Dental professionals face a number of challenges in securing consent for oral care, but there are specific consent and documentation considerations when caring for older adults.
When guiding patients through appropriate treatment options, dentists typically consider the patient’s medical status and financial resources; however, it is important to also be mindful of chronic illnesses or cognitive impairments that could affect their ability to consent to dental treatment or even accurately answer a health questionnaire.
Many older adults may find it difficult to comprehend diagnostic information or treatment options and tend to rely on their health care provider, a trusted family member or caregiver to make critical treatment decisions on their behalf.
The Dentists Insurance Company’s Risk Management Advice Line often receives calls from dentists who need guidance navigating complex patient care situations. In one case recently reported to the Advice Line, a 90-year-old patient, who had not been seen for a year, presented on an emergency basis with a broken tooth.
Upon conducting a limited exam, the dentist noticed that a significant portion of the lingual cusp was missing and recommended a crown to restore the tooth. The patient was presented with a treatment estimate and consented to initiate treatment the same day. Prior to leaving the office, the patient provided a credit card for payment of the entire treatment cost.
The office received a phone call the following day from the patient’s son inquiring about his father’s treatment. The son disputed that his father agreed to the charges and stated that his father was “forced” to go through with the treatment.
The son informed the office that his father recently suffered a stroke and was unable to make treatment or financial decisions. Therefore, he had power of attorney for his father’s financial and health care decisions. The son demanded that the office credit back the charge on the credit card and requested a copy of his father’s chart.
As illustrated in this case, dentists should be mindful of several considerations when treating elderly patients, such as determining whether the patient is able to consent to treatment and ensuring their medical history is up to date.
Assessing a patient’s ability to consent to treatment
Although the dentist took the time to explain the risks, benefits and alternatives (RBA) of treatment, there was no documentation of this discussion in the patient’s chart. To prove the discussion occurred and help mitigate any potential liability risks, dentists must make a practice of documenting the informed consent discussion in the patient’s chart as “RBAs discussed and questions answered.”
A key factor in obtaining informed consent is determining who is responsible for the patient’s treatment and financial decisions. The dentist is responsible for assessing whether the patient is capable of providing their consent prior to discussing RBAs.
Treatment decision-making capacity has four key elements. There is a general agreement that a patient is considered capable of making a treatment decision if they can:
- Demonstrate understanding of the benefits and risks of, and the alternatives to, a proposed treatment or intervention, including no treatment.
- Demonstrate appreciation of those benefits, risks and alternatives.
- Show reasoning in making a decision.
- Communicate their choice.
If the dentist is concerned about the patient’s ability to make their own treatment decisions, they should ask the patient if there is a trusted family member or caregiver who can consent to appropriate care on their behalf.
For independent elderly patients, dentists should always obtain consent from the patient before discussing treatment with a third party, including the patient’s family members.
Reviewing and updating a patient’s medical history
A health history form can provide a dentist with a clear picture of the patient’s overall health status and current medications that should be taken into consideration when providing dental care. The form should include information about illnesses, medications, the patient’s primary care physician and an emergency contact. The form should also include an area for recording and updating any noted changes to a patient’s health status or medications.
It is important that dental offices establish a system for collecting a current medical history. In this case, the office had not seen the patient for a year, yet they neglected to update his medical history prior to treatment. Had the patient’s medical history been updated to reflect recent medical issues or concerns, this problem could have potentially been avoided.
Patients should review and update their health history form at every visit. The form should be signed and dated by both the patient and dentist to serve as evidence that the information is current and was discussed prior to treatment.
When reviewing the health history with the patient, the dentist should follow up on information that seems incomplete, such as an indication of high blood pressure, but no medications are listed. Many patients, especially those who are elderly, may not remember certain medications or illnesses they have had until they are questioned. Asking open-ended questions, such as, “How are you feeling today?” may elicit this information.
Any clarifications to the patient’s health history should be properly documented on the form along with the date of discussion.
If the dentist believes there could be an undisclosed underlying health condition or information that the patient is unaware of or seems unclear about, they should send a Consultation Request for Dental Treatment Form to the patient’s physician, follow the physician’s recommendations and keep the physician’s response in the patient’s file.
Occasional required changes to a health history form may be needed. Dentists should check with TDIC or their local dental society every two years to see if there are any changes to the health history form.
Ensuring the safety and health of elderly patients requires several considerations, including their ability to understand treatment options, to provide a current medical history and to participate in the decision-making process.
TDIC recommends the following when treating elderly patients:
- Discuss future planning with the patient, the potential need for a caregiver and their long-term goals for their oral health. Documenting this information early will indicate what the patient cares about and help dentists avoid future problems.
- Review and update health histories at every visit.
- Evaluate the cognitive function of elderly patients using the four components of capacity: understanding, appreciation, rationalization and communication.
- Emphasize the importance of preventive care. Prevention is important at every age to avoid premature tooth loss.
- Create a senior-friendly environment and train staff on how to properly care for and interact with elderly patients. Consider limitations that elderly patients may have such as hearing loss or limited mobility and make the proper accommodations.
Dentists should not assume that just because a patient is older that they may not know what their needs and preferences are, and the patient’s age should not limit their treatment options. Be open to their preferences and be honest with them about the benefits, risks and costs of various treatment.
These factors underscore the importance of dental providers to have clear and thorough communication practices to ensure treatment options align with the patient’s goals and values concerning their dental care.
TDIC’s Risk Management Advice Line is a benefit to TDIC policyholders. To schedule a consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 800.733.0633. For Risk Management guidance in Idaho, Oregon or Washington, call 800.452.0504.
Reprinted with permission from the May issue of the CDA Journal.