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Established Provider-Patient Relationship

The simplest example of a duty to render care is the duty owed to a patient already under the health care provider's care. If a patient is under the care of a physician for an acute illness, the physician cannot quit treating that patient (unless released by the patient) if it would compromise the patient's recovery. The physician may arrange to transfer the patient to the care of another physician, but this cannot be done without the patient's permission. If the transfer is done without the patient's permission, the referring physician must ensure that the new physician is equally skilled, will accept the patient, and will be equally accessible to the patient. The patient cannot be referred to a physician 100 miles a way, nor can the duty to continue treating the patient be obviated by referring the patient to a physician who refuses to treat the patient. (The duty to render continuing care also applies in the hospital setting; this is reviewed later in this chapter.)

The physician has a responsibility to transfer the patient if the patient needs special care that the physician is unable to render. The physician must still ensure that the patient will receive proper care as a result of the transfer. If the patient's only choice is limited care from the original physician or no care because the receiving physician will not accept the patient, it would be legally risky to force the patient to accept the no-care alternative.

The continuing duty to treat is fairly limited in chronic conditions. If the patient has a chronic condition, such as diabetes, the physician may terminate the physician-patient relationship during a stable period of the patient's illness. The patient must be given notice of the provider's intention to end the relationship so that the patient may seek care elsewhere. This notice should be in writing, and there should be a receipt indicating that the patient received the notice. If the patient is not due for an appointment or has ceased coming to the physician, the most effective way to give notice is to send a letter by certified mail. A return receipt should be requested, with delivery restricted to the addressee. When the return receipt is received, it should be clipped to a copy of the letter and placed in the patient's medical record. If the letter is returned as undeliverable, it should be placed, unopened, in the patient's record as evidence of a good faith effort to contact the patient. The physician does not owe the patient a legal duty to recommend alternative sources of care; but it is good practice to do so, and it may defuse potential disputes with the patient.

No matter how effective the notice is, it would be questionable, from a quality control point of view, if the physician should ever knowingly refuse care to a former patient who presents to the physician needing emergency care. If the patient is injured because of a delay caused by the physician refusing to render care, the physician may be sued and may have to defend the decision to refuse care. The law may be on the physician's side, but this will not prevent the expense and trauma of litigation.

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