Informed Consent and the Right to Refuse
By Andrea Tsatalis, DDS, MS
Imagine this clinical scenario: your patient presents asymptomatic for evaluation of tooth #3. Radiographic imaging displays the presence of an untreated MB2 canal and a large periapical radiolucency. You explain to your patient that endodontic retreatment is indicated due to the aforementioned findings, but they adamantly refuse treatment due to their lack of symptoms. How do you respond?
As endodontists, one of our many roles as clinicians involves obtaining informed consent from our patients. Informed consent is an ongoing discussion during treatment, not simply a document signed at intake. The informed consent conversation involves explaining risks and benefits of treatment, the alternatives to the procedure, and the risks and benefits of those alternatives. During informed consent discussions, it is crucial to provide realistic expectations of what will likely be achieved by our procedures—a step which can mitigate potential patient misunderstanding and frustration if endodontic treatment does not prove entirely successful.
When approaching situations of both treatment acceptance and treatment refusal, there are three essential elements of patient assessment that we must consider as providers: capacity, informed decision, and voluntary decision. Let’s briefly delve into each:
Capacity describes an individual’s ability to make a decision. Patient capacity is thereby a crucial facet of patient autonomy and should be assumed until proven otherwise. Situations do arise when a patient’s cognitive intactness must be questioned—for example, when a patient presents under the influence of drugs/alcohol, or when a patient presents with impairing mental or emotional conditions (dementia). Throughout all of these clinical scenarios, the bottom line ultimately remains the same: a patient must exhibit mental capacity to provide consent.
Informed Decision Making involves the candid and clear discussion of treatment options, risks, benefits, and prognosis. These aspects of treatment should be discussed in easily understandable terms and opportunities should be presented for patients to ask questions. The consequences of failing to undergo treatment should also be emphasized.
Recalling the clinical scenario with which we began this article, if a patient indicates that they would like to refuse treatment, it is worthwhile to explore their reasons for refusal. Treatment refusal can be attributed to misinformation, fear, or personal values. Taking time to discuss the basis of their decision can potentially aid patients in surmounting treatment barriers by revealing a more agreeable solution/approach. Regardless of which path they choose, detailed documentation of a patient’s consent or refusal should always be notated in their medical record.
Lastly, when obtaining informed consent, ensure that it is a Voluntary Decision. A decision to accept or decline treatment must be made voluntarily without coercion from their clinician, family, or friends.
Keeping these principles in mind ultimately cultivates a patient-centered care environment, in which both the doctor and patient can more easily (and legally!) navigate the endodontic treatment planning process.
Dr. Andrea Tsatalis practices endodontics in Tampa, Florida. She is passionate about providing high-quality care to her patients & contributing to the greater endodontic community through her work as a lecturer, researcher, and clinician.