AMA Journal of Ethics^®

Abstract

This article summarizes AMA Code of Medical Ethics’ guidance about patient transfer practices and discharge planning that are relevant to “turfing.”

Turfing and Professional Responsibilities

How physicians refer to patients can reflect what those physicians think that patient deserves from them.¹ “Turfing” is a colloquialism referring to the practice by some clinicians of offloading to others their own responsibilities for or duties to patients they view as difficult.² Turfing can be a source of harm to patients and undermines interprofessional collaboration and quality care.³ The American Medical Association (AMA) Code of Medical Ethics offers guidance relevant to turfing: patients’ rights to continuity of care, referrals, and discharge; upholding patient-physician relationships; and collaborative care in medicine.

Care Coordination and Continuity

As detailed in Opinion 10.8, “Collaborative Care,” collaborative care means sharing responsibility for a patient’s care, avoiding lapses in care continuity, and facilitating transfers and referrals that respond to a patient’s needs and vulnerabilities.⁴ Opinion 1.1.3, “Patient Rights,” specifically outlines the nature and scope of a patient’s right to continuity of care.⁵ Patients “should be able to expect that their physician will cooperate in coordinating medically indicated care with other health professionals, and that the physician will not discontinue treating them when further treatment is medically indicated without giving them sufficient notice and reasonable assistance in making alternative arrangements for care.”⁵ In addition, Opinion 1.1.5, “Terminating a Patient-Physician Relationship,” states that “physicians’ fiduciary responsibility to patients entails an obligation to support continuity of care for their patients.”⁶

Referrals and Safe Discharge

Ethical guidelines for terminating a patient-physician relationship, referring a patient to another caregiver, and discharging a patient are outlined in several places in the AMA Code. Opinion 1.1.5 states that if physicians withdraw from that patient’s care, they must “notify the patient (or authorized decision maker) long enough in advance to permit the patient to secure another physician” and “facilitate transfer of care when appropriate.”⁶ Opinion 1.2.3, “Consultation, Referral and Second Opinions,”addresses ethical obligations of physicians seeking consultation or referring a patient.⁷ A decision to refer should be intentional, should be based on a patient’s clinical needs, and must benefit a patient. Moreover, physicians have ethical obligations to formulate a discharge plan that is safe, as stated in Opinion 1.1.8, “Physician Responsibilities for Safe Patient Discharge From Health Care Facilities.”⁸ Discharge planning requires consideration of “the patient’s particular needs and preferences” and collaboration with “health care professionals and others who can facilitate a patient discharge to establish that a plan is in place for medically needed care.”⁸

Patient-Physician Relationships

Criteria of a functional patient-physician relationship are outlined in Opinion 1.1.1, “Patient-Physician Relationships,”which specifies that a relationship“exists when a physician serves a patient’s medical needs.”⁹ Patient-physician relationships are “based on trust, which gives rise to physicians’ ethical responsibility to place patients’ welfare above the physician’s own self-interest or obligations to others, to use sound medical judgment on the patients’ behalf, and to advocate for their patients’ welfare.”⁹ While a patient is in a physician’s care, the physician is accountable for meeting a patient’s needs, including through referral and transfer practices.

Expressing regard for patient-physician relationships also requires that physicians avoid biased and discriminatory evaluations of patients that can disadvantage them. For instance, Opinion 8.5, “Disparities in Health Care,” discusses how “differences in treatment that are not directly related to differences in individual patients’ clinical needs or preferences constitute inappropriate variations in health care.”¹⁰ Opinion 1.1.2, “Prospective Patients,”similarly states that physicians must “uphold ethical responsibilities not to discriminate against a prospective patient on the basis of race, gender, sexual orientation or gender identity, or other personal or social characteristics that are not clinically relevant to the individual’s care.”¹¹ In matters of conscientious objection to providing a service to a patient, Opinion 1.1.7, “Physician Exercise of Conscience,”states that physicians are obligated to “refer a patient to another physician or institution to provide treatment the physician declines to offer.”¹²