Consentimientos

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2 CE credits This course was written for dentists, dental hygienists, and assistants.

Informed Consent and Risk Management A Peer-Reviewed Publication Written by Laurance Jerrold DDS, JD

Publication date: September 2010 Expiry date: August 2013

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Educational Objectives The overall goal of this course is to provide the reader with information on informed consent and the management of risk associated with this. Upon completion of this course, the reader will be able to do the following: 1. List and describe the dentist’s obligations and elements that should be adhered to when discussing informed consent with patients.

2. Describe the statute of limitations and the relevant windows of opportunity that exist under US law.

3. List and describe common exceptions and defenses used in claims brought regarding informed consent.

4. List and describe the practical considerations when obtaining informed consent from patients.

5. Describe the action that should be taken if a patient refuses treatment.

Abstract Dentists generally have a duty to obtain informed consent.

In order to be able to do so, the dentist must know and understand the elements that make up informed consent and how to obtain and document that informed consent has been obtained. All states utilize a statute of limitations regarding claims; understanding what constitutes a window of opportunity is another element of risk management. It is also necessary to understand the practical considerations involved in obtaining informed consent, as well as the actions that should be taken if a patient refuses treatment.

Introduction Informed consent risk management is required by the dentist in order to avoid and defend against claims around lack of informed consent. In order to do so, the difference between consent and informed consent must be understood and the obligations and requirements for informed consent must be fulfilled. The age and competency of the patient play a role in this, as does the method in which informed consent was obtained. It is crucial to keep full documentation on informed consent for each and every patient, documenting what medium was used to obtain informed consent and by whom. Last, if a patient refuses treatment after being informed of the treatment, risks and benefits, and alternative treatments, this must also be fully documented. All of these considerations, actions and documentation are necessary for risk management.

The Legal Perspective Generally speaking, a dentist has a duty to obtain a patient’s informed consent before performing nonemergency treatment, procedures or surgery or a diagnostic procedure that involves invasion or disruption of the integrity of the body. It is important to distinguish that there is a difference between consent and informed consent. Consent is a threshold issue that must be satisfied before informed consent can be given.

For a patient to legally grant consent to be treated, the patient 2

must be of sufficient mental capacity and of legal age and must voluntarily agree to the treatment. If a practitioner does not have the patient’s consent to provide treatment, then technically a battery is committed. This is defined as an unauthorized harmful or offensive contact with another person.1 Once consent for treatment has been granted, the doctor can then look at how to prevent claims for lack of informed consent from occurring.

Sufficient mental capacity may become an issue as our population continues to age, thus making our patient pool more geriatric. If there is any doubt as to whether or not the patient has the capacity to make decisions on his or her own behalf, it would be wise to request that another family member accompany the patient for visits.

Legal age may play a role in instances where treatment is ongoing and in the midst of therapy the patient reaches the legal age of majority. If the patient now requests the cessation of treatment (orthodontics, for example), but Mom is adamant about continuing treatment, be forewarned. The child is now of legal age, is not there voluntarily and is presumed to be of sufficient mental capacity.

In this instance, not removing the appliances may subject you to liability.

Finally, voluntariness may become an issue if the patient was mentally coerced, scared or “guilted” into accepting treatment. Also, voluntariness and mental capacity team up when treating minors who are not accompanied by their legal guardians. Technically neither Grandma nor a great aunt can grant nonemergency consent for treatment. Consent can be obtained by phone if necessary, but it must be given by the parent or legal guardian of the child.

For a patient to legally grant consent to be treated, the patient must be of sufficient mental capacity and of legal age and must voluntarily agree to the treatment.

Dentist’s Obligations – Informed Consent Informed consent is different than consent. If a patient accepts you as the treating doctor, that is consent. What treatment will be performed is a function of informed consent.

Claims for lack of informed consent always follow a circuitous but rational logic that goes something like this: You advised me to have this procedure done. You didn’t tell me that there was the potential for XYZ to happen. If I had known about the potential for XYZ, I never would have had the procedure done. Since I didn’t know about XYZ, I went ahead and had the procedure done. Since XYZ happened, you are responsible, since even though I had it done, I didn’t have to do it and I wouldn’t have done it if I had been informed.

