[MUSIC] Welcome back. So in a prior session, we dealt with this incredibly important set of legal rules about the formation of a treatment relationship. And as I said, formation is a really important foundational concept because once a treatment relationship exists between a patient and a provider, be it a personal provider or an institutional provider, lots of really important non-delegable duties attach. The basic duty of care, confidentiality, of informed consent. So how one enters in the law about how a treatment relationship forms is really important. And as we said then, it's very contractual. There's lots of ability outside of the EMTALA context for a medical provider to refuse to take a case for any reason, be it financial reason, be it because they're busy with other cases or just don't want to take the case. And again, this is outside the emergency department context where special rules apply. There's a lot of kind of contractual freedom not to take a case. Things are very different once a treatment relationship exists. And what I'll talk about today is it's actually quite hard and with lots of legal restrictions that apply to a provider for terminating a treatment relationship once it exists. So we have legal rules about termination or even abandonment that impose liability on providers that too abruptly terminate the treatment relationships. So what I'll talk about in the next few minutes is what are the ways that a treatment relationship can end properly from the healthcare provider's point of view, and what are the legal risks to health care providers from improperly or too hastily terminating the treatment relationship? So the basic rule is that medical providers are obliged to continue attending to the patients in the course of a treatment relationship so long as the case requires therapeutic attention. This invokes a concept that we discussed in the context of formation, this very kind of old-fashioned phrase, the spell of illness rule. Which connotes the basic idea that people present for medical care often asking for treatment for a specific condition or a specific illness. Now, that can be a very quick interaction, treatment that might last only a few days. It could be, in the case of chronic conditions, treatment that lasts for months or years or even a lifetime. So there's a really elastic quality to what we mean by the course of illness rule, but the law kind of maps onto this concept that once a health care provider starts treating somebody for a particular condition, the treatment relationship exists until the patient ends it or the therapeutic condition ends. And there's real restrictions to the medical care provider from getting out of that relationship once it starts. So let me address some ways that one of these treatment relationships can end properly from a legal perspective. The first few are easy and many of them are kind of patient focused. So first and foremost, once the condition for which the patient sought treatment is resolved, the law treats the treatment relationship as over. Now, this doesn't always align with patient perceptions or perhaps even physician perceptions. In a case where somebody has a regular physician, they very well might say this is my doctor, and they might think that it's an ongoing relationship. And of course, in a kind of ethical or relational sense, it very much is ongoing. From a legal point of view, though, and think back to this striking case of Hurley versus Eddingfield, once the treatment condition ends, the legally operative treatment relationship ends. So somebody could go back to the same doctor multiple times for different conditions. These are different treatment relationships. So number one is cessation of the treatment condition serves legally to cease the treatment relationship. Numbers two and three are both patient focused. First, the patient can terminate the treatment relationship at any time for any reason, and very abruptly. And so long as that is clear and understood by all involved, the doctor or hospital is free to treat the relationship as over as soon as the patient, certainly an adult patient who is competent, says so. The third reason related to the second is if both parties agree that the treatment relationship ought to end, that of course serves to terminate it as well. The difficult case is where the patient wishes the treatment relationship to continue in perpetuity but the health care provider, the physician or the hospital or other provider wants to terminate it. And here is where providers are really limited from the abrupt termination of patients. So very much unlike the ability to say no before a treatment relationship is formed for any reason, the law in every state kind of strictly limits the kind of time, place, and manner, and kinds of reasons that could serve to give rise to end a treatment relationship. The basic rule is that providers can terminate treatment relationships, but they can't do so immediately in ways that would jeopardize the patient's health. So what most states have said is that providers can terminate, but they need to give clear advance notice to the patient, which is typically operationalized as at least several weeks, if not a month or more. And often then assists the patient in finding an alternative care or alternative treatment plan. The basic kind of policy reason that animates this area of law is that we don't want patients to abruptly find themselves without a health care provider in ways that would lead to dire consequences. So the law kind of imposes a rule of reason here. The obligation to treat a patient is not a lifetime contract from the point of view of the provider. But nor is it a contract that can be terminated at a moment's notice. So there's this requirement of adequate notice, adequate opportunity to find alternative care, that is applied really in every state through a kind of a common law regime that either comes out of the tort law system or the contract law system. So cases of health, for instance, that in an ongoing course of treatment, failure to pay the bills on time is not by itself an adequate reason to drop a patient immediately. Again, there has to be adequate notice and opportunity to find other care. Now, keep in mind this is very different from the formation stage, where failure to make payment before the relationship exists, or produce evidence of ability to make payment, could be a reason outside of the EMTALA context for refusing to treat a patient. So abandonment liability in every state operates differently than formation rules. Doctors need to give more notice, more opportunity to find alternative care. And they can terminate, but it's a more complex process that probably oughtta necessitate legal advice in difficult cases. So what we have here is another area of law where health law strives to balance competing interests. Once a patient is under the care of a health care provider, there's a real norm and operationalized by legal rules in favor of continuous care as long as the condition exists. So it's not impossible for a health care provider to terminate a relationship once it exists, but it's much more difficult to terminate than it is to say no before the relationship was ever formed. Thank you.