, a competent patient may refuse any treatment.

A physician who encounters a patient who refuses recommended testing or treatment is advised to discuss or maintain an ongoing dialogue with the patient concerning:

1. what the testing/treatment entails
2. why it is the recommended course of action
3. the risks and benefits of the proposed testing/treatment
4. the risks of not having or delaying the testing/treatment
5. any alternatives that are possible. Such dialogues and the patient's refusal should be carefully documented and include the patient's signature whenever possible. 

• Notify the patient in writing, preferably by certified mail
• Provide the patient with a specific reason for the termination
• Agree to continue as the treating physician for at least 30 days
• State clearly the date termination becomes effective
• Recommend or provide information for identifying physicians of the same specialty
• Offer to transfer records to the new physician upon receipt of a signed authorization to do so
• Offer to see the patient in cases of emergency within a stated period of time after termination
• Include the above referenced items in the letter notifying the patient of the termination

Because legal requirements for terminating a patient relationship vary by locale, physicians should check the state policies where they practice. Careful documentation of patient non-compliance, disruptive behavior, or evidence of poor rapport will serve as the basis for the explanation and defense of the rationale for a termination of the relationship should the action be challenged.

Adapted from Risk Management Principles & Commentaries for the Medical Office, published by the AMA/Specialty Society Medical Liability Project.

Attempting to terminate a relationship in an emergency or urgent care situation, with a patient in the latter stages of pregnancy, or with a patient who may not be mentally competent, is not recommended. If termination is not currently an option, the physician should work with the health care team to develop a coordinated approach to dealing with the difficult patient. Liaison psychiatry programs and social work services can often provide valuable assistance.

Occasionally, particularly in rural areas, only one specialist may be available to treat the patient's condition. These situations require more creative approaches to provide support for a troubled relationship and may necessitate a more active role by the physician in planning alternative care arrangements.

Terminating a relationship with a patient who is HIV-positive, or who has a diagnosis of AIDS should be treated no differently than other situations. Carefully document the rationale for the termination in the medical record and follow the other steps listed above. The timing of the termination may also be critical if a claim emerges. A physician who terminated a patient close to the time he or she learned of the patient's HIV status, or when insurance coverage was dropped or reduced, might have difficulty convincing a jury such action was not discriminatory.

Yes.

The federal law requires that any hospital report improper transfers to the appropriate state or federal agency within 72 hours of the patient's arrival from another hospital. Institutions may want to provide for notification to administration or the risk manager if they have received an apparent inappropriate transfer. Any action that needs to be taken can be discussed with the "referring" hospital.

Yes.

Upon receipt of the patient's written authorization, a physician must forward copies of the medical record, regardless of the patient's payment status. In Massachusetts, the Board of Registration in Medicine (BRM) regulations allow a physician to charge a "reasonable fee" for the expense of providing a copy of the record, but specifically prohibit prior payment of the charges connected with that care as a condition of making a copy of the record available. A physician could be subject to disciplinary action by the BRM for violating this regulation.