Consent

Within our ethical and legal daily lives, informed consent is truly pivotal to supporting ethically sound dental decision-making.

Interestingly, humans aren’t very good at defining what is ethical either. We are pretty good at describing something as unethical when we see it, but to describe an ethical decision or an ethical action or an ethical day is, at best, vague. Humans are good at spotting what’s wrong rather than defining what’s right.

I’m going to try to argue that securing adequately informed consent from patients is complex to the point of worrying because it requires human interactions….and if I have one lesson from studying psychology to offer up, it’s this:

How you feel is ‘pre-cognitive’ as in you don’t think about then choose your person-to-person experiences and the resulting emotional reactions. You meet who you meet, their actions make your reality. So, this means that the world isn’t just interpreted differently by different people….it presents itself differently to us all individually. Everyone’s perception of life is unique to them.

This fact alone is the source of so much conflict and chaos in the world.

So, two people need to make a shared decision and both need adequate understanding of the subject before you can legally proceed. But your assessment of their understanding is unique to you…may be flawed…but you are duty-bound to be utterly sure. Should we make patients sit a comprehension exam?

Do we need it invigilated in case they google what neuropraxia means? Should we say numbness? But isn’t numbness a little subjective…. from reduced two-point sensation perception to total regional anaesthesia? Aren’t those words equally confusing? Maybe Rule 1 is: DO NOT CONFUSE YOUR PATIENT…

What about the patient who has a friend who has ‘caps’, who tells you they want ‘caps’ and you think they mean crowns, when what they actually want is veneers, composite not ceramic, or is that edge bonding…no it’s ‘caps!’

Informed consent involves discussion of all the elements of your proposed treatment. This includes the patient’s complaint, their interpretation of the complaint, therapeutic options, including risks and benefits, inconveniences, and uncertainties. I don’t know about you but isn’t everything at least a mote uncertain?

Our consent must include assumed mutual understanding and then perhaps a form that patients are required to read and sign, and oral communication to ensure adequate understanding to be able to proceed. Actual bloody lol. Lol, lol, lol.

16.4% of the UK adult working age population are either illiterate or described as having extremely poor literacy skills. That’s 7.1 million people or one in six you treat. Hence the despairing “lol”. That isn’t a “lol” at them. Not being able to read or having lower than average IQ doesn’t preclude us from being kind, compassionate and thoughtful—qualities we need and should value in each other more than ever. The “lol” is how absurd the assumption is.

Imagine it was a visual issue. One in six are completely unable to see. Would you hand them a consent form to read? If the goal is understanding, the outcome is the same. Fail.
And that word… ‘ensure’. I can’t even ensure my satnav doesn’t drive me into the sea…let alone that another human being has adequately understood the complexities of dental treatment planning involving, local, bonding, functional load, aesthetics, occlusion, longevity, tooth structure, lab procedures and cellular reactions, bite changes, and rubber dam. I’ve had patients see me wear loupes and ask for another dentist who isn’t visually impaired.

Let’s assume I do feel assured.

Let’s assume when I describe the change to their bite…the lexicon of descriptors I use is convincing enough to me, and the patient nods and says yes, they understand the bite will feel different. Great. Let’s say I write to them with a personal letter, give them information sheets, show them their articulated models with the wax on the anteriors and the resultant space posteriorly. Still great. Then I show them a video of another patient who has had this, and that patient shows the Dahl effect in action and describes how it feels immediately post op and at six weeks when the posterior occlusion has re-established. I ask them to explain back to me the process, how it will feel and if they are still keen. They do that all well.

I trust them; they trust me…Nirvana. Then I place the composites at the planned increased OVD and the patient starts laughing in that ‘OMG you can’t be f*&king serious’ type way.

(This is a true story BTW).I sit them up to discuss the change and they look at me as if I’ve just eaten a puppy. They roll their eyes; they are smirking in contemptuous disbelief; they say they’ll try if I want. I explain I don’t “want”…my two goals are to get the right treatment and to do it right…to make them healthy and happy. Nothing more. They call two hours later to complain, telling me they had “no idea” it would be this way and they feel like they are part of a joke. I remove the composites the next day and ask if there is anything I could have done to help them anticipate how it would feel, as I have done similar treatments many hundreds of times so would appreciate their insight. “Not really, mate, no one really knows until it happens, do they? ….I’m going to see my friend’s dentist; they did extra training and they know how to do caps.”

My entire consent process results in a dismissive “No idea.” But, their words about “no one really knows until it happens”…there is wisdom in there.

That feeling of me believing I have ensured understanding is limited to the patient telling me, an act itself predicated on the patient’s subjective impression that they are well-informed, simultaneously gambled alongside my confidence in the intelligibility and quality of the information I provided being interpreted, understood and then remembered indefinitely. Ok, mate.

The legal concept of respecting patient autonomy in medical and dental treatment decision-making is based on the assumption that the informed consent process actually leads to the patient’s full comprehension of what they are consenting to. Unless this assumption is demonstrably true, the ethical viability of the current medical experimentation practice is perhaps flawed…. fatally so, perhaps.

To summarise so far, the problems we have are:

– We must ensure all decisions, regardless of their number and complexity, are explained and fully understood

– All positives, negatives, risks and benefits, anxieties and grey areas must be detailed.

– Patients cannot meaningfully prove to us they have understood, so we have to assume this, and assumption is the mother of all cock ups.

