The question of consenton 12th July 2018
Jaswinder Gill discusses patient competence and their ability to understand all the information provided
The question of consent arises increasingly at the heart of complaints made under the NHS Complaints Procedure, and complaints to the General Dental Council on matters on professional ethics and conduct. In order, both to understand the information provided, and to give the necessary authority for consent, a patient must be competent. Competence in this context means the patient’s ability to understand the explanations given about:
• The nature and purpose of a procedure;
• Its likely effects and risks and
• Any alternative treatment and how these alternatives might compare.
Only if a patient is competent to consent, can the patient’s consent be considered valid.
The key problem I have found is that we as healthcare professionals are encouraged to believe that providing information to a patient alone is sufficient for the purposes of obtaining a valid consent. Unfortunately, this is no longer true.
Therefore, a standard consent form is not enough as it is not specific to that individual’s treatment. It also only confirms some of the details of the information provided, but tells us nothing about the communication process, the questions asked, the replies given and the level of understanding achieved by the time the consent was eventually given.
Any consent should include the following:
• The purpose of the treatment
• The nature of the treatment
• The likely effects and consequences of the treatment
• Risks, benefits, limitations and possible side effects
• Alternatives and how they compare
• Costs involved and any potential future costs for maintenance or complications
As we can see, the cornerstone of a correct consent process is effective communication. Many dentists hold the firm, but mistaken belief that they have secured proper consent by obtaining the patient’s signature on a consent form. This in no way means that the patient has understood or accepted the treatment, and the quality of consent can never be determined solely by a signature.
An excellent method to see if the patient has understood all the above is to ask them to explain it back to you. Once this has been done and the patient has been given the opportunity to ask questions, then this should all be documented. So, the records should accurately and sufficiently reflect the details of the communication process. They should allow you to demonstrate many months or years from now what information was given to the patient.
As well as consent being specific, time should also be given to the patient to consider the treatment options.
Regarding the last point, what I do at the consultation appointment, after an examination, is that I go over the general points that need to be discussed with every patient. These would include IPR (in crowded cases), attachments (in aligner cases), decalcification (In braces cases), compliance, retention and relapse (showing pictures of what a fixed and Essix retainer looks like), pain, bite, root resorption, approximate time and cost, not forgetting how often they need to attend.
I would use intra- and extra-oral photographs of the patient displayed on a screen to explain the problem and in which direction the teeth would move to achieve the solution. Not with the patient supine and with a mirror in their hand.
What happens next
Then impressions or a scan of their teeth are taken and an appointment is made a week later to discuss specific points for that patient. This is done with the help of a ClinCheck for Invisalign and CONFIDEX for Six Month Smiles.
The general consent form would be then given to them to read over to make sure that they fully understand it at the comfort of their own home and can ask questions on anything they don’t understand on the next appointment a week later.
Here we can discuss the IPR in terms of where, when and how much will be carried out. A video simulation of the predicted tooth movement can be shown to the patient so that they can visualise the result. This may show any black triangle creation that can be addressed. If any auxiliaries will be required like elastics, power chain, lingual buttons. Will bite guards be needed? The exact cost can be determined along with the exact treatment time. I would again go over Attachments and these can be shown on the ClinCheck, compliance, retention and relapse, pain, bite issues and root resorption.
To make sure that the patient has understood this I would ask them to explain it back to me and then document this. A letter then goes out to the patient and it starts by saying, ‘this is a written record of the discussion we have had…’
The fee breakdown is on a separate sheet of paper with various payment options that the patient can decide upon. This is then signed and returned. Only when we have this do we approve the ClinCheck/CONFIDEX and the aligners/indirect bonding trays start getting manufactured.
I find that by using the above method, not only does the treatment progress smoothly as the patient is more aware of everything that is happening during the treatment and there are no nasty surprises, but the patient is much more likely to accept the treatment plan as you are building a more trusting relationship with the patient from the word go by involving them fully in all the decision making.
Further tips on consent and record keeping can be found on the orthodontic CQC course at www.ocqc.co.uk