The College of Physicians and Surgeons of Newfoundland and Labrador (the "College"), as the governing body for physicians in the province, has a duty to protect the public and to act in the public interest. It has an obligation to establish, monitor and enforce appropriate standards of practice and conduct for its members. While physicians have the right to withdraw services, that right must be exercised in a manner which is consistent with their ethical and professional obligations. The following guidelines are intended to assist physicians considering withdrawal of services.Guidelines

1. Every physician, regardless of whether he or she is acting alone or as part of a group, has an ongoing ethical and professional responsibility to act in a manner which will not result in serious harm.

2. When considering withdrawal of services, physicians must carefully assess the proposed action and its consequences for patients. This assessment must include consideration of:

a) the nature and location of the physician's practice and the patient population served;

b) the availability of other physician resources in the area;

c) alternative arrangements for the care, ongoing monitoring and transfer of patients; and

d) an appropriate contingency plan for patient care to deal with unforeseen emergency situations.

3. Physicians must continue to provide care for currently ill or recovering patients for whom they have a responsibility, or see that alternative and appropriate arrangements are in place.

4. Physicians, either individually or through call groups, must be available to assess and treat seriously ill or emergency patients where the absence of such care may result in serious harm.

5. Physicians must monitor the impact of the withdrawal of services to ensure that the initial arrangements for patient care continue to be adequate.

6. In a hospital, an entire group of physicians or an entire department must not completely withdraw services. A physician must be available to provide for the care of seriously ill or emergency patients. Just as individual physicians cannot abandon their patients, groups of physicians cannot abandon their community.

7. A group of physicians in a community or a department in a hospital may effect a partial withdrawal of services if they:

a) consider the availability and adequacy of alternative resources;

b) establish arrangements for communication or consultation to ensure the appropriate transfer of care ofpatients to other physicians or facilities. There must be a physician available to assess the patient prior to transfer, and a process or protocol in place which would include physician to physician communication.

c) provide written notification of the intended withdrawal of services to medical directors and others involved in the delivery of hospital and medical services. The period of notice may vary depending upon the specific circumstances. The appropriate notice period should be determined based on the degree of disruption to patient care which will be caused by the intended withdrawal of services, and should not in any case be less than 24 hours. This will allow the hospital or health authority an opportunity to review with the physicians the nature, extent and impact of the proposed action, and to consider what arrangements must be made in response to such action.

d) monitor the impact of the withdrawal of services on patient care to ensure that the standards of care continue to remain adequate, and

e) establish an appropriate contingency plan for patient care to deal with unforeseen emergency situations. Such a contingency plan must include the designation of an on-call physician.

Summary

The above statements provide a basic framework to guide physicians who may be considering withdrawal of services. However, the ultimate responsibility for any clinical decision rests with the individual physician who has the responsibility to ensure that his or her actions are consistent with ethical and professional standards.

Patient safety must always be borne in mind. This requires a blend of common sense and good ethical practice.

The College acknowledges the assistance of the College of Physicians and Surgeons of British Columbia in preparation of this document.