As a burgeoning dentist, I am already establishing routines of practice. One such routine is offering my patients the opportunity to hold the suction – or, as the kids know him, Mr. Thirsty – ‘to give them the power,’ as I like to explain. If at any time they need a pause or, simply, a moment of extra suction, they can actively demand such, moving the suction to their lips instead of mumbling through a full mouth in gibberish for help. Through the high-pitched buzzing and lively spraying of the ultrasonic scaler, my patients’ voices matter.
The second routine: voluntary, informed consent.
But this collaborative, patient-centered approach wasn’t always present in dental and medical care. Years ago, medicine was a paternalistic field, the patient listening faithfully to whatever the doctor prescribed without question. Procedures were performed without second thought to obtaining informed consent. The patient had no chance to grow empowered – until 1914.
History of Informed Consent
In Schloendorff v. Society of New York Hospitals (1914), the New York court determined that ‘every human being of adult years and sound mind has a right to determine what shall be done with his/her own body.’ In 1960, this was extended to include the need for meaningful consent with attention to the risks and benefits disclosed by a reasonable practitioner.
Though state laws vary, the American Dental Association Code of Professional Conduct requires that dentists fulfill their ethical obligation to respect a patient’s right to self-determination.1,2 This includes informing the patient of proposed treatments and reasonable alternatives so that patients are involved in the decision-making process.
Dental schools are far from exempt from this practice, the Commission on Dental Accreditation3 including informed consent within the standards of competency for graduation from dental school and requiring that patients receive written statements containing all of the elements of informed consent.
What is Informed Consent?
At its core, informed consent protects patient autonomy and privacy. It is required for any irreversible or invasive procedure, though a patient-centered practice may engage the patient in decision-making at all stages of the exam and treatment.
The elements include disclosure of
(1) The patient’s diagnosis
(2) The recommended treatment plan
(3) Alternative treatment plans
(4) Risks of the treatment options, and
(5) Risks of no treatment.
Though many patients and attorneys may view informed consent as a means of mitigating provider liability,4 its actual function is much humbler in nature. Voluntary informed consent establishes a practice of good communication and rapport between patient and doctor. With miscommunication exceeding treatment errors as a cause of litigation, informed consent can certainly offer legal benefits. More importantly, though, informed consent empowers the patient to be a part of the decision-making process.2,5
Barriers to Informed Consent
We know informed consent is important, and yet it can still seem like a hurdle to both the patient and doctor to go through these forms! And, according to research, there are at least four primary reasons informed consent is a challenging task:
(1) Cultural and Linguistic Diversity
By 2050, ethnic minorities are predicted to be the majority in the United States.6 With this societal shift comes a change in the native language of majority. Moreover, no two cultures view oral health equally. American, Chinese, and Indian patients may all present their own, culturally unique explanations for dental disease, and, even within cultures, will all have different expectations for informed consent. In a study of Indian dentists, only 53.2% routinely obtained informed consent.7 In a study of Brazilian dentists, the number dropped to 14.5%.8 Dentists work to develop cultural sensitivity, but even with this effort, medical professionals will face challenges in translating the language and intent of the informed consent process to a format each of our patients can appreciate.
(2) Health Literacy
77 million adults in the United States have basic or below basic health literacy, with the average adult reading at an eighth-grade level.9,10 The dentist’s job, therefore, is a challenge, bringing their documents and discussions to a common level of understanding when many patients may not want to admit to a misunderstanding.
(3) Number of Documents
You go to the dentist and receive form after form after form. The dentist’s pile of papers is not quite as extensive as that in an Emergency Room visit, but the number of papers can seem overwhelming! In fact, the large number of documents is among the top reasons for not reading informed consent information.11 And with electronic health systems, the number of consent documents is growing.12 This is a challenge, one we as a profession have to not only acknowledge but address.
(4) Age Diversity
In a general sense, informed consent is a two-party process between patient and doctor. But when a child comes into the office, the legal guardian and the child are involved. Often, children do want a say in what will happen next, and have an opportunity to grow in self-autonomy through the decision-making process!13
With the growing geriatric population, not only do legal power of attorneys again come into play, but the process of obtaining informed consent or refusal itself may require more time simply to allow the patient to process the information. The older patient may even deny the information altogether, preferring a paternalistic method of healthcare, a common occurrence with patients over the age of 65.14
Recommendations on Informed Consent
Many patients are still grasping at straws to understand their care. But that doesn’t have to be the case! With a few simple changes, the dental and medical profession can enhance the informed consent process in every office:
(1) Establish treatment planning appointments as a standard of practice.
Patients want to better understand the risks and benefits of their options.15 But, that understanding takes time. Medical providers went to school for years to build this knowledge, and it is our responsibility to now give our patients the extra few days they need to also understand, at a basic level, what options lie before them. Unless in an emergency, the treatment plan can wait those few days.
(2) Create a library of consent documents for each procedure.
This library should be integrated into the electronic health record, amenable to patient personalization, and translated to patients’ preferred languages. With ease of process and standardization of forms, informed consent will become as routine and effective as checking in with the front desk.
