Just as it is an acceptable and reasonable practice to screen incoming patients, it is acceptable and reasonable to know when to end patient relationships that are no longer therapeutic. It is critical, however, to end the patient relationship in a manner that will not lead to claims of discrimination or abandonment.

It is appropriate and acceptable to terminate a relationship under the following circumstances:

• Treatment nonadherence.
• Follow-up nonadherence.
• Office policy nonadherence.
• Verbal abuse, violent behavior, or threats of physical harm.
• Nonpayment.

A few situations, however, may require additional steps or a delay or even prohibit patient dismissal. Examples of these circumstances include:

• If the patient is in an acute phase of treatment, delay ending the relationship until the acute phase has passed.
• If the practitioner is the only source of care within a reasonable driving distance, or when the practitioner is the only source of specialized care, he or she is obliged to continue care until the patient can be safely transferred to another practitioner.
• If the patient is in a prepaid health plan, the patient cannot be discharged until the practitioner complies with the terms of the payer-provider agreement.
• A patient may not be dismissed or discriminated against based on limited English proficiency, or because he or she falls within a protected category under federal or state legislation.
• If a patient is pregnant, the physician can safely end the relationship during the first trimester if the pregnancy is uncomplicated and there is adequate time for the patient to find another practitioner. During the second trimester, a relationship should be ended only when it is an uncomplicated pregnancy and the patient is transferred to another obstetrical practitioner prior to the cessation of services. During the third trimester, a relationship should end only under extreme circumstances.
• The presence of a patient's disability cannot be the reason(s) for terminating the relationship unless the patient requires care for the particular disability that is outside the expertise of the practitioner.

When terminating the relationship is appropriate and none of the restrictions mentioned above are present, termination of the relationship should be completed formally. Put the patient on written notice that he or she must find another healthcare practitioner. The written notice should be mailed to the patient by both regular mail and certified mail with a return receipt requested. Keep copies of all the materials in the patient's medical record.

More details on what to include in a written notice can be found in the expanded version of this article here.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.