This case is one in a series of case studies with commentaries by ACP's Ethics, Professionalism and Human Rights Committee and the Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's Ethics Manual, the Physician Charter on Professionalism, or other College position statements. The fifth edition of the ACP Ethics Manual, the Professionalism Charter, and additional College policy on ethics, professionalism, and human rights issues are available at http://www.acponline.org/ethics/ethics_man.htm or by contacting the Center for Ethics and Professionalism at 215/351-2839.

Case History

Peter Jones, MD, is a busy urban internist with a large population of diabetes patients. One patient in particular has been on his mind constantly in recent weeks.

Mr. Green has been a patient for just over two years. Among other medical problems, he has painful peripheral neuropathy as a result of poorly controlled diabetes. In the past year, he has also gained significant weight and has resumed smoking -- and is not consistently measuring his blood sugar or taking his many medications, except pain medications. In recent months, in fact, Mr. Green has returned to the office repeatedly without an appointment, saying he's lost his pain prescription and needs a replacement.

At the same time, Mr. Green has missed regularly scheduled appointments for hemoglobin A_1c testing and blood pressure checks. Dr. Jones was worried about his last lipid profile and discussed it in depth with Mr. Green, but Mr. Green did not seem to focus on the results.

Dr. Jones has counseled Mr. Green on care management, its importance and the potential consequences of uncontrolled diabetes. But he is concerned the patient is not doing his part. Dr. Jones also reviewed a "pain contract" with Mr. Green in detail. Mr. Green said he understood its terms and agreed to abide by them, but Dr. Jones believes the patient is abusing the pain drugs, selling them, or both.

Dr. Jones is now reluctantly considering severing the treatment relationship, but is not sure if and how to do that. He also worries that the "pay-for-performance" initiatives he is involved in may be influencing his views of the situation, because his performance profile would surely improve if Mr. Green were not his patient. But if not his patient, Mr. Green will still need care from someone in the community.

Commentary

The patient-physician relationship is one of the most important aspects of medical care. Recent literature^[1-4] emphasizes the importance of this relationship, the need for trust and openness in the relationship, and its therapeutic implications for patients.

One central tenet of that relationship is ensuring continuity over time. Physicians have an ethical obligation to maintain the relationship once it is established^[5-7] and in doing so, to be honest with patients.^[5,7,8] Physicians must also be committed to maintaining appropriate relationships, given the power imbalance between physicians and patients and the inherent vulnerability illness can bring to individuals.^[5,8] Although physicians have obligations to patients from the outset, those obligations become even stronger over time as the patient comes to depend on the physician. That is particularly true if dissolving the relationship would harm the patient.^[9]

In the language of ethics and the law, a physician may not abandon a patient.^[5] Abandonment has been defined as the physician's unilateral withdrawal from the relationship without formal transfer of care to another qualified physician.^[10] However, the ethical obligation of the physician to maintain a relationship with a patient is not without limits.^[11] Experts have argued that a physician may refuse to continue caring for a patient when, for example, continuing that relationship may harm other patients or the physician, as in the case of a patient who threatens physical violence.^[12] Likewise, a physician is not required "to violate fundamental personal values, standards of medical care or ethical practice, or the law^[5]" in providing patient care.

A physician may discharge a patient from the practice after concerted attempts to resolve the matter have failed, if adequate replacement care is available and the patient's health is not jeopardized in the process. But the physician must ensure that the reasons for discharging a patient are justifiable and ethical.^[5,9,12,13]

As both an ethical and legal matter, for instance, physicians must make sure that discrimination plays no part in any patient discharge decision. According to the ACP Ethics Manual, Fifth Edition, a doctor may not discriminate against a class or category of patients.^[5] In addition, the federal Americans with Disabilities Act of 1991 prohibits physicians from refusing to care for disabled patients. A number of cases have arisen, for example, involving physicians who have refused to care for HIV positive patients.^[14,15]

Dr. Jones must also honestly assess his concerns and motivations about "pay for performance" in considering discharge of the patient. Discharging a patient because of economic concerns or reimbursement levels is ethically objectionable.

Dr. Jones needs to explore the reasons why Mr. Green is acting as he is. Although Mr. Green's actions seem to clearly sabotage his own best interests, patients do have the right to make decisions in keeping with their own values, despite the risks.^[16] At the same time, physicians have their own set of values and beliefs, and must try respond to patient goals and values without violating them.

