Many of the procedures that we carry out for patients carry a risk of complications, and on occasion the particular circumstances of a case give rise to a more limited prognosis than would normally be expected.
The process of obtaining valid consent requires that this information be communicated to patients in a way they can understand and, as GDC Standard 3.1.2 makes clear, it is the discussions with the individual patient which determine the validity of any consent which is given. These discussions must be documented.
In the hurly-burly of busy practice, colleagues are often working under significant time pressures. It can be all too easy to under-explain an element of the treatment plan, along with its material risks and benefits, which later turns out to be significant.
The following case example shows how an inadequate explanation of risks can lead to a dissatisfied patient, and a dentist being seen to make an excuse - rather than giving a reason - for why things didn't go to plan…
A new patient attended the practice for a consultation. The dentist, a DDU member, was running late due to a combination of factors earlier in the treatment session, including a difficult extraction and a socially urgent re-cementation of a crown.
The dentist carried out a clinical examination and exposed bitewing radiographs. Due to the time pressures on both the dentist and the patient, who had a subsequent business appointment, it was agreed that the radiographs would be developed and reported later that day. The results would be communicated to the patient at the next appointment, scheduled for the placement of an occlusal composite filling in a lower first molar along with a scale and polish.
The bitewings indicated that there was, in fact, a significant radiolucency in the lower first molar suggesting that the caries may be more extensive than clinical examination alone had indicated. A large distal pulp horn further complicated the situation. These findings were set out in the radiographic report.
Because of his business commitments the patient rearranged the scheduled appointment, meaning it was some six weeks before he was seen for treatment. Once again, time pressures were such that treatment started without the dentist fully reviewing the radiographs or his report, relying entirely on the charting and treatment plan.
Unfortunately, during the procedure it became evident that there was a significant pulpal exposure and that endodontic treatment was indicated. This was explained to the patient, the tooth appropriately temporised and a revised treatment plan provided which set out the cost of the endodontic treatment along with a cast cuspal coverage restoration.
This patient…concluded that the information provided was simply an excuse to explain something that had gone wrong.
The dentist later received a letter of complaint from the patient, in which he alleged the dentist had ‘over drilled’ his tooth causing him to need further complicated and costly treatment.
The dentist sought our advice and responded empathetically, explaining the situation in detail. Nothing further was heard from the patient.
While the matter did not progress, this was a distressing and anxious time for the dentist; as a caring practitioner, he was naturally upset that any patient could conclude that his treatment had shortcomings and also about the possible reputational damage to his practice.
The difference between a reason and an excuse may simply be time. In this case, an explanation given in advance of any tooth preparation would have made clear to the patient that there was a real risk of such a complication.
After the event, this patient - with whom there had been little time to build trust and rapport - concluded that the information provided was simply an excuse to explain something that had gone wrong.
Although the clinical treatment was entirely appropriate, the dentist became vulnerable to criticism because of inadequacies in the consent process - the initial explanations became insufficient when further, significant information came to light.
- The time taken to fully explain matters is a good investment. Handling a situation after it has occurred can be difficult, embarrassing and may undermine trust.
- Record keeping, including the details of pre-operative discussions, can be vital to refute allegations after the event.
- A signature on a form may evidence part of the consent process but is not, of itself, consent.
- Routine systems and processes to allow the checking of previous notes and records such as radiographs and medical histories are vital. Teamworking is important in this regard.
- Re-affirm consent before treatment starts.
Head of the DDU
John Makin BDS PgDL PgCDE FHEA is head of the DDU. He qualified in Manchester in 1983 and has worked as a general dental practitioner in Lancashire and Devon before joining the DDU as a dento-legal adviser. He was involved with foundation training for many years as both a trainer and VT adviser/training programme director with the Manchester and Exeter DFT schemes.
See more by John Makin