Physicians’ Obligations When Transferring a Patient’s Care

A recent decision by the Health Professions Appeal and Review Board (the “Board”) provides guidance on a physician’s obligations when transferring care to a colleague in a hospital setting. The decision relates to a complaint to the College of Physicians and Surgeons of Ontario regarding the care provided by a physician in connection with the treatment of the Applicant’s late father (the patient) and his transfer to another hospital. The Inquiries, Complaints and Reports Committee (the “Committee”) investigated the complaint and decided to “caution” the physician. The Applicant asked the Board to review the decision of the Committee.

Background Facts

The patient had complaints of persistent back pain which led him to attend the Emergency Department of a hospital on two occasions. On the patient’s second attendance on November 2, 2014, testing established that he had suffered kidney failure.  The patient was admitted to the hospital under the care of the respondent physician, an internist. On November 16, 2014, the patient was sent by ambulance to another hospital for dialysis.  He received his first treatment at this facility on November 19, 2014.  Unfortunately, he suffered a cardiac arrest and died in hospital on November 20, 2014.

The Applicant complained that the physician did not provide adequate treatment in the management of the patient’s kidney failure and did not act professionally during her father’s admission to the hospital.  The Applicant was particularly concerned that the physician: failed to ensure dialysis was provided promptly; did not transfer the patient to a facility in Hamilton despite the family’s request; did not assess or diagnose the patient’s labored breathing and ongoing pain; incorrectly advised the family that the patient could not receive dialysis due to high potassium levels; and was dismissive, condescending, and abrupt with the family during their interactions.

The physician submitted that the care provided to the patient was reasonable and that the patient’s renal failure was treated in a timely fashion. He stated that the patient was transferred for the purpose of receiving dialysis.  The physician inquired into transferring the patient to Hamilton, but could not locate a physician willing to accept the patient. He could not recall being rude or dismissive to the family, but apologized if that was how he was perceived.

The Committee was concerned about the delay in arranging dialysis and that the receiving physicians who accepted the patient at the new hospital received very little information. It specifically noted that the physician’s discharge summary was dictated three months post-discharge and that the failure to transfer care appropriately may have delayed the start of dialysis.

After investigating the complaint, the Committee required the physician to attend at the College to be cautioned “with respect to consulting with a nephrologist and taking urgent action on a patient whose creatinine is elevated for days, and to documenting transfer of care to the next [most responsible physician], and writing a transfer note immediately so that it can accompany the patient on transfer.”

The Board

The Board confirmed the Committee’s decision. While the Applicant may have felt that the doctor should be “punished”, the Board noted that the Committee’s process is not intended to determine liability or “punish” physicians. The Committee’s role is designed to protect the public by determining what action would best enhance the quality of medical care of the particular physician. The physician had indicated that he accepted the Committee’s concerns and the Board concluded that the caution serves to protect the public interest by guiding the physician’s practice in the future. The significance of the caution remaining on the physician’s permanent and public record with the College was also noted.

The lesson here for physicians who transfer patients to other facilities for care is to be comprehensive in the information provided and vigilant in ensuring that the right people receive the information. The transferring physician should have dictated a discharge summary promptly, ensured that this was provided to the receiving hospital when the patient was transferred, and personally taken a clear and assertive approach with a nephrologist regarding the urgent need for dialysis. When transferring a complicated patient, physicians should also expressly transfer accountability as most responsible physician (MRP) to a colleague, to ensure that care is transferred appropriately.

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