To drill or not to drill
Successful relationships between dentists and patients depend on trust and goodwill. Preserving the rapport is crucial, but the balance within that relationship is shifting.
The time-honoured approach, where the patient would receive the amount of information a ‘reasonable dentist’ would give in the circumstances, has changed. The dentist should now give the facts that a ‘prudent patient’ would want to know in order to be in a position to agree to a particular treatment.
Any competent adult has a right to give or withhold consent to examination or treatment. Dentists who treat patients without their consent may face civil or criminal actions (though the latter is very rare). The consent must be valid. Precise legal criteria about the amount of information to be provided is unclear, but the dentist must supply the patient with sufficient details to make an informed decision. Questions raised by the patient must, of course, be answered truthfully.
Consent may be implied, either orally or in writing. A patient opening his or her mouth for example invites the dentist to look in it, but any activity involving touching the patient should be accompanied by a verbal approval and the record should bear a note confirming the provision and nature of the consent. Written permission is not normally essential or a guarantee, but it can provide a useful document if evidence is required months or years later. Written consent is a requirement for GA and sedation procedures.
Consent is a process, not an event. The fact that a patient may have agreed to a programme of treatment, and that treatment may have been commenced does not mean that the consent cannot be withdrawn by the patient at any stage. Any such wish must be respected.
If treatment is incomplete, or indeed if the dentist is in the middle of doing a conservative or surgical procedure, he or she should stop and discuss with the patient the consequences of the withdrawal and how to proceed. Detailed notes are essential in case of a subsequent dispute about the reasons for, or nature of, a change in treatment plan.
The amount of information provided will also depend on the nature of the proposed treatment; more details will be required about procedures with higher risks or significant long-term implications. The explanation should normally be delivered by the practitioner carrying out the procedure or, if not, by someone who is suitably qualified and knowledgeable about the treatment.
It may be appropriate for the patient to bring along a friend, relative or an interpreter. Explanations may be enhanced by materials such as models, brochures, diagrams and photographs. In more complex treatments, it is wise to provide the patient with verbal and written information. They should then go home to consider the options, discuss them with friends or relatives and perhaps do their own research on the Internet or elsewhere.
No one can provide consent on behalf of another adult, even if that person lacks the capacity to make the decision for him or herself. In such circumstances the dentist must act in the patient’s best interests, ascertaining past wishes where possible, encouraging the person to participate and consulting with friends, relatives and carers. In practice this means handling the situation sensitively and adopting a consultative approach.
It is vital that detailed notes are written of the reasons leading up to particular decisions in case the dentist is asked to explain and justify his or her decisions at a later time. Any competent adult may refuse any treatment. The dentist should not do what they think is best for the patient, but what the patient has agreed after consideration of the options.
Consent by a child below the age of 16 was defined by the Gillick Case (1986). In this particular instance, a girl aged less than 16 received an oral contraceptive from a doctor without her mother’s knowledge. The mother subsequently took the doctor and the Health Authority to court and the judge found in favour of the doctor’s actions.
He said that, providing the girl understood, would not tell her parents, was likely to have intercourse, might suffer physically or mentally without advice and treatment and if the decision was in her best interests, the doctor should prescribe the pill. The verdict was then rolled out across healthcare in England and Wales. In Scotland, consent to any medical, dental or surgical procedure is enshrined in the Age of Legal Capacity (Scotland) Act 1991.
In a changing environment where all healthcare professionals are becoming more accountable, it is increasingly important for dentists to explain carefully and fully the nature of the procedures they are undertaking. When verbal consent is obtained, the records should include a note of the agreement.
There is no longer a place for paternalism and the theory of ‘leave it to me, I’ll do whatever is necessary’ should be consigned to history. Where possible, explanations about more complex treatments should be accompanied by supporting documentation including pictures or diagrams. The patient should be given time to reach a decision and any change should be respected.
Finally, if you think the patient did not understand what you were saying to them, go through it again. Careful explanation to a patient at the outset may save you an awful lot of explaining to a lawyer or the GDC later down the line.
Patients giving consent must be competent. They must understand:
• The nature and purpose of treatment
• The benefits, risks and alternatives
• The consequences of refusal
Furthermore they must:
• Retain information long enough to make a decision
• Make a free choice