Patient right to refuse

This person asks about the sticky area of dental patients who refuse treatment. She heard about a practice that lost a lawsuit with a patient who had signed the refusal of treatment form, yet still sued the practice when he lost his teeth. To top it off, the state board informed her coworker that RDHs could lose their licenses for failure to provide SRP to perio patients who need it. Dianne sets the record straight.

Jan 2nd, 2019
Content Dam Rdh Print Articles Volume 39 Issue 1 1901rdhwat 360x200

Dianne Glasscoe Watterson, MBA, RDH

Dear Dianne,

I’ve written to you in the past and I always look forward to your advice in RDH magazine because the issues are so relevant in our day-to-day practice life.

My question to you is twofold. We have a conundrum in our office regarding scaling and root planing (SRP). My coworker has taken over for a hygienist who recently retired, and she has found that many of our patients need SRP. The difficult part is getting some patients to agree to treatment. These are longtime patients of the practice who have been informed repeatedly of the need for SRP and have declined time and again.

Here’s the rub. My coworker has told me that she once worked in a practice where they allowed a patient to forego scaling and root planing, and he actually signed a “refusal of treatment” form stating that he was aware of the risks involved in not receiving treatment. It further stated that he would not hold the hygienist or doctor responsible for any negative consequences. Then, when he lost teeth, he sued the practice and won!

My coworker contacted our state board of dentistry, and someone there informed her that failure to provide scaling and root planing to periodontal patients who require this service could result in legal action and loss of our hygiene licenses.

I am very concerned. Now my coworker refuses to treat any patients who have been diagnosed with periodontal disease and refuse scaling and root planing when it has been treatment planned.

I fully realize that SRP is the gold standard in treating periodontal disease, and I completely agree that patients who have periodontal disease will benefit from treatment. I’m just confused about our requirements versus the rights of patients to do as they choose with their treatment.

I do not want to lose my license or be neglectful in any way by not providing treatment to a patient, but I believe there are exceptions to this. I’ve had patients who fully realize the extent of their disease and are aware of the systemic effects their periodontal disease may have on them. However, I’ve been told by more than one patient that they cannot afford periodontal debridement. They have to choose between paying their bills or having dental treatment.

We also have a patient who is 91 years old and refuses treatment by telling us that she doesn’t even “purchase ripe bananas,” and we have a patient who has terminal cancer and elects not to have the treatment. I’ve spoken to hygienists in other practices who tell me that patients have the right to choose what they feel is best for them, and it is not our place to force them into doing something they don’t want to do. What are your feelings on this matter?

Also, we have a number of patients who have a fair amount of attachment loss, but no inflammation, bleeding, calculus buildup, or significant pocket depths. What is your opinion regarding scaling and root planing for these patients?

Western RDH

Dear Western,

Thanks for the good words! I always hope that my columns are timely and helpful.

When a patient has documented evidence of chronic periodontitis (which means bone loss and continuing and worsening disease activity that has been documented over time), the appropriate treatment is SRP. The diagnosis should be delivered by the doctor and appropriate treatment should be discussed.

If a patient refuses definitive treatment, that refusal should be documented, along with the patient’s signature on a document that states he or she understands the ramifications of nontreatment. It is the doctor’s decision whether to retain or dismiss the patient from the practice.

The safest route is to dismiss anyone who does not agree to definitive therapy, but “safest” is not always the most palatable. The reality is that most dentists today are not willing to dismiss patients. Social media has enabled and emboldened patients to post negative reviews that can result in great damage to a practice. The fact remains that the dentist is ultimately responsible, and the hygienist as an employee should follow the directions of the dentist-owner.

The information given to your coworker from a state board representative is disturbing and, I believe, blatantly wrong. If a hygienist refuses to provide services that a patient has agreed to, the hygienist would probably lose his or her job. But if the patient refuses a particular recommended treatment, it would be considered unethical to attempt to coerce the patient into agreement. The hygienist as an employee cannot dictate care. Can you even imagine a hygienist (or dentist) losing his or her license simply because a patient refused a particular treatment? That would be ludicrous.

What I want to know is where is the doctor? Is the doctor willing to let this hygienist dictate who she will or will not see? I know some owners are very nonconfrontational, but this is extreme. The dentist-owner is supposed to direct his or her staff members. The dentist-owner has to step in at some point and take a stand. Is he willing to allow patients to stay in the practice when they refuse needed care? If so, then the hygienist must render an alternative treatment, and maybe not the ideal treatment. For some patients, I believe it’s better to refer them on to a periodontist.

Patients have rights but so do practice owners. Whereas a patient can legally refuse a treatment recommendation, a practice owner can legally remove a patient from the practice. I heard an attorney make this statement: “Patients have more rights than responsibilities, and dental professionals have more responsibilities than rights.” So true!

Informed refusal is a hot topic today in legal circles. All competent adults have a right to have the final say in what happens to their bodies. I can refuse any treatment, up to and including resuscitation. But I bear the consequences of that decision. If my doctor tells me I need an appendectomy and I refuse, and my appendix ruptures and I nearly die, is my doctor liable? Of course not. He told me I needed the surgery and I refused.

The problem in many offices is that they do not want to involve patients in decision making, nor are they willing to involve patients. It’s the dentist’s way or the highway. The reality is that often there are alternative treatments, even for the short term, that allow patients time to make the right decision.

I heard author, speaker, and entrepreneur Steven J. Anderson state: “One of the biggest challenges for us in dentistry is learning how to balance the clinical ideal with the patient reality.” Wow, what a profound statement! The reality for many patients is that dentistry is a luxury that they cannot afford. I believe there are growing numbers of people who fall into this category; that, plus the fact there is distrust from patients toward the dental profession due to a number of negative articles about over-diagnosis. Every profession has its bad apples.

The reality in your patient examples is that some people have overwhelming reasons not to have extended treatment. There are exceptions to every rule.

Regarding your final question, I would surmise that if the patient does not have any signs or symptoms of disease activity and has demonstrated continuing improvement over time, then the patient is stable. Inflammation would be a key activity marker. We must be ever diligent in monitoring for signs of reinfection or recurrence of disease.

All the best,

Dianne

DIANNE GLASSCOE WATTERSON, MBA, RDH, is an award-winning author, speaker, and consultant. She has published hundreds of articles, numerous textbook chapters, and three books. Her new DVD on instrument sharpening is now available on her website at wattersonspeaks.comunder the “Products” tab. Visit her website for information about upcoming speaking engagements. Watterson may be contacted at (336) 472-3515 or by email at diannemba@gmail.com.

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