How do we defend against claims for lack of informed consent? The following elements should be adhered to and documented: www.ineedce.com

a. Explain the procedure in a manner understandable to the patient. Telling the patient he or she has periapical pathology and needs an apicoectomy may be correct, but telling the person he or she has an infection at the root tip and requires a surgical procedure to correct it is certainly more comprehensible. b. Explain what you propose to do. In other words, describe the proposed treatment plan, including how long treatment should take, the costs involved, etc. c. Explain the risks, benefits and alternatives to the proposed procedure or therapeutic approach. There is no way to decide among viable alternatives unless one can balance the potential benefits against the potential risks for each option offered. d. Explain the risks of undergoing the recommended therapy versus forgoing treatment. No treatment is often a viable treatment alternative for some patients utilizing the same risk/benefit ratio. e. Discuss any necessary secondary treatment before undertaking the primary treatment. For example, if endodontics is a viable treatment option for a fractured tooth, make sure the patient is aware that at some point after the canal is sealed, a post, a core and a crown will be necessary. f. For all the above, explain any information that a reasonable patient would deem to be material in helping him or her to decide whether or not to accept or reject the proposed treatment. g. Give the patient ample opportunity to ask and have answered any questions he or she may have pertaining to all viable treatment options.

If a patient accepts you as the treating doctor, that is consent. What treatment will be performed is a function of informed consent.

Separate Claim From Dental Malpractice Even if a procedure is properly performed (thus no malpractice was committed), a patient could still prevail on a claim for lack of informed consent if a complication or risk that subsequently occurred was not properly disclosed. The statute of limitations for a cause of action for lack of informed consent is generally the same as it is for malpractice.

Statute of Limitations Risk management cannot be fully appreciated without an understanding of the statute of limitations (S/L). Courts recognize that it is not fair to hold doctors accountable for their actions forever. At some point, they have to be free from the prospect of litigation for previous acts. The S/L is essentially a window of time or opportunity during which the patient must bring forth an action or be barred from doing that. There are essentially two approaches that states use regarding this issue; think of them as window sashes. www.ineedce.com

The Window of Opportunity One type of sash is the occurrence type. In states that use this type of statute, the window of opportunity or period of time begins to run from the time of the occurrence of the negligent act. In states that employ the second type of sash, the window of time starts to run from the time the negligence or the injury is discovered or should reasonably have been discovered. Obviously, the discovery jurisdiction is more favorable for the patient, as the window is open for a longer period of time, while the occurrence jurisdiction favors the doctor. There are several tolling provisions that the various states have adopted that prevent the statutory period of time from running. Think of them as sticks that can be placed in the sash to keep the window propped open. The two most applicable to dentistry are the continuous treatment doctrine and infancy.

Since not every state utilizes these doctrines, the reader is urged to seek legal counsel in the state in which he or she practices.

Continuous Treatment Doctrine Under the continuous treatment doctrine, public policy encourages patients to return to their dentists in order for remedial treatment to continue without the threat of litigation coming between the parties. Thus, as long as treatment for a certain condition is continuing in the form of regularly scheduled appointments and a continuing professional relationship exists between the parties, the period of time available to file a lawsuit will not commence.2 For example, you construct a bridge for a patient but it requires many post-insertion visits prior to permanent cementation. There may also be a few more visits for purposes of equilibration. The S/L will not start to run from either the date of the initial insertion or the date of the cementation, but rather from the date of the last visit, the final equilibration visit, regarding the provision of this service. If, years later, additional adjustments are required, this will not trigger the tolling provision, as treatment has been noncontinuous.3

Under the continuous treatment doctrine, the period of time available to file a lawsuit will only commence after regularly scheduled treatment for a certain condition has ended.

