Dealing with patients who wish to dictate treatment

Originally appeared in the February/March 2016 issue of Dispatch

From time to time, patients may present to your office with demands for treatment that, as a dentist, you know are not in their best interest. Some may have exceedingly high expectations that you feel are unrealistic and cannot be achieved, while others may request treatment that is beyond your expertise or comfort to provide.

Some patients may decline the treatment you recommend due to financial limitations, lack of knowledge or personal opinions for which there is no generally accepted scientific or empirical basis. Some may even try to dictate the materials and/or methods used for treatment, which may be inconsistent with the standards of practice.

Common examples of situations that dentists may encounter in their practice include patients who:

• decline diagnostic radiographs because of the associated cost, but still expect an accurate diagnosis;
• refuse radiographs that are required for treatment, such as root canal therapy or extractions, due to concerns about radiation;
• request the extraction of healthy teeth, which they feel are the cause of a systemic condition;
• decline local anesthesia before an invasive procedure, because of apprehension about needles;
• request the removal of sound amalgam restorations, due to concerns about mercury toxicity;
• refuse treatment for existing periodontal disease, but still expect extensive restorative work;
• express desires for exacting cosmetic results, like those of a particular movie star;
• decline a referral to a specialist for reasons that are related to cost or convenience, and then request complicated treatment that is beyond their general dentist’s expertise or competence.

In this digital age, patients have ready access to clinical information from numerous sources, such as websites and social media. They may believe that they have the appropriate knowledge and judgement to take control of their dental health by directing which treatment they wish to receive and even how it should be performed. Of course, not all sources of information are equal in terms of reliability and completeness.

It is a dentist’s responsibility to take the time to properly engage their patients in the informed consent process and provide them with evidence-based information about all reasonably available treatment options. This genuine effort may prompt some patients to reconsider their requests and, hopefully, accept their dentist’s recommendations.

As a health care practitioner, you naturally strive to meet your patients’ expectations and address their concerns. Understanding and respecting the autonomy of patients, there may be times that you feel pressured to accede to their demands. While patients have the ultimate right to make informed decisions based on their personal values and beliefs, you should be wary of demands that appear to be unreasonable and potentially harmful if carried out.

It is important to note that the following are acts of professional misconduct under the Dentistry Act, 1991:

• contravening a standard of practice or failing to maintain the standards of practice of the profession;
• treating or attempting to treat a disease, disorder or dysfunction of the oral-facial complex that the member knows or ought to know is beyond their expertise or competence;
• recommending or providing an unnecessary dental service.

The following advice will assist you in meeting your professional, legal, and ethical obligations, while still respecting a patient’s autonomy.

1. Consider the merits of the requested treatment and whether it may harm the patient or is likely to fail. In some cases, the requested treatment may not be the ideal option or the one you would choose, but it does not breach the standards of practice and offers a clinically acceptable solution.
2. If a patient requests treatment that is not ideal, but that you determine is reasonable, you should clearly inform the patient of the risks and limitations associated with this treatment. You should also ensure that the patient has realistic expectations about the potential treatment outcome.
3. If the patient is requesting treatment that you judge to be below the standards of practice and/or you believe is not in the patient’s best interest, you should NOT provide that treatment. Explain your reasons for refusing treatment.
4. If a patient requests treatment that is beyond your expertise or you do not feel comfortable providing, you are NOT obligated to provide that treatment. Explain your reasons for declining treatment. You may offer a referral to one or more specialists in the appropriate fields and let the patient decide whether they will proceed with the referral.
5. If a patient refuses to accept your treatment recommendations, such as the taking of radiographs that are required for treatment, explain the rationale for the recommendations and consequences associated with the refusal. If you feel that the patient’s refusal compromises your ability to provide appropriate treatment according to the standards of practice, do NOT provide the treatment.
6. If a breakdown of the patient-dentist relationship occurs, you may decide to dismiss the patient from your practice. 

It is very important to document the informed consent discussion in the patient’s chart. This documentation may be critical in the event of a formal patient complaint to the College or lawsuit.

It is important to remember that you have a fiduciary relationship with your patients, which creates a legal duty to act solely in their best interests. Although a patient may wish to dictate treatment and offer to sign a release document or waiver in order for you to proceed with their request, you should keep in mind that this will not absolve you of your fiduciary duty or protect you from liability.

Of course, each case is unique and needs to be evaluated on an individual basis. If you require further guidance about a particular situation, please contact the College’s Practice Advisory Service.