Terminating The Dentist-Patient Relationship

The majority of your patients are likely conscientious about honoring appointments, compliant with your treatment decisions, and pleasant with you and your staff.  However, every practice has its share of problem patients: those patients who repeatedly no-show to appointments or cancel at the last minute, who refuse to follow even simple instructions, or are just plain difficult to deal with..  Although it is always best to try to work through any issues with the patient, there may come a point when you conclude that it is simply better for everyone to terminate the treating relationship with the patient.

Practical And Ethical Considerations

Ending a relationship with a patient is not something to take lightly.  Not only will you lose a patient from your practice, but the patient may take other actions that could potentially harm your practice, such as leaving negative, and possibly false, reviews on websites like Yelp and Google Reviews.  If this happens, you may need to take additional action against the patient to preserve your practice’s goodwill.

After considering the pros and cons, once you have made the decision to end the doctor-patient relationship, you have to make sure you follow the legal and ethical guidelines under Arizona law to properly terminate the relationship.  Under the Arizona Administrative Code, the regulations which govern the practice of dentistry, a dentist of record for a patient must remain responsible for the care of a patient during the course of treatment and be available to the patient at all times.[1]  The failure to do so constitutes patient abandonment, and can be grounds for disciplinary action under Arizona law.[2]

The potential discipline for patient abandonment under Arizona law can include revocation or suspension of your license, a censure, probation or fines and penalties.[3]  In order to avoid potential patient abandonment issues, you must make sure you properly terminate the relationship.

Terminating The Relationship

The Arizona Board of Dental Examiners has issued a non-binding “Agency Substantive Policy Statement” to help guide dentists in terminating a patient relationship.[4]  Specifically, Agency Substantive Policy Statement #14 defines “patient abandonment” as “A dentist or physician who discontinues his services to a patient before the need for those services has ended and without giving that patient notice and an opportunity to procure the services of another [dentist or] physician.”

The Policy Statement also warns that a dentist may withdraw from treating a patient but he or she “is bound first to give due notice to the patient and afford the latter ample opportunity to secure other medical attendance of his own choice.”  If the dentist has not done so, then in addition to potentially violating his or her ethical obligations, he or she may also be liable for malpractice, if the patient is harmed in any way as a result of the inadequate notice and refusal to provide additional services.  For example, if a patient has an abscessed tooth that needs prompt extraction, and you terminate the relationship without treating the abscess, you could be liable to the patient for any damages suffered as a result of any delays caused by your refusal to treat the abscess.

Therefore, in considering whether a dentist has abandoned the patient, as opposed to properly terminated the relationship, the Board will look at the circumstances of each case and determine whether the dentist provided sufficient notice to the patient.  This means that there is no bright line rule for what constitutes proper notice.  If the patient has a particularly complex set of issues that only a limited number of dentists can provide, or if your practice is located in a more remote geographical area with fewer alternative treatment options, you will need to provide more notice than for a patient with run-of-the-mill treatment needs in the Phoenix or Tucson metropolitan areas.

Once you have decided on an appropriate notice period, after consulting with counsel, the following steps are generally how the termination should be communicated to the patient:

  1. Prepare a letter advising the patient that you are terminating the relationship. You should usually also give the patient a reason for the termination, such as missing too many appointments, hostility to the staff, failure to meet financial obligations, or that there has been a breakdown in the interpersonal relationship between the patient and the doctor.

  1. If applicable, the letter should inform the patient of any health issues that he or she is currently facing, the recommended treatment, and the risks of not seeking further care.

  1. State in the letter that the termination is effective as of the date of the letter, but that you are available to provide emergency care or other necessary services during the notice period.

  1. Advise the patient that he or she should find a new treating provider as soon as possible, and assure the patient that you will cooperate fully with transferring his or her dental records to the new treatment provider, and will provide the records to the patient, upon request.

  1. Send the notice to the patient by certified mail, return receipt requested, to be opened by the patient only, and make sure to save the signed receipt.

These are just general guidelines, and it is important to remember that every situation is different and there may be other considerations you must take into account.  For example, if the patient is enrolled in a third-party payor plan like AHCCCS or Delta Dental, there may be contractual requirements you must follow in order to terminate the patient.  Additionally, you cannot terminate a patient relationship for any discriminatory reason, such as on the basis of age, race, or disability.

Even under the best circumstances, terminating a patient relationship can cause animosity.  With problem patients, especially ones who have already shown hostility to you or your staff, terminating the relationship can be a legal and ethical minefield that you may not want to enter without experienced legal counsel, after you have given serious consideration to the possible consequences.

[1] See A.A.C. § R4-11-501(E)

[2] See A.A.C. § R4-11-501(F)

[3] See A.R.S. § 32-1263.01 and 32-1263.02.

[4] https://dentalboard.az.gov/substantive-policy-statements