Infancy The other common tolling provision is infancy. As a general rule, a minor has the same period of time to file a malpractice claim in his or her own name after reaching the age of majority. This obviously exposes the practitioner to liability for a greater period of time. Many states have statutes of repose, which maximize the tolling provision for infancy as well as other tolling provisions.

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Documentation Is Required Claims involving lack of informed consent almost always involve questions of fact between the dentist and the patient.

Therefore, it is essential that all practitioners document the following information in the patient’s chart when oral informed consent is obtained: • The date, time and place of the discussion • The name(s) of all people present • Evidence that the risks, alternatives and benefits of the proposed treatment, all viable alternatives and the option of no treatment were discussed • Any diagrams, models, brochures or other aids that were used (These should also be saved.)

• Documentation of all significant questions asked by those present and your responses to them

Claims involving lack of informed consent almost always involve questions of fact between the dentist and the patient.

Consent Forms If an informed consent form is used, it should be routinely reviewed and updated. If the form is the type that requires filling in blanks, it must be filled out before being signed by the patient. Forms must be signed and dated and should also be witnessed. The mere fact the form is signed is NOT evidence that informed consent was obtained. As previously noted, the circumstances under which the information on such forms is obtained are the determining factors as to their sufficiency.

The dentist must make sure the patient can read and understand not only the form, but all other material distributed. If the patient’s native language is not English, suitable alternatives must be used.

Defenses to Claims for Lack of Informed Consent The following are common exceptions or defenses to a claim for lack of informed consent4: a. Emergency situation – if the patient is unconscious or in extremis, the law implies consent, i.e., a child avulses a tooth and consent for replantation cannot be obtained in a timely manner from the parents. b. Where the risk is not disclosed because it is too commonly known to warrant disclosure, i.e., the risk of infection following a surgical procedure; ; OR, the risk was unknown at the time treatment was rendered; e.g., the rsk of enamel fracture upon debonding ceramic orthodontic brackets. c. The patient assured the dentist he or she would undergo the procedure regardless of risk. Be sure to document this in detail.

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d. The patient assured the dentist he or she does not want to be informed of the risks. Again, document this in detail. e. The dentist, after considering the patient’s overall condition, used reasonable discretion in not disclosing the risks, alternatives and benefits to the patient because he or she reasonably believed that disclosure would adversely affect the patient’s condition. This can occur when treating a true dentophobic. f. The lack of proximate causation between the lack of informed consent and the injuries sustained.

Understand that the above are merely defenses to a claim for lack of informed consent; they do not mean you will be exonerated. They merely explain why certain actions were or were not taken vis-à-vis obtaining a patient’s informed consent. Also, although these defenses can be asserted and used at trial, prevention is the better road to take. Discuss, disclose and document the risks, alternatives and benefits of the proposed procedure.

The Risk Management Perspective There are practical considerations to effectively obtaining a patient’s informed consent: 1. Explaining to patients the risks and benefits of both the recommended procedure and any alternatives brings the patients on board as participants in the process; thus, they assume most of the responsibility for the choices made.

The purpose of an informed consent discussion is to help the patient make an informed decision regarding care that the person will receive. Remember two things: firstly, that doctors should not be paternalistic, imposing their will and judgment upon their patients, and secondly, that a patient is free to refuse treatment.

2. Include the patient in the decision-making process by also discussing: i. How the patient may expect to feel afterward ii. The expected length of treatment iii. The recuperative period, if any, and how long until the patient can resume his or her regular activities iv. The fees associated with the recommended treatment, as well as any secondary treatment necessary, who will provide it and whether it was figured into the original cost 3. Test the patients’ comprehension to be sure they understand what you are saying. Give a patient time to consider the information; never give a patient a guarantee as to the result.

4. Once patients consent to the procedure/treatment, ask them to sign the consent form(s) (not required). It would be a good practice to use preprinted or stock forms for procedures routinely done in the office. These may act as a helpful guide during a discussion with the patient regarding the proposed treatment. www.ineedce.com

5. Aside from the consent form, summarize your discussion with the patient in his or her chart, making sure to include all the elements previously discussed.

