Parting ways - the right way: Terminating the client relationship

The COVID-19 pandemic has caused widespread disruptions to several health professional services.^[1] During the pandemic, it may be necessary to transfer clients to other services providers who are better equipped to provide virtual care during this period of social distancing. In post-COVID context, it may well be necessary to relocate, transfer, close a practice, or otherwise formally discontinue client services.

An early ending to a therapeutic relationship can be stressful for both clients and health professionals, which may result in conflict. For this reason, it is important to reflect on the reason for discontinuing services, and appropriately plan the termination process to ensure both client and clinician part ways in a safe, ethical and professional manner.

The Decision to Terminate

It is a health professional's obligation to ensure that he or she acts in the best interest of his or her clients at all times, including when discontinuing services. There are several legitimate reasons for discontinuing services to clients, and may include circumstances where:

• the health professional believes the client will not benefit from continued therapy/services or is non-adherent to treatment plans;
• the health professional would be at risk of serious harm if she/he were to continue working with the client, e.g. the client threatens or assaults the member;
• the health professional lacks the necessary competence to continue working with a client;
• the health professional is relocating, transferring or closing their practice.

Of course, what is considered a valid reason for termination varies among Regulatory Colleges. For instance, in certain Regulatory College jurisdictions non-payment of fees or the conclusion of a fixed number of sessions may not be sufficient grounds for immediately discontinuing services. In others, lacking the necessary competence triggers an obligation to refer the client to another professional with the requisite expertise. It is therefore important for health professionals to review their College policies and standards of professional conduct to ensure there is a valid and reasonable basis to terminate the client relationship.

Health professionals should also be aware of applicable human rights legislation and regulatory policies to ensure that they do not discontinue services on a discriminatory basis. For instance, the Human Rights Code in Ontario prohibits discrimination based on 17 grounds, whether perceived or otherwise, including disability, ethnic origin, place of origin and race.

The Ontario Human Rights Commission has taken the position that COVID-19 is a disability under the Code, as it constitutes a medical condition or perceived medical condition that carries significant social stigma. However, the right to be free from discrimination can be limited under the Code (for example, where health and safety risks are serious and would amount to undue hardship). The grounds for terminating the client relationship must in any case be reasonable and valid. 

The Termination Process

For most health professionals regulated under the Regulated Health Professions Act in Ontario and similar legislation other provinces, it is considered professional misconduct to discontinue services that are needed by a client unless, (1) the client requests the discontinuation, (2) alternative services are arranged, or (3) the client is given a reasonable opportunity to arrange alternative services. In determining the right approach to termination, it is critical to review the Professional Misconduct Regulations and College Standards of Practice that apply to the regulated health professional. The appropriate termination process will vary depending on the circumstances, and so health professionals should consider the following:

What to Say: Inform the client of the decision to terminate. It is advisable to clearly communicate the reasons for termination, giving due consideration to issues such as your personal safety and the patient's particular circumstances.

How to Say It: Under certain College standards of practice, members must take reasonable steps to hold a termination session[2]. If a face-to-face meeting is not advisable (e.g. due to safety concerns), the health professional should send written correspondence to the client, by registered mail or electronic mail, where appropriate. Certain Colleges require the member provide written notification to the client that the relationship has been discontinued, and document the notification in the patient record.

When to Say It: Where possible, health professionals should provide clients with reasonable notice of their decision to discontinue services. Key factors in determining whether notice is reasonable include (1) the patient's circumstances, health status and vulnerability; (2) the availability of alternative resources in the community; and (3) whether the client poses a risk of harm to themselves, the health professional, or others third parties.

Document: In all cases, it is important to document the reason for discontinuing services and the process taken to ensure clients were not abandoned and had a reasonable opportunity to arrange for alternative services.

Termination of the client relationship is an important phase in clinical practice. On occasion, a health professional may have to discontinue services earlier than intended, for a variety of reasons.

Whatever the case may be, the end of a client relationship comes with legal and clinical responsibilities. These responsibilities vary between Regulatory Colleges. In all cases however, by thinking systematically about the reasons and process for discontinuing services and by following the appropriate legislative and regulatory guidelines, health professionals can ensure that they do so in a safe, ethical, and professional manner.

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