(3) Obtain the patient’s signature after each element of the informed consent document.
How many times have you glossed over a document without reading all the words? When it comes to health care, the words matter.
Medical professions function with a checklist to ensure quality performance. Informed consents should be no different. To ensure a patient reads through and understands each element of the informed consent document, it is only wise to create checkpoints of understanding within the document itself.
(4) Obtain provider signature, date, and time at the end of the informed consent document.
A sedated patient cannot consent in full presence of mind. But only with a timestamp can we know that consent preceded the start of a procedure.
A dental assistant cannot provide the same knowledge base to a patient as the dentist herself. But only with signature of a dentist and patient can we know that the patient had opportunity to ask the doctor his/her questions.
Details matter on a consent form, this being just one of those vital details.
(5) Incorporate multimedia elements into the consent documents.
A picture, a video … find any tool to make your consent form more understandable to the patient. If words don’t make sense, some other medium of communication might, and we best be prepared as providers to make those explanatory tools readily accessible to our patients at the office and at home.
And finally, as a point of advocacy in the realm of dental academia:
(6) Incorporate discussion of informed consent into all four years of predoctoral dental education.
Proper practice management and patient-doctor interactions begin in the formative years. It is therefore a duty as a profession to carry the ethics of informed consent as a standard and subject of discussion throughout the dental school curriculum. Even in continuing education, informed consent remains a topic of such importance it warrants returned attention.
But what does this mean in actuality?
Think of your patients. Enhance your informed consent processes. And let this sample informed consent document inspire you:
1. Sfikas PM. A duty to disclose: Issues to consider in securing informed consent. JADA 200; 134(10):1329-33.
2. Dym H. Risk management techniques for the general dentist and specialist. Dental Clin North Am 2008;52(3):563-77.
3. Commission on Dental Accreditation. Accreditation standards for dental education programs. Chicago American Dental Association, 2016.
4. Koch VG & Elster NR. Introduction: under attack: reconceptualizing informed consent. J Law Med Ethics 2017;45:6-9.
5. Marei HF. Medical litigation in oral surgery practice: lessons learned from 20 lawsuits. J Forensic Leg Med 2013;20:223-225.
6. Colby SL & Ortman JM. Projections of the size and composition of the U.S. Population: 2014-2060. U.S. Department of commerce 2015;1-13.
7. Gupta VV, Bhat N, Asawa K, Tak M, Bapat S, Chaturvedi P. Knowledge and attitude toward informed consent among private dental practitioners in Bathinda City, Punjab, India. Osong Public Health Res Perspect 2015;6(2):72-8.
8. Rodrigues LG, De Souza JB, De Torres EM, Silva RF. Screening the use of informed consent forms prior to procedures involving operative dentistry: ethical aspects. J Dent Res Dent Clin Dent Prospects 2017;11(1):66-70.
9. Office of Disease Prevention and Health Promotion. America’s health literacy: Why we need accessible health information. U.S. Department of Health & Human Service. 2008.
10. Flinn JJ. Personalizing informed consent: the challenge of health literacy. St. Louis University Journal of Health & Law Policy 2010;2:379-412.
11. Kakar H, Gambhir RS, Singh S, Kaur A, Nanda T. Informed consent: cornerstone in ethical medical and dental practice. J Family Med Prim Care 2014;3(1):68-71.
12. Ploug T & Holm S. Routinization of informed consent in online health care systems. Int J Med Inform 2015;84:229-36.
13. Mukherjee A., et. Al. Informed consent in dental care and research for the older adult population: A systematic review. JADA 2017;148(4):211-20.
14. Zinman E. Dental and legal considerations in periodontal therapy. Periodontology 2001;25(1):114-30.
15. Tahir MAM, Mason C, Hind V. Informed consent: optimism versus reality. Br Dent J 2002;193:221-4.
Please note, I am neither an attorney nor a licensed dentist. These recommendations and definitions arise from research-based evidence and offer no claim to legal or practice management standards. The author has no responsibility for the outcomes of using the information contained in this article. Consult professional regulations in your state and legal counsel as you develop informed consent processes for your offices.
Original representation of the above research:
Mirissa D. Price is a 2019 DMD Candidate at Harvard School of Dental Medicine and future pediatric dentist. She serves as a Scholar of Dental Education at Harvard School of Dental Medicine and a Give Kids a Smile Leadership Ambassador. Mirissa’s research and outreach interests include social-emotional development in youth; addressing barriers and access to pediatric dental care; interprofessional collaboration; and dental education. As a child, doctors told Mirissa that she would live in a nursing home, confined to a wheelchair, crippled by pain. Instead, Mirissa uses her medical experiences to inspire others, living each day with a passion to spread pain-free smiles through her dental work, writing, improv comedy performances, and nonprofit work with children.
You can stay up to date with Mirissa’s writing at mirissaprice.wordpress.com and follow @Mirissa_D_Price on Twitter or Facebook. You can even take home a few inspirations of your own, at Mirissa’s Etsy shop, A Smile Blooms.
© 2017 Mirissa D. Price: A Dental Student, A Writer, A Journey to Share.