The concepts and processes of consent have changed considerably over the years.
With the development of patients’ rights under the Health and Disability Commissioner Act 1994, and the practice standards required by the Dental Council, reaching a decision about patient treatment is a core component of a dental practitioner’s work.
The emphasis is now on sharing decision making with the patient or their carer. It requires an understanding of patient expectations (especially those that are unrealistic) and a requirement for patients to share in the ownership of treatment choices.
Informed consent is an ongoing process and not just a signature on a document. Under the Code of Health and Disability Services Consumers’ Rights, patients are entitled to:
Autonomy is the fundamental principal of consent – the right to decide what happens to us in a health-care setting. When we review our own practices and our informed consent processes we should be mindful of any bias or coercion involved. If we have a particular interest, technique or equipment it may affect the way we present options to our patients. If we are unable to carry out a particular treatment we still need to include it in the options presented to our patients.
Clinicians will vary in their diagnoses and treatment decision making. Many practitioners are adopting a Caries Management System, which may include identifying early caries and taking the decision to manage them conservatively. Decisions on when to intervene and restore may differ between practitioners. In these situations, there is a requirement to include patients and carers in the decision making so that second opinions or alternative recommendations will not cause complaints or notifications to the Council. The main question is what alternative views or opinions could be presented to the patient?
Diagnostic safety-netting is a concept that addresses the possibility that dentists have got their diagnoses wrong.
Recently, the Council received a complaint from a patient regarding the management of their pain. The patient presented to their dentist with pain associated with the teeth on the upper left quadrant. A radiograph revealed a periapical infection associated with tooth 26, and two options were given – root canal treatment or extraction. The patient opted for endodontics because it was the last remaining molar on the top left.
The root canal treatment was completed in one visit but afterwards the pain remained much the same – maybe slightly worse but it continued.
The patient then had a diagnosis of chronic pain with somatisation. The patient now believes the dentist is responsible for the ongoing pain, which has spread across the forehead to the other side of the patient’s face.
The concept of safety-netting involves asking ourselves if we have got our diagnosis right. Is there a possibility of another explanation for the symptoms? In the case study above, root canal treatment and crowning the tooth was probably required, but it is doubtful the tooth was ever the cause of the pain. The presence of this doubt, if communicated to the patient may have prevented what has become a stressful and demanding action against the dentist.
Safety-netting is also a useful tool to use on the completion of treatment. Careful thought on possible outcomes of treatment can be communicated to patients, and in the event of an adverse outcome there is less likelihood of complaint or notification to the Council.
Reference: Almond S, Mant D, Thompson M (2009) Diagnostic safety-netting. British Journal of General Practice 59(568): 872–874.