6. A dentist should familiarize himself or herself with the informed consent policies in all the offices in which he or she practices, in order to ensure compliance with each of them.

Refusal of Treatment Occasionally, informed consent discussions conclude with the patient deciding not to undergo the recommended procedure or to delay the proposed treatment. These refusals and delays require detailed documentation. Often it is the patient who refuses the recommended care who later returns to blame the doctor for any untoward outcome. Sometimes, it is the family of the patient (in the event where a dentist is treating a child), with the family probably unaware of the doctor’s efforts to bring the patient into compliance and later bringing a suit against the dentist. When this occurs, the doctor’s note should be detailed as to: 1. The reason for the recommended care/treatment 2. The risks of not following professional advice 3. The reasons given or statements made by the patient or guardian regarding the refusal.

Some practitioners choose to prepare a statement for the signature of a patient who refuses treatment. Often we see this as a form titled ‘Refusal Of Treatment Against Medical Advice’. Where this is done, the statement should be on a separate sheet of paper and not on the patient’s treatment chart, although reference to the statement should be in the chart. The statement should be dated and witnessed.

Documentation of Informed Consent There are many ways to document that informed consent was given. Think of documentation as standing on a risk management ladder. The rung with the highest degree of credibility is to videotape the discussion. Audiotape is the next best method of proof. Having the patient describe the discussion in his or her own words and handwriting would be the next step down on this risk management ladder. Having the doctor summarize the discussion in the chart with the patient’s signature would be next, followed by the same notation without a signature. Giving the patient a booklet or form with and without a signature follow. Having a note in the chart that informed consent was given would be the next rung to the bottom, with no notation at all being last.

A dentist should familiarize himself or herself with the informed consent policies in all the offices in which he or she practices, in order to ensure compliance with each of them. www.ineedce.com

Hypothetical Informed Consent Problem and Analysis My name is Dr. Reason Able. I practice in Allover, USA. I can’t believe what happened recently. Mr. Iam Frugal came into my office for a routine checkup. I did a comprehensive exam, X-rays, charting, everything. He had lost three lower anterior teeth a few months ago in a car accident, along with a deciduous second molar on the lower right side that never exfoliated as there was no permanent successor. He also had periapical pathology on a lower left molar. I told him he had a choice of either a root canal or extraction of the lower molar. I informed him that I would have to refer him to an oral surgeon since I don’t do extractions in the office. He opted for the root canal.

I obtained informed consent regarding the root canal procedure: explaining the procedure, the chance of success and the risks of the procedure and alternative treatment, i.e., extraction. The mesial roots were very curved, and the mesial buccal canal was perforated during the procedure. I reminded him of our conversation about the risks involved, and he admitted to remembering something like that. I then advised him that if the tooth were to be saved, it would require a root amputation. I explained what that was and again went over the risks and the additional fee involved. He started ranting and raving about how he was not going to pay a dime more than he originally agreed to, especially since it was my fault that he needed another procedure. My sister-in-law, Dr. Ican Coverit, is a periodontist; so she did the surgery for Mr. Frugal without charging him a fee. All went well.

After everything had healed, I scheduled Mr. Frugal for a post, a core and a crown on the molar. When I asked him for a down payment, he went crazy. He told me that between the endo and the restorative, the amount I was charging to save one crummy tooth was insane, that I was out of my mind and that anyone who would spend that kind of money was nuttier than I was. He then stormed out of the office screaming how I’d pay for stringing him along in order to squeeze out every last dime.

Well, now I’m being sued for lack of informed consent.

He is claiming that if he knew that he was going to need a post, a core and a crown on the molar, he would never have had the root canal performed. Instead, he would have opted for extracting that tooth and restoring the space with a partial denture to replace that tooth and the other missing ones. If that’s not enough, he is also suing me for negligence regarding the endodontic treatment, failure to refer, loss of consortium, pain and suffering, the whole nine yards. I don’t get it; all I tried to do was provide the best dentistry possible. Did he really think I was going to do the work for free?

