Dr Philip Chien, the runner up in Dental Protection’s Young Dentist Award for Professional Excellence last year, looks at consent and its complexities
As a junior dentist, one of the challenges I often face revolves around the process of consent. By ‘consent’, I am not referring to the act of the patient simply giving permission to undergo a procedure, but specifically the concept of ‘informed consent’.
Informed consent is inherently complex in its nature – it consists of three essential elements: voluntarism, information disclosure and decision-making capacity.1
Voluntarism, or volition, is the ability of someone to judge what is best for themselves without coercion. Information disclosure involves education – our patients must be educated about all the possible treatment options, including the risks and benefits of both undergoing and not undergoing a procedure, and the long-term implications of each treatment option. This information must then be reconciled to a level of understanding where the patient is able to make an appropriate decision for themselves. Not only is obtaining informed consent a good idea – it is our duty to do so. We must remember that our patients have come to seek our professional advice at a time of need, and as a result, we must impart our privileged knowledge so that they may make the best decision.
"Despite its integral role in our daily practice, I do not find obtaining informed consent to be simple and easy."
Akin to our motor skills in clinical dentistry, being able to get comprehensive informed consent requires experience and practice.
The devil is in the detail
I recount a memorable example where I was discussing a rather routine endodontic procedure with a patient. Eager to demonstrate my knowledge, I began explaining the nature of the procedure: the rationale behind the treatment, the intended outcomes and the intricacies of the treatment. Eventually, I began to discuss the complications and risk of the treatment. I talked about the success rates and why it may not always be 100% successful even when done well, for instance due to the possibility of small lateral and accessory canals that may not be disinfected. I talked about potential procedural problems - notably file separations.
I talked about what may happen to the tooth afterwards – how it will become more brittle and prone to fracture, and may require a crown in future to protect the longevity of the tooth. The more I talked, the bigger the frown on the patient's face, and I could see her concern for the treatment option. Eventually the patient declined root canal treatment as the treatment of choice.
At a later point in time, I replayed that same interaction in my mind. I listened to myself go through the risks and complications. I tried to see it as if I was in the patient's chair. Upon reflection, root canal treatment sounded like a terrible idea. So many things could go wrong! Why would anyone go through an expensive, long procedure that spans multiple appointments where things could go wrong?
However, things do indeed go wrong at times in dentistry. I humbly believe there would not be a clinician that would claim they’ve had a perfect streak in their career, where all their treatments have never failed and things have gone according to plan all the time.
Getting the balance
Herein lies the complexity that I mentioned earlier. It was my duty to inform the patient of the possible things that could go wrong, and I felt I had accomplished that comprehensively. Morally, I felt I had done right by myself and by the patient. Dentolegally, I ticked all the boxes. The patient was given the information about things that may happen during and after the treatment, and I felt she had sufficient knowledge to give informed consent. Yet, the end result was scaring the patient away from treatment.
Therefore, despite all the risks a certain treatment option poses, it is also important to convey why you see value in undergoing such a procedure. The advantages and disadvantages of going through the treatment must be clearly outlined – part of the process also includes explaining if you think the benefits would outweigh the risks: and this judgement is why the patient seeks our professional opinion. What would have been the benefits of undergoing root canal treatment in that previous example? The lifespan of the tooth could have been extended with a low risk of procedural and post-operative problems.
What probably further complicates the issue is the lack of foresight I currently possess. As I am currently my first year out, I am unable to say with absolute confidence what the treatment outcome would be a few years down the track. For those who trained in Australia as a dental student, you rarely even get to see your patient again for a six-month review. Sure, we have the textbook knowledge of what is likely to happen, and we had lecturers that would tell us what the outcomes may be if certain treatment objectives were met, and we also have the luxury of updated research and journals to give us the most recent findings and studies. But I feel these are things we have to experience ourselves clinically to validate those findings. If I have not seen my own work five years down the track, how can I assure them that they will be fine then? How can I say that my fillings have an average lifespan of X number of years when I haven’t even been practising as a graduate dentist for that long? Will the informed consent still be accurate then, if I’m only predicting outcomes from others’ experiences, and not my own?
For these reasons I think informed consent can be quite complex. It is an integral and critical part of clinician-patient relationships, but I believe it takes considerable experience and communication skills to convey this kind of information well. Discussing treatment procedures can be very sensitive and emotional for our patients, and we should dedicate effort to providing the most comprehensive information possible when obtaining consent, in spite of the inherent challenges.
Gupta U, Informed consent in clinical research: Revisiting few concepts and areas, Perspect Clin Res 2013 Jan-Mar; 4(1): 26–32.