– One in six patients cannot adequately read or write

– We use words which are subjective – (a long time can be an hour or a decade)

– IQ is normally distributed, and some people comprehend much more slowly, and may disguise this with false positive affirmation (people pretend they have understood when they don’t)

– The amount of information we are trying to convey is potentially vast and needs to be both understood and remembered (and we don’t do memory tests)

On that last point, it’s worth noting that if I get to teach other dentists certain techniques it can take a while for them to fully understand a subject and they are all smart as hell, have a glowing hot degree in the subject and use the same terminology as me day in day out. Take localised anterior tooth wear, with a mixed aetiology, varying expression due to a localised parafunctional pattern, in a 23-year-old, in group function on the left and canine guided on the right, requiring an increase in OVD with options for composite, ceramics or monitoring, add in mixed commitment to maintenance and prevention and oscillating oral hygiene. A sprinkle of a psychological schema that assumes dentists are all rich and just want money…oh, I know, add in silent reflux, and several refractory life stressors.

My new concern is that our technological platform is evolving quickly. What we can do has never been more sophisticated nor more varied. That’s a good thing as we can help people and helping other people is a very good thing. As the technology evolves, however, it’s not obvious to me that a truly consented patient is getting any closer within reach.

I’d like to lean on someone I admire more than I can adequately express. Mostly for his diligence and candour. Henry Marsh. Please read his book Do No Harm.

“The operating is the easy part, you know,” he said. “By my age you realize that the difficulties are all to do with the decision-making.”

“ ‘Informed consent’ sounds so easy in principle – the surgeon explains the balance of risks and benefits, and the calm and rational patient decides what he or she wants – just like going to the supermarket and choosing from the vast array of toothbrushes on offer. The reality is very different.”
– Henry Marsh – Neurosurgeon

I watched a webinar run by the RCS discussing consent. Henry pointed out that it is impossible for him to consent even the brightest of patients for all the nuanced intraoperative decisions he must make, and consent simply comes down to them looking at him and deciding ‘if they trust him or not’. He would fulfill all the legal requirements for consent, but when a brain operation was unsuccessful, and the patient never walked again, he paid such a deep personal price: the patient’s family looked at him accusingly using words like ‘we trusted you’, which cut so deep into the soul of this benevolent and dedicated human.

I would ask you now to consider the concept of two-way trust. Yes, we should earn the patient’s trust, but it seems to me they need to earn ours too. Can you name a few patients now you don’t trust? I expect the answer is yes (Of course it bloody is!!). Not because they are malevolent Machiavellian types (although they certainly exist) but because, despite your current efforts, you don’t sing from the same hymn sheet. You don’t have the green light to know you fully understand their wishes and if they fully understand every detailed nuance of the dentistry that you think may suit them best.

So, what can we do?

I am lucky to work with some real smart people. Hospitals tend to have a certain amount of administrative architecture dedicated to clinical governance, and consent fits into that. We have clinical governance meetings where we discuss all complaints, all adverse outcomes and audit or standards, analyse feedback, and we are now running a big project on consent. We learn from other care groups and we try to improve.

What we really need is a benevolent predatory lawyer to help us (perhaps that is an oxymoron, and we would have more success finding a pink unicorn wearing Louboutins and a tutu ordering ice cream in Italian).

I don’t have the answers, but we are looking for them. It seems to me that, without advocating supplanting your authentic heartfelt dental planning with stressful limited defensive dentistry, you simply need to do all you can.

I worry we are becoming so defensive that the actions we take are motivated primarily by keeping ourselves safe rather than being our true selves and being the best we can be.

Ideally both authentic and defensive practice work in concord, but I have come to believe that many dentists are understandably so fearful that they are avoiding any aspects of care that feel even remotely uncomfortable and prioritise the not getting complaints over being the best they can be. They don’t suggest treatment they may think is of benefit to patients. Some elements of defensive dentistry are now inevitable for us all. Let’s recognise that it is both stressful and exhausting to practice defensive (threatened) dentistry. It means you are worried every day, you are hiding or at least camouflaging. It is limited and limiting. It is not conducive at all to flow state, growth mindset nor an ingredient for a rich and fulfilling career.

So, we do all we can.

This may include: information sheets, written letters, open frank discussions, audio and video explanations, audio and video recording of the consultations (as part of your records), examples, and more. Once they are given, it is the duty of the patient to convince you it’s understood.

Short of an emergency I would encourage you to establish a framework for elective care that genuinely feels robust. Analyse areas of it where patients are still surprised by the outcome despite your best efforts. Whatever comes out of our autumnal project I will share with you and I will also get a few lawyers’ input into this.

You may have read this line from me before, but I make no apology in repeating it:

‘Communication is giving access to each other’s minds.’

That means you share your mind honestly and they share back.

I’ll end on a deeper thought. What to do if there is a communication error. What to do if the world does present itself so differently that we come into disagreement or conflict. Well, then I offer you a choice.

The choice is whether you wish to live in a world where forgiveness is or is not part of it.
Do you want forgiveness to be part of what it means to be alive, to be human, to live with other humans?

Neither you nor I are perfect, yet we aim for that, and we are judged against it. We will always fail. Until then, stay authentic, keep doing your absolute best and know that forgiveness can be earned. Forgive yourself for your flaws but try to improve them and perhaps we can hope the world forgives us. MLK over to you:

“We must develop and maintain the capacity to forgive. He who is devoid of the power to forgive is devoid of the power to love.”

Wow. This man. A King if there was one.

The BDA resource here below is very good!!

https://www.bda.org/advice/ba/Documents/Consent.pdf