CONSENTING can be a dynamic and somewhat subjective process: one man’s explanation is another man’s persuasion.
An advisory colleague uses a very effective means of demonstrating this reality to vocational trainees. He asks them to consider a scenario in which a new patient attends with an upper left 5 which has one foot in the grave and one foot on a banana skin.
He then divides the delegates into four groups and asks each to talk to this hypothetical patient with a view of securing consent to one of the following: a post crown, a dressing, an extraction or no treatment.
Without exception, these newly qualified dentists are able to rehearse a discussion that is perfectly reasonable and factually accurate, but which is framed in such a way as to maximise the chance that the patient will ‘choose’ the desired treatment for this dodgy premolar.
Clearly, this teaching model is designed to illustrate the importance of providing patients with comprehensive and neutral information. However, if we reflect carefully on our own consenting processes, many of us will acknowledge that the choices we offer may from time to time be a little selective.
Perhaps the manner in which we present these choices can be slightly slanted in favour of one particular treatment. We do this not because we wish to mislead our patients, but because we genuinely feel that certain approaches are second-best, too costly, excessively risky etc. So we perform a mental calculation and offer advice which emphasises the benefits of the option which we truly believe to be in that patient’s best interests.
Usually we are ultimately proven right – we are, after all, drawing on significant education and experience when assessing cases. Yet this justification misses an important point: it is really up to the patient to decide which (viable) treatments to accept and which to refuse and, in order to make this judgement, the patient needs to be given all relevant facts.
Alternatives, together with their own material risks, must be explained accurately and comprehensibly
Those who doubt this premise need look no further than the General Dental Council’s Standards for the Dental Team where registrants are required to “find out what your patients want to know as well as what you think they need to know”, being sure to explain “all the relevant treatment options”.
The legal system has also endorsed this doctrine in the recent Supreme Court ruling, Montgomery v Lanarkshire Health Board. Healthcare professionals are now required to treat their patients “…so far as possible as adults who are capable of understanding that medical treatment is uncertain of success and may involve risks, accepting responsibility for the taking of risks affecting their own lives, and living with the consequences of their choices”.
This requires dialogue, empathy and, not least of all, time. Patients must not be bombarded with reams of technical information. Discussion of material risks cannot be reduced to percentages. As GDC guidance states: “You must check and document that patients have understood the information you have given”, and give them a “reasonable amount of time to consider that information in order to make a decision.”
To be clear, this ruling does not require practitioners to carry out bad dentistry just because it has been requested by a wellinformed patient. However, assuming the patient wants to be informed, all recognised alternatives, together with their own material risks, must be explained accurately and comprehensibly.
In short, an effort must be made to gain an insight into patients’ wishes and the subsequent advice must be tailored to those wishes. To quote the Montgomery ruling, “…the assessment is therefore fact-sensitive and sensitive also to the characteristics of the patient”.
In the midst of a busy session, the temptation to make a judgement call on behalf of your patient cannot be underestimated. However, this philosophy, irrespective of how well intentioned it may be, leaves clinicians vulnerable to criticism. The so-call ‘prudent patient’ test, long endorsed by the regulator, is now enshrined in law. Medical paternalism is truly consigned to history.
Doug Hamilton is a dental adviser at MDDUS