This information sheet is intended to provide a general understanding of the consent process. Links to suggested resources are included for those seeking more detailed or specific information.
If you have queries regarding a particular situation or type of consent process, please don’t hesitate to contact Advisory Services to discuss your concerns with a Peer Advisor.
What is informed consent?
The overarching principles of informed consent are covered in section 4.2 of Ahpra’s Code of Conduct which defines informed consent as “…a person’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved.”
For consent to be valid, information must be provided in a way that the patient understands.
Information should include:
- a discussion of the condition
- the aims of treatment
- the intended benefits and potentials risks of treatment
- the costs of the treatment proposed
- other treatment options, and
- the risk of postponing treatment or no treatment.
The patient should be given the opportunity to ask questions and be given time to consider their options, or, to seek a second opinion if there is disagreement or uncertainly, or if the treatment is particularly complex or carries significant risks.
How is consent obtained in dentistry?
Consent is a two-way process where the patient is given adequate time and explanation to understand the issues discussed and agree to a course of action.
For routine, simple procedures, the process of obtaining consent may be straight forward (e.g. consent for an examination can be inferred when a patient makes a booking and attends for a recall exam). Consent may also be obtained verbally (e.g. a chairside discussion will generally suffice to establish consent to proceed to perform a simple restorative procedure).
For more complex situations the dentist may need to refer to radiographs, photographs, diagrams, models or take-home information sheets to explain the disease, the treatment process and the potential benefits and risks of a procedure. Where extensive or costly treatment is proposed, a treatment plan should document exactly what treatment is intended and the costs involved.
It is recommended that consent for complex treatment is obtained at an appointment prior to the scheduled treatment. This allows patients additional time to consider the information they have been given and the opportunity to seek advice or a second opinion.
In addition, consent should always be confirmed verbally at the time of the treatment appointment. A common technique is to ask the patient to explain what they believe they are having done in any given appointment. If they describe what was discussed at the previous appointment the dentist can be very confident that consent is established – this should be clearly recorded. If the answer is not consistent with the records, the dentist should take the time to repeat the consent process.
The ADA Federal Policy Statement 5.15 – Informed Financial Consent provides guidance and may be accessed at https://ada.org.au/policy-statement-5-16-informed-financial-consent
Documenting consent
The Consent Process needs to be documented in the patient’s clinical record.
The most appropriate form of record will depend on the type and extent of treatment being proposed or the involvement of third parties who may have their own requirement for documentation e.g. the Child Dental Benefits Scheme (CDBS). For most routine dental treatment, it would be usual to make notes in the clinical record regarding the patient’s agreement to the procedure.
Consent documentation should show that the patient understands their oral health status (the diagnosis), what can be done (the treatment options), what the risks are (routine complications as well as risks that would be important to the patient even if considered remote), what the treatment objectives (outcomes) are and how much the treatment will cost (financial consent). It is generally expected that the option of not having or of postponing treatment, and the repercussions of this should also be discussed and recorded.
Documentation of consent is vital for defending complaints. The more thorough the documentation the better. Listing details such as what the patient has consented to, the diagnosis, treatment options and risks that were discussed is superior to a generic statement such as ‘consent obtained’.
It is easier for a practitioner to prove that consent was obtained if the notes are specific to the patient and situation. This may include documentation of patient engagement such as questions the patient asked in response to the information provided, or diagrams made by hand or the provision of a patient information sheet. Similarly, if you are employing a generic consent form, consider annotating or highlighting the form to customise it and to emphasise what has been discussed prior to the procedure. It is often helpful to allow a patient to take the form home to read before signing and also to provide them with a copy once signed.
The use of consent forms
If the proposed treatment involves:
- complex or invasive procedures
- general anaesthetic or sedation
- significant expense
- elective or cosmetic treatment,
good professional practice includes the use of a signed consent form confirming the patient’s agreement to treatment. A signed form alone however, will not protect a practitioner legally if it was not completed with true patient understanding and without coercion. A patient who signs a form without clear understanding the proposed treatment, the treatment options and the anticipated outcome (as well as possible complications or adverse outcomes) has not provided valid consent.
Consent forms should be written in plain language, using terminology the patient understands rather than using technical phrases or dental jargon. If technical language is unavoidable, it is a good idea to take the time to explain to the patient what the terminology means. You could initial the form at various stages to confirm your discussion and verify the patient’s understanding.
While a form is used to confirm the process that has taken place chairside, good communication with the patient is key. Ahpra’s Code of Conduct encourages dental practitioners to enter into a partnership with patients, engaging with them on a level they can easily understand.
Communication is the key
Clinicians who are good communicators have been shown to have the most satisfied patients and share certain qualities:
- They are active listeners who seek the patient’s input into treatment discussions
- They explain things in language/ terminology that the patient understands
- They actively encourage feedback and questions
- They supply adequate information so that the patient is able to understand the nature of their condition and the proposed treatment
- They spend (a little) longer with patients per visit
- They ask open questions to encourage the patient to discuss their situation
- They create a warm, friendly and welcoming atmosphere.
Good communication at the outset and at all stages during treatment helps patients to provide informed consent. As a treatment plan is developed, it is important the patient understands what is proposed and is engaged in the decision-making process. Answering all questions in an honest, factual and straight-forward manner provides the information patients need to make their own choices. With the patient’s consent, other treating clinicians and family members should be informed of the plan. This is especially important for children and patients with impaired cognitive ability.
For more information regarding consent for children or those with diminished capacity or cognition see: https://ncat.nsw.gov.au/ncat/case-types/guardianship/consent-to-medical-or-dental-treatment.html
Avoiding complaints
One of the most important aspects of consent is ensuring that the patient has reached their treatment decision freely and without pressure. Information relevant to the decision must not be withheld or misrepresented.
Some of the most commonly encountered consent issues in dental practice are:
- Not alerting the patient to all their treatment alternatives
- Not discussing common treatment complications BEFORE the treatment starts
- Not explaining all the risks (e.g. that a deep filling may later require RCT/extraction)
- Not offering referral to a specialist before starting complex treatment
- Not advising of the full extent of treatment (e.g. that a tooth requiring RCT may require a crown)
- Not explaining the likely outcome of not proceeding with treatment
- Not explaining the costs of treatment
- Patients being misled that a general practitioner dentist is a specialist (e.g. from comments made by the dentist or staff or from wording on signs, stationery or advertising).
Taking time with the patient before starting a course of treatment, is beneficial for practitioners and patients alike. Well informed patients are usually more satisfied with their treatment and less likely to raise complaints.
Practitioners are required to use their own clinical judgement before proceeding with patient treatment, even if consent has been obtained and particularly where a patient has unrealistic expectations. Where a practitioner’s clinical judgement or scope of practice does not align with the patient’s treatment requirements, it is recommended that the practitioner refers the patient to a more experienced colleague or specialist dentist for a second opinion.
Disclaimer: This is one of a series of Advisory Services information sheets created by ADA NSW. They are intended as general guides that highlight key pieces of information frequently requested. They do not set out to provide comprehensive information about a topic and they are not legal advice. Please be mindful that information provided in these resources can change after the publication date.
