Challenges in treating patients in a long-term care facility

Originally appeared in the November/December 2015 issue of Dispatch

Providing dental treatment and oral care in a long-term care (LTC) facility can present unique challenges. Dentists who work in LTC facilities must still meet the standards of practice: they must ensure that the available physical facilities are adequate, keep dental records that adhere to the RCDSO’s guidelines, and obtain informed consent before initiating any treatment. Obtaining informed consent in LTC facilities can be particularly challenging and warrants careful analysis.

Due to dementia and other conditions that result in cognitive decline, some patients cannot understand information relevant to making a decision about treatment or appreciate the reasonably foreseeable consequences of a decision about treatment. Such patients are incapable of providing informed consent for treatment.

If a patient is incapable, the Health Care Consent Act, 1996, allows a substitute decision-maker to provide the required informed consent. The substitute decision-maker could be, for example:

• an individual granted the Power of Attorney (POA) for Personal Care;
• the patient’s spouse, child, or other family member;
• an individual appointed by the provincial Consent and Capacity Board.

The dentist should assess a patient’s capacity each time informed consent is sought. A patient’s ability to provide informed consent may depend on his or her condition that day or on how complicated or extensive the planned treatment is.

Dentists cannot assume that a patient who has named a POA for Personal Care is incapable of providing informed consent on his or her own behalf. In fact, the patient had to be capable in order to grant the POA for Personal Care.

Dentists should be aware that a caregiver sometimes attends a dental appointment with a capable patient and may provide information about the patient’s health history. If that occurs, the dentist should still obtain informed consent directly from the patient.

The normal principles of informed consent apply when obtaining consent from a substitute decision-maker. Informed consent discussions should precede treatment and include the nature, risks, benefits and costs of the proposed treatment, treatment alternatives, including no treatment, and any other relevant information.

The patient and the substitute decision-maker must have an opportunity to ask questions and to have those questions answered. If the treatment plan changes, the dentist must obtain informed consent from the substitute decision-maker for the amended treatment plan.

To facilitate discussions with substitute decision-makers, it is recommended that dentists collect contact information that can be used to reach substitute decision-makers on short notice, such as cell phone numbers or email addresses.

All informed consent discussions, including the efforts made to contact a substitute decision-maker or the circumstances leading a dentist to believe a patient could not personally provide informed consent, should be carefully documented in the records.