by Dr Gerard Clausen
The term informed consent is universally used to describe a significant part of the process in providing healthcare to the public. As a complaint, the lack of consent to treatment is a recurring theme in many dental cases, varying from a simple extraction to extensive periodontic reconstruction. In nearly every case the major concerns expressed are:
- The full range of treatment options was not presented
- The limitations/constraints of the chosen treatment were not explained
- The total cost of treatment was not clarified and
- The potential subsequent complications and cost of rectification were not explained.
If we consider the endodontic treatment of a heavily restored molar tooth in light of the above comments, it becomes apparent that the process of informed consent involves a thorough explanation and discussion with the patient prior to the initiation of treatment. This discussion is both a legal and regulatory (Dental Board) requirement.
Treatment options should also be on the top of your list of things to discuss with your patient. It varies from case to case, but it is not essential that all molar teeth be retained. It may be that the unopposed, non-functional molar could be extracted without any untoward effects. In other cases, retention of the tooth in question may be more critical.
A further consideration would be whether to remove and subsequently replace the tooth. This may be a very appropriate choice when dealing with a vital site but the combined endodontic and restorative prognosis for the tooth in question is poor. These issues need to be discussed with the patient so that the choices and their advantages and disadvantages are understood. Simply presenting an ‘option list’ to the patient and allowing the patient to choose does not constitute informed consent.
The second focus area in this clinical scenario is frank and thorough discussion about potential complications. Endodontic instruments can fracture, canals can be calcified and difficult to locate or instruments and previous interventions may compromise the expected outcome. These concerns must be conveyed to the patient.
Finally, as well as clinical management, discussion around financial matters must be clear and transparent. If the tooth in question needs a core foundation and crown after endodontic treatment this should be explained and the costs involved outlined prior to treatment. In several cases patients have asserted that the option of endodontic treatment would have been refused if they had known about the additional restorative cost involved. In such matters the financial aspect of treatment and incomplete disclosure thereof has a direct effect on the treatment chosen by the patient.
Obtaining informed consent is a process that involves more than just presenting treatment options or signing a form. It is the careful explanation of treatment and the consequences thereof, in a manner that the patient understands and accepts. At the end of that process it is also imperative that the clinical notes incorporate the questions raised, any discussion relating to the treatment and consent provided by the patient regarding the chosen treatment. In recording the process always bear in mind the potential view "if it isn't written, it didn't happen".
Always document carefully your informed consent discussions in the patients record.
The Dental Board code of conduct references to note and understand reside at 3.5 Informed consent .It is by this code the regulator will test your healthcare provided.