by Dianne Glasscoe, RDH, BS
The current dilemma in our office is the number of patients with signs of periodontal disease who refuse to have periodontal treatment. We recently heard a risk management speaker say it was outright fraud for hygienists to do a “prophy” in the presence of disease. This speaker further suggested that we dismiss from the practice any patients who refuse to submit to our treatment recommendations. This seems a little harsh to me.
Nevertheless, I don’t want to be guilty of fraud. How can we help people who refuse our treatment recommendations?
- Caught in th Middle
The problem you describe is in every dental office in America, and it is a regular occurrence in some offices. Further, as the job situation continues to deteriorate and more people lose their jobs along with dental benefits, the scenario of people refusing definitive periodontal treatment is expected to worsen.
Patients refuse treatment for a variety of reasons, but one of the main ones is finances. When people struggle to pay for housing, transportation, food, clothing, and medicine, dental care might be restricted to emergency only. We can and should offer our patients ways to finance their care through good companies such as CareCredit, and help them overcome the financial barrier to good dental care.
Other reasons for refusing definitive treatment include fear, inconvenience, and mistrust. Some of our patients have been through unpleasant experiences in other dental practices that have left them mentally “scarred” toward dental treatment. Some of our patients are so busy with their work that they don’t see how they can find time to address dental care. Other patients mistrust us because we have not earned their trust with excellent patient service.
Informed Consent or Refusal
Whatever the reason for refusing treatment, we must understand that patients do have the right of refusal. In fact, every competent adult has the right to a say in what happens to his or her body. The two legal precedents pertinent to our discussion are “Informed Consent” and “Informed Refusal.” The health-care provider should make it clear to the patient that he or she is participating in a decision. According to Jill Nield-Gehrig in Patient Assessment Tutorials — A Step-by-Step Guide for the Dental Hygienist (2006, Lippencott, Williams, & Wilkins):
Informed consent is about a patient’s understanding and willingness to voluntarily agree to proposed treatment after the recommended treatment, alternate treatment options, and the benefits and risks of treatment have been thoroughly described to the patient in language understood by the patient. Informed consent must be voluntary. Informed consent originates from the legal right the patient has to direct what happens to his or her body and from the ethical duty of the health-care provider to involve that patient in his or her own health care.
Informed refusal is about a patient’s refusal of all or a portion of the proposed treatment after the recommended treatment, alternate treatment options, and the likely consequences of declining treatment have been explained to the patient in language understood by the patient. A patient has a legal right to refuse proposed medical or dental care.
Informed consent may be either verbal or written. Many dental health-care providers prefer to have the patient sign and date a written consent for documentation of the consent process. Once signed, a written consent document becomes part of the individual’s permanent dental record.
If a written consent document is not used, the patient’s verbal consent should be documented in the patient chart. An example of documentation of verbal consent is: “Discussed the diagnosis; purpose, description, benefits and risks of the proposed treatment; alternative treatment options; the prognosis of no treatment; and costs. The patient asked questions and demonstrates that he understands all information presented during the discussion. Informed consent was obtained for the attached treatment plan.”
If a patient refuses recommended treatment and further refuses to sign an informed refusal form or the chart notes, this notation should be made: Patient refused recommendations for treatment of periodontal disease and also refused to sign documentation of refusal. (Your name) (Witness name) The witness should be another staff member and/or the doctor.
First, we all like to deliver “ideal” treatment, and it’s wonderful when patients agree to our treatment recommendations. However, if I, as a patient, refuse my doctor’s treatment recommendation, I bear the consequences of that, not my doctor.
Consider what dentists do in a similar situation. If a patient needs a crown on a tooth but informs the doctor that he or she simply cannot afford to have it done, what will the doctor do? Will the doctor refuse treatment completely and possibly remove the patient from the practice? In all my 30 plus years of practice, I’ve never seen a doctor dismiss a patient because he or she could not afford a particular treatment.
So what does the doctor do? In most cases, the doctor does an alternative, not ideal, treatment, possibly a temporary crown or a large restoration. For the dental hygienist, an alternative treatment could be a debridement. While not ideal, this is an alternative treatment option for the patient who refuses periodontal treatment. There’s no harm in it, and certainly no risk to the licensee, as long as the documentation is thorough.
In fact, documentation is key to preventing future liability for the dental professional. Any and all refusals should be thoroughly documented in the patient chart. Sometimes I think we lose sight of what we are called to do in our profession — help people. When we become rigid and dictatorial about how we will help people, we actually limit our ability to help. In dentistry, it is rarely an “all or nothing” proposition. In many cases, we can give patients options. I don’t think there is a periodontist or general dentist anywhere who would say, for that rare patient who refuses periodontal treatment for whatever reason, that it would be better to terminate the patient than to provide an alternative treatment — not an ideal treatment, but an alternate treatment that would be helpful. It is certainly better to do a debridement than to do nothing for a periodontal patient. An alternative treatment is not fraud if there is clear documentation in the patient chart about the need for more definitive treatment.
I do not, nor would I ever, advocate a prophylaxis for a frank periodontal patient. However, debridement with a power scaler is an appropriate alternative treatment for the short run.
We are in a people profession, which means that we strive to help people any way we can within the boundaries they have the right to set. When I become a dictator, I lose my empathy, respect, and compassion. As Steve Anderson of the “Total Patient Service Institute” so eloquently states, “We balance the clinical ideal with patient reality.” We should accept patients without judgment, listen to them, and show appreciation that they trust their care to us.
When we do that, the good news is that some who initially refused will agree to proposed treatment recommendations later.
Finally, the doctor should be involved in diagnosis, with the hygienist in a co-diagnosis role. It is inappropriate for the hygienist to make decisions about who will or will not be treated.
About the Author
Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or e-mail [email protected]. Visit her Web site at www.professionaldentalmgmt.com.