To resolve this dilemma, Dr. Jones should take a negotiated approach with the patient before he considers ending the relationship. A key component of this negotiation is communication with the patient that centers on understanding the patient's values and motivation. As part of this approach, Dr. Jones should ask Mr. Green about smoking, missed appointments, and nonadherence to drug regimens, diet and laboratory work.

Trying to work with Mr. Green to correct some of these issues will respect and help the patient, and potentially improve the patient-physician relationship. Both the patient and physician should discuss their concerns and expectations for ongoing care. The physician should try to understand the patient's wishes and beliefs, make a serious attempt to resolve differences, and document all these efforts before considering discharge and transfer of the patient's care.^[5] Although there are obviously health systems differences between the U.S. and U.K., it is noteworthy that in one survey of British general practitioners who discharged patients from their practices, nonadherence was not listed by any respondents as the cause of the dismissal.^[17] If physicians do discharge patients for nonadherence, it should be only a last resort.

Concerns about a patient's use or abuse of opioids are sometimes a reason why physicians consider the discharge of a patient. Specific information in the U.S. is not available, but such occurrences were noted in only 4% of British physicians' instances of patient dismissals,^[17] although they are probably more common than is reported. However, patients often exhibit behavior that appears to be "drug seeking" when in fact, they are simply responding to increasing pain. Dr. Jones needs to explore the possibility of this "pseudoaddiction" with the patient. He does not seem to have evidence to confirm that the patient is selling his prescribed opioids -- but if Mr. Green has violated his pain agreement, Dr. Jones should look for another way to address Mr. Green's pain or should refer him to a pain management center where Mr. Green can be more closely monitored and treated. He might tell Mr. Green clearly what care he will and will not provide, and that Mr. Green should assess whether he would be more satisfied seeking care elsewhere if he is not happy with the arrangement.

Despite the physician's good intentions and communication with the patient, the patient-physician relationship may break down to the point where it is best for the physician to sever the relationship. Discharge, however, should be an absolute last resort, given how much distress discharge can cause patients.^[18,19] Some physicians make it a policy to not discharge a patient short of threats of violence, especially if a challenging patient will just remain challenging with a colleague.

Dr. Jones may move to discharge the patient if he meets the following criteria:

• He has done everything possible to address Mr. Green's problems;
• He has informed the patient of the consequences of his actions, both for his own health and his relationship with his physician; and
• He feels Mr. Green would be better off with another physician.

Before moving ahead, however, he should check the rules of Mr. Green's insurer. There may be limitations on his ability to discharge patients from that plan or some specific mechanisms for doing so.

Once Dr. Jones has made the (uncommon) decision to discontinue his relationship with the patient, he must do so in a way that is ethically and legally sound. Care must be available elsewhere, the patient's health may not be jeopardized during the process^[5] and several elements of the discharging process must be adhered to.^[11]

Dr. Jones would need to notify Mr. Green in writing that he is being discharged from his practice. That communication should include an explanation of the ethically valid reasons why the discharge is taking place. In his letter, Dr. Jones also needs to note that he will continue to provide care for a reasonable amount of time to allow Mr. Green the opportunity to find replacement medical care. He also should offer to transfer records to the new physician with patient authorization.^[20]

While there is no standard definition for the amount of time to allot, most practitioners give patients 30 days to find another physician and usually offer them resources or help for doing so. During that 30-day window, Dr. Jones is obligated to continue to provide medical care to Mr. Green, should the need arise.

Dr. Jones should send the letter sent via certified mail return receipt requested,^[19] and should also have a conversation with the patient about the end of their relationship. He should also ensure that Mr. Green's medical records are released to his new physician in a timely manner when Mr. Green finds another physician. If the ending of the patient-physician relationship is necessary, by adhering to these standards, Dr. Jones can ensure that the transition of Mr. Green's medical care to another physician is as smooth as possible and that he is conforming to the ethical principles of nonmaleficence, the duty to do no harm, and of beneficence, the physician's obligation to promote the good of the patient and to act in the patient's best interests.

Acknowledgment: The Ethics, Professionalism and Human Rights Committee would like to thank Neil J. Farber, MD, FACP, and Lois Snyder, JD, authors of the case history and commentary.