Successful dentist-patient relationships are based on mutual respect and trust. Patients should feel confident their dentist can provide appropriate treatment that will meet reasonable expectations.
A professional relationship is established when a dentist accepts a patient for consultation or treatment and continues until such time as management of the patient ceases.
Patients may terminate a relationship with a dentist by repeatedly failing to attend or by advising that they have moved or will no longer be seeking treatment with them. They may request copies of their records to be forwarded to them and/or their new practitioner. It is the patient’s legal right to be provided with a complete copy of their dental records.
Generally, patients do not understand that a practitioner also has the right to end the professional relationship. However, dental practitioners have a statutory duty of care to their patients that extends to providing the required level of clinical skill, and maintaining professionalism in all patient communications and relationships.
Situations where a dentist might consider ceasing treatment are:
- A patient who repeatedly disputes the dentist’s findings and recommendations.
- A patient who responds aggressively or with threats.
- A patient who repeatedly fails to attend appointments or cancels appointments at short notice, despite respectful communication from the practice to discourage this.
- A patient who has unrealistically high expectations of the treatment outcomes.
Ceasing to treat early and general consideration before starting treatment
It is important that patients are aware of the option to consult a specialist at the treatment planning stage, so that decisions by the patient to proceed with elective treatment are fully informed.
Before starting aesthetic (or complex) restorative cases, it is wise to ensure that the patient understands the extent to which retreatment may be offered without charge.
If a procedure is complex or carries a reasonable risk (e.g. a deep filling), it is helpful if the resultant possible treatment (e.g. root canal therapy and a crown, or extraction +/- tooth replacement) and its cost is discussed and documented prior to treatment commencing.
It is important to consider that there may be contributing factors such as dental phobias, social circumstances, body image issues, psychological factors or other health concerns that could complicate a patient’s management and care. Ideally these factors are identified and managed prior to any treatment commencing.
Where an obstacle to quality care is identified, or where a practitioner has ongoing reservations regarding a patient’s expectations or where the treatment is complex, it may be in the patient’s best interest to consider referral either for a second opinion or for their ongoing care. When having such discussions, it is important to be tactful and sensitive to the patient’s circumstances, whatever they may be.
It is the practitioner’s duty of care to avoid providing any treatment that is not in the best interests of the patient. This position is enforced by the regulators when responding to formal patient complaints. These cases are difficult because they raise issues of appropriate consent for treatment.
Where a patient insists on a course of treatment that is against the practitioner’s better judgement or beyond their scope of practice, referral to a specialist or experienced practitioner for a second opinion and/or treatment is prudent. Treatment with questionable prognosis of success would fall into this category. In this situation, it is not uncommon for patients to refuse an initial specialist referral due to cost, until the treatment fails. At this point, a claim for remediation often follows on the basis that the dentist should not have proceeded with treatment.
Ceasing to treat after starting treatment
Some patients become dissatisfied despite the best efforts of even the most skilled dental practitioners. Even in these cases practitioners should consider referring patients to a specialist colleague for a consultation/second opinion (or treatment as appropriate).
Practitioners are expected to use their professional judgement in providing or discontinuing treatment in the best interests of the patient. When advising a patient that treatment will be discontinued, it is essential to emphasise that the decision is based on satisfying the patient’s needs and is not an act of retaliation by the dentist for perceived poor patient behaviour.
When a dentist makes the decision to cease treatment, a patient may become angry or abusive and may not pay outstanding accounts. It is becoming increasingly common for other retaliatory actions such as complaining to the Health Care Complaints Commission (HCCC) in NSW or the Australian Health Practitioner Regulation Authority (Ahpra) in the ACT, a consumer complaints body such as the Department of Fair Trading or NSW Civil and Administrative Tribunal (NCAT) Consumer division, making a legal claim, engaging in online criticism or posting negative reviews.
It is essential that a practitioner makes no statements or comments that could be misconstrued as being discriminatory. If a situation like this arises, the best thing to do is to seek advice from ADA NSW Advisory Services.
Responding to a difficult situation in the heat of the moment is the most common mistake practitioners make. Duty of care requires that professionalism is maintained in all patient communications and relationships. Additionally, an ill-considered response can give credence to an otherwise unfounded complaint. It is always in the practitioner’s best interests to try to defuse the situation by reassuring the patient that you have heard their concerns, offer to review the circumstances of the case and undertake to provide a response as soon as possible.
When Not to Cease Treatment
A practitioner’s duty of care extends to ensuring no foreseeable harm comes to a patient from any action or omission by the practitioner.
It is essential that the patient’s condition is stabilised prior to the discontinuation of treatment. This does not mean that all treatment must be completed. It will be dependent on individual circumstances, for example, it may be unwise to discontinue treatment midway through a complex prosthodontic rehabilitation. However, where treatment is not complete but the patient is caries-free and their condition is stabilised, then no immediate harm will come to the patient if the treatment is delayed. The best person to make this decision is the treating practitioner and this duty should never be delegated to any other person.
To place a patient in a compromised position midway through treatment may leave the dentist open to a charge of ‘abandonment’. An example would be the situation where the dentist prepares a tooth for a crown, but does not complete the treatment. Abandonment is a serious issue which can lead to action against the practitioner by the statutory authorities or a legal claim for negligence.
How to Cease Treatment
The decision to cease treatment is often met with amazement and dismay by patients who may have a genuine lack of insight into any difficulties in the practitioner-patient relationship. In these situations, reactions can be unpredictable or even aggressive.
It is imperative that the decision to cease treatment encompasses:
An assessment of the treatment provided to date.
- The patient’s present condition.
- Any treatment not yet provided.
- A pathway for the patient to access further appropriate care elsewhere.
A decision to discontinue treatment should be formalised in writing.
To help avoid inflaming a situation, practitioners can seek professional guidance and confidential support from a Peer Advisor on the Advisory Services team before ceasing to treat a patient.
If you require more information, please do not hesitate to email Advisory Services at advisory@adansw.com.au or call 8436 9944.
