Article Review: Treating elderly patients - Minimise risk with informed consent and updated health history

Article Review: Treating elderly patients - Minimise risk with informed consent and updated health history

Summary

There are specific consent and documentation considerations when caring for older adults.  Chronic illnesses or cognitive impairments can affect a patient’s ability to consent to dental treatment.

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. 

One example of a 90-year-old patient
  1. Had not been seen for a year by the dentist
  2. Presented on an emergency basis with a broken tooth.
  3. Based on a limited exam, the dentist noticed that a significant portion of the lingual cusp was missing
  4. The dentist recommended a crown to restore the tooth.
  5. The 90-year-old patient was presented with a treatment estimate
  6. The 90-year-old patient consented to initiate treatment the same day.
  7. The patient provided a credit card for payment of the entire treatment cost.

    The next day, the practice received a call from the patient’s son asking about his father’s treatment
  1. The son disputed that his father agreed to the charges
  2. The son stated that his father was “forced” to go through with the treatment.
  3. The son informed the office that his father recently suffered a stroke and was unable to make treatment or financial decisions.
  4. The son had power of attorney for his father’s financial and health care decisions.
  5. The son demanded that the amount be credited back to the credit card and requested a copy of his father’s chart.
Lessons:

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. 
Assess 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.”
Determine 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.

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
  • Emergency contact.
  • The form should also record and update 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. 
  1. Using the example above, the practice had not seen the patient for a year
  2. They neglected to update his medical history prior to treatment. 
Had they updated the patient’s medical history to check on recent medical issues or concerns, the son would not have had to intervene. 

For this reason:
  • Every visit, patients should review and update their health history form.
  • 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.
  • Then 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.
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