The right to refuse

There are frequent discussions in online forums about what to do when patients refuse recommended treatment. There is no easy answer to this dilemma. While refusing treatment might appear to be a single act, there are many reasons why people choose this option, and the discussions can become heated at times.

Every patient is different. Every practice philosophy is different. Differences between coworkers or dentist and staff members can lead to some uncomfortable situations that are often not addressed directly. True professionals focus on providing the best treatment options for patients.

In most states, dentists have final diagnostic responsibility, so the buck stops with them. Dental hygienists are expected to “recognize disease.” Under the best circumstances, we can create a dental hygiene diagnosis, meaning we can diagnose conditions and formulate treatment plans for procedures that we can perform in a particular jurisdiction. Problems arise when a supervising dentist does not support the clinical treatment that falls within hygienists’ scope of practice.

Padding the bottom line

Sometimes the diagnosis is downgraded to fit a patient’s benefit plan. At other times, a patient’s clinical presentation barely fits the criteria for advanced procedures. The situation is further complicated when clinicians are expected to provide more expensive treatments to reach production goals. None of these are good plans. Performing a procedure that does not match the diagnostic findings is not appropriate, and is considered insurance fraud in the eyes of a third-party carrier.

The situation gets even more complicated when patients announce that they “only want what their insurance covers,” or a front desk person dictates that a procedure, such as radiographs, must be performed because a patient’s benefit plan covers the cost. We have an ethical responsibility to determine if a patient really needs to have a procedure. For example, patients at low risk for caries should not be subjected to a biannual series of bitewing radiographs. Procedures should be recommended and performed based on relative risk and need.

Three very important concepts come into play when treating patients. Many dental professionals worry about being accused of supervised neglect if a patient refuses treatment. The definition of supervised neglect is clear—a patient who is examined regularly and shows signs of disease, but is not informed of the presence of disease or the progress of the condition. It is unlikely that most of us are practicing in that manner.

It’s important to remember that we’re in the service business. People can opt in or opt out, and if no one is coming in for our services, then the business will fail.

Most hygienists and dentists go to great lengths to inform patients of their disease conditions. Many agonize when patients refuse treatment. Informed consent is a communication process where a patient or a patient’s proxy agrees to an investment plan after a complete discussion of the advantages and disadvantages of proposed treatment, the risks involved in accepting or not accepting a treatment, and all alternative forms of treatment, including no treatment. Before you start patting yourself on the back, understand that it takes a concerted effort to keep up with all potential treatments and all adverse outcomes. This is one of the most important reasons for keeping up-to-date with your continuing education.

Informed Refusal

Informed refusal allows a patient to decline any or all proposed treatment options, but there are specific guidelines regarding refusal. All treatment options must be presented in a manner that the patient understands, and the patient must be advised of the consequences of refusing treatment. Informed refusal also applies to patients who decline a referral to a dental specialist.

The keys to informed consent and informed refusal are communication, and documentation in the patient’s record.

If a patient refuses recommended treatment, it is prudent to have the patient sign a document that states he or she refused treatment. My fellow columnist, Dianne Watterson, wrote a very detailed article in the September 2012 issue of RDH titled, “Informed consent and informed refusal in dentistry.” For any practices trying to come to grips with these concepts, Dianne’s article is worth reviewing.

Fluoride is often a hot button issue. While most dental professionals believe that fluoride is beneficial, a growing number of patients are opposed to the use of any products that contain fluoride. Is there any benefit to arguing with patients, or would it be more productive to learn about alternative strategies that can remineralize and strengthen tooth structure?

There is a growing body of information about the benefits of alternative therapies and products. Are you up-to-date with the latest information about the actions and benefits of arginine bicarbonate calcium carbonate, xylitol, erythritol, calcium sodium phosphosilicate, theobromine, or licorice root extract? Can you offer patients an alternate approach or product? Do you understand how different alternatives work, and are you comfortable with talking about products that are not fluoride based?

A similar hot button issue surrounds traditional string floss. Some dental professionals get up in arms when patients don’t floss. Again, there are many reasons why people will not adopt the strategy, so why do we beat a proverbial dead horse? Patients feel scolded. No one is winning that battle, so why not let it go?

The real goal is biofilm disruption, not scraping bacteria off a tooth surface with a piece of string. Look at the amazing number of strategies that are available—oral irrigators, interproximal brushes, sticks, picks, power brushes, and rubber tip stimulators. We’ve all seen patients who have a stable oral environment even though the only time their teeth are flossed is when they visit us.

Refusal—now what?

There are many reasons patients decline, and it is really none of our business why they don’t go along with recommended treatment. Refusal can stem from insufficient financial resources, fear, distrust in the treatment, uncertainty about the outcome, embarrassment, or lack of understanding about the benefits. Beware of approaching patients with an “It’s my way or the highway” ultimatum.

No one likes a hard-sell approach. People can feel bullied, and pressure does not build trust. People want to be guided, and providing scientifically sound information can help them decide what action to take. Sometimes patients just need time and space to process recommendations. It can also be a trust issue. Time, empathy, and education can go a long way toward improving trust. Other people might need time to restructure their budgets to accommodate the fees.

Some practices refuse to treat patients if they decline a recommended service. Some even dismiss these patients from the practice, which is harsh. It’s important to remember that we’re in the service business. People can opt in or opt out, and if no one is coming in for our services, then the business will fail. It’s important to remember that patients are customers and we need to work hard to earn their trust and respect. This takes time.

People want to think that their health-care professional has their best interests in mind. While it is our ethical responsibility to advise patients of all treatment options, it is still their option to accept or decline our recommendations. So, work on the information you provide to patients, keep up on the facts, learn about new treatment options, and then relax and have fun with your patients.

ANNE NUGENT GUIGNON, RDH, MPH, CSP, provides popular programs, including topics on biofilms, power driven scaling, ergonomics, hypersensitivity, and remineralization. Recipient of the 2004 Mentor of the Year Award and the 2009 ADHA Irene Newman Award, Anne has practiced clinical dental hygiene in Houston since 1971, and can be contacted at [email protected].