Discontinuing or Declining to Provide Care: Guidance for Nurse Practitioners
The purpose of this online resource is to further support Nurse Practitioners’ (NPs) application of the accountabilities outlined in the Discontinuing or Declining to Provide Care practice standard.
An NPs role and responsibility within their employment setting informs their accountabilities and duties to provide care. The therapeutic NP-client relationship is the foundation of the quality-of-care received. The relationship is based on mutual trust, respect, professional intimacy and empathy, and requires proper use of the power inherent in the care provider’s role. NPs have a responsibility to establish and maintain professional relationships.
Nurses should try to resolve conflicts and disagreements when possible before deciding to discontinue care. This includes addressing differences of opinion with the client, health care team, or employer with the goal to preserve the therapeutic relationship and offer the best care. However, there may be situations where the NP has reasonable grounds to end the therapeutic relationship.
This resource is adapted from Nurse Practitioners Closing or Leaving Practice – Temporarily or Permanently (2024) and from Ending the Therapeutic Nurse Practitioner Client Relationship (2024), with the permission of the College of Registered Nurses of Newfoundland and Labrador.
Discontinuing Care
NPs may discontinue the NP-client relationship in certain circumstances, including but not limited to the following:
- NP-client relationship has broken down to where the NP cannot provide safe, competent, or ethical care. For example, the client or their family exhibits threatening or abusive behaviour toward the NP, staff or others, posing a risk of violence or harm, including comments of a sexualized or racist nature
- the client requests the professional relationship be ended
- the client has relocated and/or another provider has assumed the client’s care
- NP takes a planned leave from practice
- the client is discharged as the terms of the service agreement have been met
- NP’s registration status no longer permits them to meet their professional responsibilities for client care
- client has been absent from the practice for an extended period (for example, missed appointments without proper cause or notice)
- real or potential conflict of interest emerges (for example, change in familial status)
NPs’ Considerations when Discontinuing Care
- demonstrate professionalism in all interactions when discontinuing or declining care
- act with integrity and ensure your decisions are well-communicated, well-reasoned and ethically sound
- make reasonable efforts to resolve or repair issues to ensure the client care is not jeopardized
- notify or consult the employer or broader health care team (if applicable) of the intent to end the NP-Client relationship
- comply with employer policies or service agreement about discontinuing care as required and seek legal advice as needed
- communicate clearly with the client about the situation, and the reason for discontinuing care
- communicate to the client, in writing, the reason the relationship has ended, that is, if the NP has given verbal notification during an appointment, a written communication should follow, which includes the date the relationship will conclude
- document the reasons for discontinuing care, including any actions taken to resolve the issue and the client's referral or transition to other services
- continue to provide essential health care services (for example, renewing prescriptions) whenever feasible, until another health care professional has been identified and an effective referral has been made
- provide client information on how to access urgent or emergency services, if needed
- understand accountabilities within the health care team for example,
- if serving in an allied health provider role where you are not the most responsible provider [MRP]), communicate with the employer and/or other team members to ensure continuity of care
- if acting as the MRP, transfer care to another health provider or ensure the client has continued access to primary care
- transfer of medical records with consent complying with the Personal Health Information Protection Act, 2004 (PHIPA)
- arrange coverage and follow up on pending laboratory or diagnostic tests, if coverage is not possible inform clients how best to follow up on results (such as using walk-in clinics or the emergency department)
- provide or allow clients a reasonable amount of time to find an alternate care provider
- the timeframe will vary based on circumstances including the client's mental well-being and condition
Strategies for Resolving Issues before Discontinuing Care
Before discontinuing care, the NP should make reasonable efforts to resolve issues to ensure the client care is not jeopardized and document these efforts. Examples include:
| Issue |
Strategies for Resolving |
| if the client’s behaviour is abusive or disruptive |
- consider if the behaviour is an isolated incident vs a pattern of behaviour
- inform the client of any expectations or employment policies related to client conduct
|
| if fees are not paid |
- consult with the health care team about alternative payment options
- allow flexibility for repayment, if possible, especially if the client is unable to pay due to personal circumstances
|
| if a client relocates, discuss alternatives to offering care (when appropriate) |
- for example, combination of virtual/in person care
- discuss how their relocation could impact the client’s ability to receive the care they need
|
| if a client is absent for an extended period |
- make a reasonable effort to determine whether the client would prefer to maintain the relationship
- send a letter of inquiry to the client’s last known address (residential or email)
|
| if a conflict of interest exists with a client |
- inform the client how the conflict of interest impacts their NP’s ability to provide quality care
- assist client to find another health care provider to take over their care or offer reasonable time for the client to find an alternative care provider
|
| if there is conscientious objection |
- nurses must make sure their personal beliefs do not interfere with the client’s access to care
- inform their employer and the health care team and help make timely referrals to other health care professionals.
|
NPs must consistently apply their knowledge skills and judgement when faced with decisions about discontinuing care. This accountability extends beyond clinical considerations to include ethical duty to prioritize the nurse-client relationship. Understanding and integrating the accountabilities outlined in the Discontinuing or Declining to Provide Care standard, NPs can navigate complex situations with professionalism, ensuring safe and client centred care remains at the forefront of their practice.