Making an informed decision

AS DENTAL professionals, we strive to respect patients’ dignity and choices in our day-to-day work. This principle is central to the notion of informed consent. Although a topic hammered home in undergraduate courses, consent can present a challenge in practice. And external factors like treatment cost, time constraints and provider regulations often only compound the complexity of this essential process.

The General Dental Council’s Principles of Patient Consent makes it clear that to obtain valid consent a clinician must ensure they are suitably trained and qualified and know sufficient detail about the intervention, that they understand the risks and follow the principles set out in the guidance.

Although most treatments are routine procedures for dentists, following this guidance is not always straightforward. This can be particularly evident in a hospital setting where you may be consenting for a complex procedure with greater associated risks that you are unfamiliar with. In these cases, a senior member of staff can help you perform the relevant consent procedure.

The GDC explains that “for consent to be valid, the patient must have received enough information to make the decision.” Although the risks and benefits of treatments are discussed at a new patient examination and treatment plan visit, it is important to remember that informed consent is a journey, and not a one-off discussion.

If, for example, a patient needs multiple treatments, they can easily become confused at the vast array of benefits, drawbacks and costs to consider. Even if a patient reaches a decision during the appointment, it is worth having practice literature for them to read after their consultation.

Booklets and flyers explaining a wide variety of treatments are available commercially, but there is nothing to stop you creating your own. Patients retain very little of the information given to them by healthcare professionals and are sometimes embarrassed to ask for further explanations.

Be sure to note down in the patient’s record which literature you give them as this can help defend against any claims made by patients who allege they were not told of the side-effects or risks of a procedure. Problems can arise if a patient rushes into a decision and later regrets having treatment, or equally if a patient takes a particularly long time to decide and later regrets consenting. If you are in any doubt that a patient cannot grasp the implications of proposed treatment, then you should seek advice before proceeding.

The ease with which you obtain informed consent will vary according to the patient. Indecisive patients can be a challenge and while it may be tempting to take the ‘Well, if it were my tooth….’ approach in a bid to push them towards a specific treatment, as a clinician you must resist this urge. Although it is perfectly justifiable to explain which treatment option you feel is best and why, for consent to be valid it must be given voluntarily. Inevitably, indecision is a frustration during a busy working day, but where appropriate a patient should be supplied with the appropriate information and given time to consider the options before consenting. Remember, patients have a right to refuse to give their consent for an investigation/treatment and you should be prepared to respect this decision.

Consent can be given verbally or in written form. Written consent should be obtained for complex treatments and for treatments involving sedation or clinical photography. Having a list of the benefits and common complications of the proposed treatment on a consent form can be another important step along the patient’s journey of informed consent. GDC guidance on consent advises that a written treatment plan and cost estimate is essential.

The process of obtaining consent becomes altogether more complicated when it is unclear if a patient has the capacity to make a decision about their own treatment, often because of their mental health or their age. A patient must be legally competent to grant valid consent. Any adult over the age of 16 is assumed to be competent unless a lack of capacity can be established. A child under the age of 16 can grant valid consent if they can show sufficient maturity and intelligence to understand the nature and purpose of what is being proposed. But in all circumstances, capacity for consent requires that the patient is able to:

• comprehend what the treatment is and its purpose when explained in simple non-technical language
• understand the principal benefits, risks and alternatives
• understand in broad terms the consequences of not receiving the treatment
• retain the information long enough to make an effective decision
• believe the information
• exercise free choice.

Assessing capacity is not straightforward and you should always follow guidance or seek advice from a senior colleague or MDDUS adviser. Regardless of the decision you make, detailed patient notes are a must.

A thorough process of informed consent will establish a rapport and trust between you and your patient. This will not only prepare the patient for the treatment they are about to embark upon, but will help improve communication and understanding if complications arise.

Martin Nimmo is a dentist at the Harley Street Dental Group, London and editor of SoundBite