The Physician-Patient Relationship: What Constitutes It and How to Terminate It

By Ross E. Stromberg, Esq.

[Digest, Spring 1992]

Once begun, a physician-patient relationship cannot be abruptly terminated by the ophthalmologist if doing so would cause the patient additional harm. This is the theory of patient abandonment, a theory which has existed in the law of medical malpractice for decades. Today, particularly in the world of managed care and HMO contracting, it takes on renewed implications affecting the ophthalmologist's responsibilities to patients. Abandonment has been defined as the unilateral severance by the physician of the professional relationship between physician and patient without reasonable notice and at a time when there is still the need for continuing medical treatment. The physician may be held liable for injuries the patient suffers as a result of the termination.

The Physician-Patient Relationship

Allegations of abandonment can only be sustained against an ophthalmologist who has a legal duty to treat the patient and fails to do so. The physician's legal duty exists only to individuals with whom there is a physician-patient relationship. This relationship commences when the physician undertakes to treat an individual who approaches the physician for medical services, and it ends upon proper termination. During the course of the relationship, the physician must use his or her best efforts to treat the patient.

The physician-patient relationship may be established even after only slight involvement of the physician with the patient. In O'Neill v. Montefiore Hospital,¹ the court found that a physician who attempts to diagnose an individual's condition over the phone enters into a physician- patient relationship. In this case, as well as in cases involving, for example, an ophthalmologist-patient relationship, the ophthalmologist may be subject to a lawsuit for malpractice if he or she does not continue to treat the patient before termination has been effected. Needless to say, documentation of such phone conversations may be critical in determining the nature of the relationship.

A physician may, however, arbitrarily refuse to provide treatment to individuals who are not his or her patients. Under most circumstances, a physician is under no legal duty to render services to anyone who requests medical services and, unless statutorily required, may even refuse to provide emergency care to an injured person. Once a physician does provide emergency care, however, courts may determine that the physician must continue to provide treatment, at least until the individual is transferred to a hospital or until another physician assumes responsibility.

Termination of the Patient Relationship

An ophthalmologist's duty to treat is terminated upon the conclusion of the physician-patient relationship. The relationship is properly concluded when the patient dismisses the ophthalmologist or when the ophthalmologist and the patient mutually agree to terminate their relationship. Upon dismissal under these circumstances, the ophthalmologist should guard against later allegations of improper termination by confirming the termination in a letter sent to the patient. As a measure of further protection, the ophthalmologist should provide his or her successor with all information necessary to enable the patient to receive continued treatment without delay and, where appropriate, should advise the patient in writing of the necessity for further care.

Proper termination of an ophthalmologist-patient relationship also occurs when the ophthalmologist brings the case to its medical conclusion. That is, the relationship concludes when the ophthalmologist's services are no longer needed. For example, where a patient engages an ophthalmologist to treat an illness, the relationship is terminated upon the cure or death of the patient; where an ophthalmologist acts only as a consultant, the relationship terminates upon completion of the consultation. Similarly, if the patient's condition calls for a series of treatments, the relationship concludes when the series of treatments are completed. At times, however, the point at which the case reaches it medical conclusion can be difficult to ascertain. Courts could determine that follow-up examinations and check-ups which are reasonably foreseeable are within the necessary scope of treatment. Once again, documentation may be critical.

Finally, the physician also may properly terminate the patient relationship by withdrawing as the treating ophthalmologist. Before doing so, however, the ophthalmologist must first provide reasonable notice of termination so the patient has time to secure the services of another ophthalmologist. Although the law does not specify the amount of time that a physician must provide before services are terminated, factors that might be considered include the nature of the medical problem, the proximity of qualified substitute physicians, and the willingness of potential substitutes to assume treatment of the patient.

Applying these principles to cases involving troublesome patients can be vexing, particularly where treatment is required over a long course of time. Nevertheless, these rules, and common sense, should resolve most if not all situations. In the absence of proper termination, the ophthalmologist must continue to provide care to the patient as long as the doctor-patient relationship exists. This is so even if the patient refuses to pay the medical bill. However, if the patient fails to keep or renew appointments with the ophthalmologist, the patient, as a general rule, cannot claim abandonment providedthe doctor has a clear record of such conduct in the patient's chart.

Nor can the patient claim abandonment if the ophthalmologist's own ill health prevents him or her from providing treatment. In such cases, it is sufficient that the physician took reasonable steps to provide a qualified substitute.

Managed Care and Limitations on the Patient Relationship

Managed care or contracting with HMOs adds new dimensions to the issue of patient abandonment. For instance, a typical provision of a physician services agreement with an HMO provides that, if the agreement is terminated, the physician must continue to be responsible for providing services to assigned enrollees under his or her care at the time of such termination until services rendered are completed, or the HMO makes other arrangements. Often, such agreements are vague as to the HMO's responsibilities to continue to pay an ophthalmologist for services rendered in these wind-down periods. In any event, normal rules governing doctor-patient relationships and the theory of patient abandonment apply even though the ophthalmologist may have difficulty collecting payments for services rendered.

When the ophthalmologist enters into a doctor-patient relationship with an individual, the physician may place limitations on the scope of the relationship. If the patient agrees to these limitations, the physician's duty to treat the patient will be circumscribed accordingly. An ophthalmologist may, for example, restrict his or her practice to the doctor's office or to a certain geographic region. Under those circumstances, the physician's declination to make a house call or to render care outside the geographic region would not likely constitute abandonment of the patient. Moreover, where an ophthalmologist is brought into a case as a one-time consultant or limits his or her duty to one call, further treatment by the ophthalmologist is not legally required. It is vital that the physician make any limitations on the relationship clear to the patient at the inception of the relationship and document this fact in order to avoid later allegations of abandonment.

Negligence or Breach of Contract

A patient who alleges abandonment may bring a malpractice lawsuit against an ophthalmologist based either on negligence or breach of contract. Generally, the patient will pursue an action based on the tort of negligence because damages for pain, suffering and mental anguish are available in tort actions. In an action based on breach of contract, on the other hand, the patient who prevails usually can receive only out-of-pocket expenses. However, as the statute of limitations typically is longer for contract actions than for tort actions, a patient who waits too long might have no choice but to file for breach of contract.

In conclusion, an ophthalmologist is exposed to potential allegations of abandonment whenever the doctor ceases treatment of an individual for which he or she has undertaken care. To limit the possibility of being held liable for damages resulting from an alleged abandonment, an ophthalmologist should continue treatment of any individual with whom he has a physician-patient relationship until proper termination is effected. The ophthalmologist should, moreover, make the patient aware of any limitations on the care to be rendered at the inception of the relationship. The ophthalmologist can further guard against potential liability for abandonment by confirming in a letter sent to the patient any termination of the relationship by the ophthalmologist or the patient and any unusual limitations placed upon the relationship by the physician.

A sample letter of termination of care is presented in Figure I. A sample health care agreement describing the responsibilities of both parties and defining the parameters of care was published in The Western Journal of Medicine in an article titled "Disruptive Medical Patients: Forensically Informed Decision Making" (May 1992). Reprint requests should be addressed to Landy F. Sparr, MD, Dept. of Veterans Affairs Medical Center (116A-OPC), PO Box 1036, Portland, OR 97207.

Notes:

1. O'Neill v. Montefiore Hospital, 11 AD 2d 132,202 NYS 2d 436 (1960).