Informed Consent (Risk Management) Problems 1. Lack of informed consent 2. Breach of the duty to refer 3. Poor patient management

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Analysis of Informed Consent (Risk Management) Problems 1. The doctrine of informed consent requires that a patient be informed of (1) the diagnosis in a language that the patient can comprehend; (2) the treatment plan, along with all viable treatment alternatives; (3) the risks, consequences and limitations associated with each; (4) the prognosis; (5) the option of no treatment along with the sequelae of that decision; and (6) the opportunity to ask and have answered any questions that the patient may have regarding the proposed treatment.

In addition, if the treatment being proposed carries with it the need for a distinctly different but necessary secondary or follow-up procedure, the patient should be informed of this as well, along with all attendant ramifications in order to accept or reject the proposed initial phase of therapy.

In the above scenario, the patient was not told he would need any secondary treatment associated with the primary procedure. Had Mr. Frugal known of the necessity for a follow-up post, core and crown he might never have agreed to the initial procedure being performed. In addition, there was no mention of the treatment option to extract the tooth and construct a partial denture, which due to the number of missing teeth in the lower arch, may have been a viable alternative method of treatment.

2. The legal question here is whether or not the patient should have been referred to a specialist. The answer will turn on whether or not expert testimony can prove that this was the type of case which a general dentist would or would not normally treat. If it was not, then it should have been referred to the appropriate specialist. Generally, one has a duty to refer when (1) it is in the best interest of the patient to do so; (2) when the average practitioner in good standing within the community would have done so; or (3) where a reasonable chance for success was beyond the level of the doctor’s skill, knowledge or expertise. In addition, other reasons for referring patients are because patients often expect a higher standard of care when treated by a specialist and, finally, because it is good risk management to spread the risk. The facts reveal that the molar root was very curved, thus raising the possibility that this might become more than a routine endodontic procedure. If true, it would provide a credible argument that the patient should have been referred to an endodontist to perform the procedure.

3. Dr. Able engaged in poor patient management. Apparently his normal routine was to diagnose the problem and provide adequate informed consent regarding the procedure in question. The financial considerations regarding the proposed treatment were not discussed until it came time to require payment. The cost of any proposed therapy should be discussed up front, as it may often play a role as to the treatment plan chosen by the patient. This has even greater importance in the situation where, as here, secondary follow-up therapy will eventually be required and this subsequent procedure will carry with it additional financial ramifications.

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If the treatment being proposed carries with it the need for a distinctly different but necessary secondary or follow-up procedure, the patient should be informed of this as well the financial costs involved in both the primary and secondary treatments.

Summary The dentist’s obligation to obtain informed consent is very clear. Not obtaining informed consent opens the dentist up to patients’ claims for lack of informed consent. There are a number of elements and requirements for a dentist to follow in order to prove that informed consent was obtained. This does not prevent a patient from still suing the dentist for negligence. Nonetheless, the best defense against legal claims around informed consent is to follow the requirements and fully document that informed consent was obtained and how, as well as any instances of patients refusing treatment.

References

1. The Legal Law Library’s Legal Lexicon. Available at: www. lectlaw.com 2. Swang v. Hauser, 180 N.W.2d,187 (1970) 3. Tolling & Extensions to the Statute of Limitations. Available at: www.NoNonsenseLaw.com 4. Available at: www.enotes.com/everyday-law-encyclopedia /informed consent

Additional Resources

Berg JW, Appelbaum PS, Parker LS, Lidz CW. Informed Consent: Legal Theory and Clinical Practice. Oxford University Press, 2001. 2nd ed.

Faden RR, Beauchamp TL. A History and Theory of Informed Consent.

Oxford University Press. 1986.

