In our image-conscious society, cosmetic dentistry can transform people’s confidence as well as their smile. But as word spreads about the latest treatments, it is important to ensure that patients have realistic expectations of what can be achieved. This is when an effective consent procedure and good communication skills can make all the difference.
Such is the wealth of information available about the latest dental treatments that it has become increasingly common for patients to conduct their own research before consulting a dental professional.
Although occasionally challenging, this phenomenon generally reflects patients’ engagement and determination to be fully involved in decisions about their dental health. At the same time, it demonstrates that dental professionals are not so much ‘in charge’ of an individual’s dental treatment plan, as a partner in determining the best treatment for them.
In this context, the consent process is not a one-off box-ticking exercise but an ongoing dialogue about available treatment options and associated risks. As the GDC and a recent Supreme Court judgment have made clear, the significance of a risk should be for the patient to consider, rather than the dental professional alone [see the box below]. In this context, an honest discussion with patients is the ethical way to ensure they can make fully informed decisions.
From a dento-legal perspective, effective communication is also key to managing patients’ expectations and thereby reducing the chances of a complaint. This is especially true when patients are considering elective treatment for cosmetic reasons, compared with clinically necessary interventions to treat disease or maintain dental function. For while popular aesthetic procedures such as orthodontic treatment, veneers or tooth whitening can be transformative, there is also a danger that some patients will be tempted to invest their money and hopes in treatments that cannot match the hype.
The consequences are increasingly apparent in the complaints and claims about aesthetic treatments seen by the DDU. While every case has its own unique characteristics, a significant number of unhappy patients are spurred to take action because they felt their treatment had been ‘unsatisfactory’, rather than because of an injury caused by the treatment itself.
For example, recent complaints about short-term orthodontic treatment include the length of time required, the aesthetic result and the level of discomfort involved. Although these issues would usually be addressed during the consent process, the DDU regularly encounters cases where patients complained they had not been given sufficient warning about risks or had been encouraged to believe a procedure would achieve more impressive results than was warranted.
In our experience, disputes about the adequacy of the consent process can still arise, even if the patient was apparently eager to go ahead at the time. The message is that it is not enough to habitually warn patients about the common side-effects and complications of treatment; it is equally important to actively listen too.
Ten golden opportunities for good communication
In line with this approach, the DDU advises members to think of consent as a communication process – not a one-off exercise – which provides a number of opportunities to ensure you are on the same wavelength as the patient. Here are ten principles to bear in mind:
1. Encourage the patient to set out their priorities and concerns at the outset – appearance, comfort, anxiety, and so on. Try to address these directly when discussing your treatment recommendations. For example, when discussing risk, focus on how an outcome would particularly affect the patient, rather than the percentage chance of it occurring. The GDC suggests things that patients might want to know under paragraph 3.1.3 of its Standards guidance.
2. Avoid technical jargon and give the patient as long as they need to fully understand their choices, including the risks and benefits of different procedures and the option of taking no action. Patients with communication difficulties may benefit from the presence of a friend or carer to aid understanding.
3. Don’t assume a patient understands exactly what is involved with a procedure, even if they appear well-informed. The surest way for patients to be prepared for complications is if you explain these in advance.
4. Consider the value of providing an explanatory leaflet or recommending a reputable website. However, bear in mind that bombarding the patient with information is no substitute for talking to them about their hopes and concerns.
5. Ask the patient to confirm what they have understood, rather than relying on their signature on the treatment plan to indicate their decision is informed.
Disputes about the adequacy of the consent process can still arise, even if the patient was apparently eager to go ahead at the time.
6. Acknowledge a patient’s right to withdraw consent at any time and follow their wishes, in line with GDC standards guidance (paragraph 3.1.5).
7. A cooling-off period before elective treatment gives the patient an opportunity to reconsider or ask questions. If the patient’s consent is obtained when they are already in the dental chair it could be alleged that consent was given under pressure.
8. After assessing the patient, you must be convinced that the treatment is reasonable, in line with current accepted practice and in their best interest. Be prepared not to provide treatment if it is not appropriate in your clinical judgment. Equally, if the patient’s expectations seem unrealistic and they appear reluctant to accept your advice, it may be better to explain that you are sorry but you cannot provide the treatment they want.
9. Make a detailed record of the treatment plan and discussion, including information provided to the patient about the risks involved in proposed treatment, any concerns they have raised and the cost. The patient should also be given a copy of their signed treatment plan.
10. Be open about the progress of long-term treatment plans; orthodontics, implants and so on. Review the patient at regular intervals and be prepared to reassess your plan with the patient’s consent. In the event of changes, issue an amended plan in writing and include a revised cost estimate.
Consent and clinical negligence law
As a dental professional, you have an ethical duty to 'find out what your patients want to know [before starting treatment] as well as what you think they need to know' (GDC, 'Standards for the dental team' (2013), p. 3.1.3).
In 2015, this approach to consent was underscored by a legal ruling by the Supreme Court1 which required clinicians to take reasonable care to ensure that the patient is aware of any material risks involved in proposed treatment, and of reasonable alternatives. In contrast to established case law, the concept of consent was considered from the patient's perspective.
The Court determined that a risk is 'material' if a reasonable person in the patient's position would be likely to attach significance to it, or if the clinician is or should reasonably be aware that their particular patient would be likely to attach significance to it. This assessment might take into account the nature of the risk, the effect it would have on the life of the patient if it were to happen, the importance to the patient of the benefits of the treatment, and alternative treatments and the risks associated with them.
The clinician's role is to talk to the patient to ensure they understand the seriousness of the condition, the anticipated benefits of the proposed treatment and the risks it carries, and any reasonable alternatives. Information must be comprehensive, but not so technical that the patient could not reasonably be expected to understand it.
Although the need to obtain informed consent is already enshrined in ethical guidance, the Supreme Court judgement reinforces the importance of making a detailed record of the information provided to the patient about the risks involved in proposed treatment.
Alison Large graduated from Newcastle Dental School in 1999. After qualification she worked in general practice for over 10 years, initially in the north east of England before relocating to Oxfordshire. She gained an MFGDP(UK) diploma in 2007, has been a vocational trainer and has also provided mentoring. She joined the DDU in 2008 and currently combines her dento-legal adviser role with looking after her young family.
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