“No” is not the easiest word to hear. It’s often difficult to prevent the typical knee-jerk reaction to defend, qualify, re-phrase, or simply speak slower or louder to make your point. Differing opinions, misunderstandings, and conflicting information make interpersonal communication challenging.
Like many relationships, patient interactions may benefit more from listening than convincing. In a practice setting, a refusal doesn’t have to put patient rapport, or you, at risk.
What Is Informed Refusal?
Informed refusal is a decision by a patient to forego treatment, either from you or from a specialist you’ve recommended. There are varying degrees of refusal; a patient may identify specific treatments or alternatives he or she wishes to allow or not allow.
Patients have the right to make their own decisions about orthodontic treatment, and you, as the orthodontic specialist, have an obligation to provide all necessary and relevant information. Whether refusing treatment or consenting to it, the patient should fully understand the need, prognosis, time, and cost of treatment, as well as the alternatives and risks of no treatment.
Why Do Patients Refuse Treatment?
There are 114 million Americans without dental insurance.1 Even if an individual (or patient) is lucky enough to have dental insurance, chances are high that the plan doesn't cover orthodontics. The cost of insurance plans themselves, as well as the high cost of diagnostics, treatment, and medication, can all affect a patient’s decision to refuse.
Factor in unemployment rates and the general state of the nation’s economy, and it’s not surprising that many individuals are forced to forego treatment for financial reasons. In addition to refusing care due to monetary stress, fear or denial can also dictate a patient’s treatment decisions.
Determining the underlying reasons for refusal requires patience and support, but this extra effort may strengthen the patient/practitioner relationship, thus increasing overall patient compliance and reducing risk for both parties.
How Do You Ensure a Patient Is Fully Informed?
An informed refusal (or consent) should involve more than getting a patient to sign a form. Open communication between patient and practitioner establishes a healthy relationship that can support a complete understanding of health issues.
Outlining proposed treatments (need, prognosis, time, cost); alternatives (including no treatment); and likely risks (including risks of no treatment) are the hallmarks of informed refusal (or consent). In addition, practitioners are encouraged to use language that is easy to comprehend, and incorporate open-ended questions to facilitate two-way communication and assessment of a patient’s level of understanding.
A refusal (or consent) should include a verbal discussion, and it may require further written or recorded documentation depending on the recommended treatment. Ensuring comprehension without seeming to coerce is a delicate balance to achieve, but it protects the patient and protects you and your practice.
How Do You Accurately Document Informed Refusal in a Patient Record?
An informed refusal should be accurately and promptly recorded in patient records. A refusal of treatment form can be used, although a blind signature on a form will not completely mitigate risk.
Clear notations on the patient’s condition, proposed treatment, possible risks, and consequences of failing to undergo treatment should accompany the form. In addition to any alternative treatments offered, indication of any referrals to specialists should be noted with the reason and risks of not seeing the specialist.
Finally, an account of the patient’s refusal should be included with details on the reason provided and any specific instructions on the degree of acceptable treatment, if any. Documentation and a signed refusal form would provide the strongest protection against a possible claim and offer an additional opportunity to verify full understanding by the patient.
What Can Practitioners Do to Maintain Patient Relationships After a Refusal?
Open communication is the key to maintaining patient relationships. Patients who feel their concerns and questions are being adequately addressed will feel well-informed and better able to make decisions.
Practitioners should not take a refusal as an indication of professional worth, but rather the patient exercising their right to make healthcare decisions. Respecting the personal values, beliefs, and goals of the patient may facilitate resolution.
A refusal does not necessarily mean the relationship is at an end. Practitioners may choose to provide alternative treatment as long as the patient understands the expected outcome. Reviewing a patient’s ongoing treatment on a yearly basis may result in further discussion of a treatment option that may be reconsidered under different circumstances.
So, Do You Treat a Patient Refusing Your Treatment Plan?
If a patient declines your treatment plan after it is explained thoroughly, be very careful and ask yourself some questions.
1. Will an alternative treatment plan improve the patient’s condition functionally and/or aesthetically?
2. Will the alternative treatment plan prevent an ideal correction in the future if the patient decides to have his/her case completed ideally?
3. Is the patient willing to accept the limitations of treatment and agree to those limitations in writing?
4. Will the patient dictate treatment throughout their care?
If the answers to these questions make you uncomfortable, it is most likely best to not treat the patient.
If you do not consent to alternative treatment, and no mutually acceptable resolution can be found, the patient may be dismissed. You are not required to treat every patient that comes into your office.
You increase your chances of a claim against you if you perform treatment the patient really doesn’t agree with or the outcome is a disappointment—even if they agreed to the limitations of a compromise treatment in the beginning. In all instances, accurate notation in the patient record is critical.
With candid conversation and a willingness to listen, relationships can withstand a difference of opinion or temporary discord. By working in partnership with patients and taking the interests of both parties into account, healthcare can become better and safer for everyone.
To learn other practical ways to reduce your risk of malpractice claims, visit aaoic.com.
Sources
1“Who has Dental benefits?” National Association of Dental Plans. National Association of Dental Plans, 2014. Web. 16 December 2016.
“Informed Refusal.” The Doctors Company. The Doctors Company. Web. 13 December 2016.
Glasscoe Watterson, Dianne. "Informed Consent and Informed Refusal in Dentistry." RDH. PennWell Corporation. Web. 12 December 2016.
Harper, Marianne and Rutledge, Colleen. “Consent or refusal: What every dental practice should know.” Dentistry iQ. PennWell Corporation, 2015. Web. 13 December 2016.
Selde William, MD. "Know When and How Your Patient Can Legally Refuse Care." Journal of Emergency Medical Services. PennWell Corporation, 25 March 2015. Web. 13 December 2016.
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