Terminating Treatment, Physician Perspective

The involuntary dissolution of an established physician-patient relationship can be one of the more difficult medical decisions a clinician must make. Cultivating a relationship and gaining the trust of patients is a fundamental skill in clinical medicine. Without trust, patients will not provide the necessary information for an accurate diagnosis and are less likely to comply with recommended treatment. The process of gaining trust and establishing a relationship is more overt in primary-care specialties, where it is often necessary to obtain sensitive historical details for clinical decision making. However, the establishment of trust is no less necessary in surgical specialties, where the consequences of clinical decision making are more immediate and where the risks of poor decision making are often higher.

In nonprofessional relationships, trust is acknowledged to require equal participation by both parties. Trust is both earned and given in equal measure by both participants. This is not the general view of clinicians, who understand that there is an unequal power balance between physician and patient and who therefore feel disproportionately obligated to earn the trust of their patients in order to provide good care. During training, it is understood that this empathetic skill will be required of trainees even when patients are personally objectionable or even hostile toward the physician. Physician trainees are considered to bear the majority of the responsibility for establishing a mutually trusting and beneficial therapeutic relationship. As a result of this professional socialization, a physician-patient relationship that has deteriorated to the point of termination can be experienced as a sign of failure on the part of the clinician. This feeling can contribute significantly to the emotional difficulty of the decision to terminate treatment.

Having said this, it is widely acknowledged that not all physicians will be able to cultivate mutual trust with all patients and that a small percentage of physician-patient relationships will need to be terminated. The difficult medical decision comes in determining which relationships [Page 1129]have reached this threshold and when they have reached it. There are three accepted reasons for terminating a physician-patient relationship: (1) noncompliance with treatment, (2) disruptive behavior, and (3) nonpayment of bills.