Miller FG, Wertheimer A, eds. The Ethics of Consent. Oxford University Press, 2010

Author Profile

Laurance Jerrold DDS, JD Laurance Jerrold is the President of Orthodontic Consulting Group. He received his Undergraduate and Postgraduate dental education at NYU, his JD from Touro University, and his Certificate in Bioethics and the Humanities from Columbia University. Dr. Jerrold has integrated over 25 years in the private practice of orthodontics with more than 20 years teaching dental risk management, 15 years practicing law, and over 10 years teaching clinical bioethics. With his unique and practical perspective on risk management for the dental practitioner, Dr. Jerrold has been recognized nationally for his contributions to the field of dental risk management education. He has presented risk management courses for six of this country’s dental malpractice carriers and has presented or written over 200 lectures, articles, or multi media presentations dealing with risk management and/or ethics for dental organizations nationwide.

Disclaimer

The author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

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Questions 1. Informed consent risk management is required by the dentist in order to _______.

a. avoid lack of claims regarding informed consent b. defend against claims regarding lack of informed consent c. avoid and defend against claims regarding lack of informed consent d. none of the above

2. Generally speaking, a dentist has a duty to obtain a patient’s informed consent before performing _______. a. nonemergency treatment b. surgery that involves invasion or disruption of the integrity of the body c. a diagnostic procedure that involves invasion or disruption of the integrity of the body d. all of the above

3. Consent _______.

a. follows informed consent b. precedes informed consent and must first be satisfied c. is the same as informed consent d. none of the above

4. For a patient to legally grant consent to be treated, the patient _________. a. b. c. d.

must voluntarily agree to the treatment must be of legal age must be of sufficient mental capacity all of the above

5. If there is any doubt as to whether or not the patient has the capacity to make decisions on his or her own behalf, it would be wise to _________.

a. refer out the patient’s treatment b. refuse to treat the patient c. request that another family member accompany the patient for visits d. all of the above

6. If a patient reaches legal age while undergoing treatment such as orthodontics and decides he or she does not want to continue treatment while the parent does, leaving the orthodontic appliance in to continue treatment _________. a. b. c. d.

is the right thing to do is better for the patient as the parent knows better is essential and will satisfactorily complete the case may subject you to liability

7. Consent _________.

a. can be obtained by phone if necessary b. must be given by the parent or legal guardian of the child c. can be obtained from whomever brings the child in for treatment d. a and b

8. What treatment will be performed is a function of ________. a. b. c. d.

consent informed consent what the clinician wants all of the above

9. To help defend against claims regarding lack of informed consent, the clinician should ________.

a. explain the procedure in simple terms that a layman would understand b. explain what the treatment is and how you propose to do it c. explain the benefits, risk and alternative treatment(s) d. all of the above

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10. If emergency treatment of a child is necessary, ________.

a. informed consent must always be obtained first from the closest relative present b. informed consent must always first be obtained from the parent or legal guardian c. the emergency treatment may be performed without first obtaining informed consent d. a and b

11. If a procedure is properly performed (thus no malpractice was committed), a patient _________. a. b. c. d.

a patient cannot sue for lack of informed consent a patient cannot sue if consent was obtained a patient could sue for lack of informed consent none of the above

12. A patient could prevail on a claim for lack of informed consent _________.

a. if a complication or risk that subsequently occurred was adequately disclosed and documented together with all other pertinent facts b. if a complication or risk that subsequently occurred was not properly disclosed c. only in 10% of cases d. none of the above

13. The statute of limitations is _________.

a. a window of time or opportunity during which the patient must bring forth an action b. a time beyond which the patient is barred from bringing an action c. generally the same as for malpractice d. all of the above

14. The window of opportunity

a. starts from the time of the occurrence b. starts from the time of the discovery of the occurrence c. depends on the state d. all of the above

15. The ________ jurisdiction(s) is/are more favorable for the patient. a. b. c. d.

occurrence discovery discovery and occurrence all of the above

16. A tolling provision _________.

a. charges according to how long ago the occurrence happened b. speeds up the stator period of time c. prevents the statutory time from running d. a and b

17. Under the continuous treatment doctrine, the period of time available to file a lawsuit _________.

a. commences as soon as regularly scheduled treatment for a certain condition begins b. commences after regularly scheduled treatment for a certain condition has ended c. commences when adjustments are made a year or two later d. none of the above

