Gaining informed consent before orthodontic treatment
Priya Sharma explains the importance of gaining patient consent when it comes to orthodontic and dental care.
Informed consent is a fundamental and crucial aspect of providing dental care to patients.
It is a continual process where the patient has full autonomy to exercise their rights in the decision-making process in their orthodontic and dental care. It is a concept that has legal and ethical implications and it is imperative that the orthodontic practitioner is fully aware of all aspects of informed consent.
What the General Dental Council (GDC) says?
The GDC states that ‘patients expect to be asked for their consent to treatment before it starts’. The Standards for the Dental Team, principle three states that the dental professional must:
‘3.1 Obtain valid consent before starting treatment, explaining all the relevant options and the possible costs
3.2 Make sure that patients (or their representatives) understand the decisions they are being asked to make
3.3 Make sure that the patient’s consent remains valid at each stage of investigation or treatment.’
In essence for consent to be valid it must be informed. The registrant has a duty to provide unbiased information in an easy to understand manner without using dental jargon.
The GDC says that it is your responsibility to carry out the following:
‘3.1.3 You should find out what your patients want to know as well as what you think they need to know. Things that patients might want to know include:
- Options for treatment, the risks and the potential benefits
- Why you think a particular treatment is necessary and appropriate for them
- The consequences, risks and benefits of the treatment you propose
- The likely prognosis
- Your recommended option
- The cost of the proposed treatment
- What might happen if the proposed treatment is not carried out
- Whether the treatment is guaranteed, how long it is guaranteed for and any exclusions that apply.’
Seeking informed consent
The cornerstone to the informed consent process is having a two-way open discussion about the patient’s orthodontic care.
Discuss all treatment options along with the option ‘to do nothing’. Also discuss the risks and benefits of each treatment option.
Encourage patients to share their own personal expectations regarding their orthodontic treatment. Documentation of the discussion is important.
It is mandatory to ascertain that the information provided to the patient is understood in order for them to provide informed consent.
Throughout the consultation it may be helpful to the patient to use models, diagrams, video simulations and such forth. Invite the patient to consider both your consultation, written treatment plan and any other supplementary information. Be aware of the individual patient’s communication needs.
Provide a reasonable amount of time for the patient them to assimilate and reflect on their future orthodontic care. Give them time to arrive at a decision that they are fully comfortable with.
It is helpful to ask the patient to describe in their own words what they have understood from the discussion. Seeking consent is not a one-off snapshot event but rather an ongoing dynamic process.
If you are carrying out treatment over several appointments then it is your responsibility to determine you have full informed consent to carry out that specific treatment.
It may be that throughout the course of treatment the orthodontic treatment plan needs changing. It is advisable to then discuss this with the patient, provide a revised treatment plan and seek informed consent.
Critical to this process is also providing a maintenance and long-term plan. Stressing the importance of indefinite retention is of great importance in orthodontics. Clinicians should reinforce this before treatment starts and throughout treatment.
If possible, give leaflets to the patient and then document in the patient’s records.
Many dental practices seek a signature at the end of the written orthodontic treatment plan where the patient confirms that they have read, understood and agree with their future orthodontic care.
Be mindful that the signature does not indicate valid consent. But rather the information provided to patient is of value. Written consent is mandatory in clinical situations where general anaesthetic or conscious sedation is administered.
At any stage of treatment a patient may decide to withhold or withdraw consent no matter how unwise the decision may seem clinically or otherwise.
Clinicians must respect the patient’s decision at all times. A discussion should follow, however without exerting any pressure for the patient to change their decision. Once again, make contemporaneous records.
At what age can a patient give valid consent?
This question is very relevant in orthodontics. Many cases will commence before the age of 18 years.
If the child is 16 years of age or under and competent to make the decision, then they can do so, without permission from their parents/guardians. If they are not competent then their parents/guardians must consent to treatment as long as it is valid and in the patient’s best interest.
Patients who are competent between the ages of 16 to 18 years are able to consent to their dental treatment. Only the court can override this consent.
It is also helpful that when the treatment is discussed with both the patient and parents/guardians simultaneously. In any case a supportive environment with parents/guardians will ensure that the patient receives maximum success with their orthodontic treatment.
Does the patient have capacity to provide valid consent?
The Mental Capacity Act (MCA) has five main principles as follows:
- ‘A person must be assumed to have capacity unless it is established that they lack capacity
- A person is not to be treated as unable to make a decision unless all practical steps to help them to do so have been taken without success
- A person is not treated as unable to make a decision merely because they have made an unwise decision
- An act done, or decision made under this Act or on behalf of a person who lacks capacity must be made in their best interests
- Before the act is done or decision is made, regards must be had to whether the purpose for which it is needed can be as effective of the person’s rights and freedom of information.’
In assessing the capacity of a patient the dental practitioner should determine if the patient has understood the information presented, if the patient can retain the information long enough to make an informed decision and if they are able to use and scrutinise the information provided.
A thorough medical history will prove helpful to understand if capacity is an issue. Brain injury and/or disease (eg stroke or dementia), learning disabilities, mental health illness amongst others may comprise a person’s ability to make a decision.
A patient may be competent to make a decision in one sphere of their life but not in another. In addition a person’s capacity may change with time.
Two-stage test of capacity
The MCA has a two-stage test of capacity:
- Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use?
- Does the impairment mean the person is unable to make a specific decision when they need to?
Competence is the patient’s ability to understand the proposed orthodontic treatment along with all options, risks and benefits, oral health maintenance, retention and so forth.
You must make all decisions and consent provided on behalf of the patient, solely in the best interests of the patient. The dental team should be able to evaluate the decision in order to be fully satisfied that it is in the best interest of the patient’s oral health.
At the heart of the informed consent process is the patient.
Remember to consider each patient’s requirements and expectations individually. You must inform and provide consent voluntarily.
The power lies with the patient in deciding what dental treatment they would like to receive. The orthodontic practitioner should not make any assumptions about a patient’s views, values or code of conduct.
The patient’s best interests are of paramount importance.
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