18. A statute of repose _________.

a. minimizes the tolling provision for infancy as well as other tolling provisions b. maximizes the tolling provision for infancy as well as other tolling provisions c. removes the tolling provision for infancy as well as other tolling provisions d. none of the above

19. Claims involving lack of informed consent almost always involve _________. a. b. c. d.

untruths collaboration questions of fact b and c

20. If an informed consent form is used, ______. a. b. c. d.

it should be routinely reviewed and updated it must be signed and dated by the patient it must be filled in before the patient signs it all of the above

a. b. c. d.

the patient is unconscious the patient is in extremis the patient is over a certain age a and b

21. The law implies consent if _________.

22. By explaining to a patient the risks and benefits of both the recommended procedure and any alternatives, _________. a. the patient is brought on board as a participant in the process b. the patient assumes most of the responsibility for the choices made c. the patient will always accept the proposed treatment d. a and b

23. The purpose of an informed consent discussion is to _________. a. b. c. d.

help the patient make an informed decision avoid a lawsuit provide defense in the case of a lawsuit all of the above

24. _________ is a discussion point that should be included in the discussion with the patient. a. The expected length of treatment b. The anticipated recuperative period c. The fees associated with the treatment and any secondary treatment d. all of the above

25. When discussing proposed treatments and alternatives with a patient, it is important to _________. a. b. c. d.

test the patients’ comprehension give the patient time to consider the information never give the patient a guarantee as to the result all of the above

a. b. c. d.

in order to be able to cite these if a lawsuit occurs in order to ensure compliance with each of them to make sure they are not only verbal all of the above

26. A dentist should be familiar with the informed consent policies in all the offices in which he or she practices, _________.

27. If a patient or parent/guardian refuses treatment, the dentist must note in as detailed manner as possible _________.

a. the reason for the recommended care/treatment b. the risks of not following professional advice c. the reasons given or statements made by the patient or guardian regarding the refusal d. all of the above

28. If a statement is prepared for the signature of a patient who refuses treatment, it _________. a. b. c. d.

should be on a separate sheet of paper should be in the patient’s chart need not be dated or witnessed all of the above

29. _________ is an informed consent (risk management) problem. a. b. c. d.

Lack of informed consent Breach of the duty to refer Poor patient management all of the above

30. The best defense against legal claims regarding informed consent is to _________. a. refuse to treat patients you perceive may be awkward b. follow the requirements and fully document what informed consent was obtained and how c. fully document any instances of patients refusing treatment d. b and c

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ANSWER SHEET

Informed Consent and Risk Management Name:

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822 If not taking online, mail completed answer sheet to

Educational Objectives 1. List and describe the dentist’s obligations and elements that should be adhered to when discussing informed consent with patients.

2. Describe the statute of limitations and the relevant windows of opportunity that exist under US law.

3. List and describe common exceptions and defenses used in claims brought regarding informed consent.

5. Describe the action that should be taken if a patient refuses treatment.

P ayment of $39.00 is enclosed.

(Checks and credit cards are accepted.)

Course Evaluation

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No

9. Would you participate in a similar program on a different topic?

A Division of PennWell Corp.

P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447 For immediate results, go to www.ineedce.com and click on the button “Take Tests Online.” Answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619.

4. List and describe the practical considerations when obtaining informed consent from patients.

1. Were the individual course objectives met?

Academy of Dental Therapeutics and Stomatology,

Charges on your statement will show up as PennWell

10. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________ 11. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________ 12. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________

AGD Code 555

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. AUTHOR DISCLAIMER The author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant. No manufacturer or third party has had any input into the development of course content.

All content has been derived from references listed, and or the opinions of clinicians.

Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.

COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com.

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INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination.

EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell.

Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 2 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $39.00 to $110.00.

Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANB’s annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANB’s Recertification Department at 1-800-FOR-DANB, ext. 445.

Customer Service 216.398.7822

RECORD KEEPING PennWell maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.

CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. © 2010 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

CODE

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