Case study – the importance of detailed and careful assessment, treatment planning and communication when dealing with patients of advanced age

The case:

When the patient was 78 she attended the specialist practitioner (periodontist) for the placement of an implant at site17. This tooth had fractured and required extraction. A crown was subsequently placed by the referring general dental practitioner. The process was uneventful and the treatment outcome successful.

The patient returned to see the periodontist when she was 83 as she was experiencing discomfort and sensitivity associated with an old bridge replacing missing teeth 14 and 15.

The practitioner took a fresh medical history which disclosed changes since he had seen the patient 5 years previously. This exchange allowed the practitioner to assess the patient’s intellectual capacity generally. He formed the view that she still had capacity to make decisions about her healthcare.

He then performed a careful and thorough assessment which included updating the medical history, the periodontal chart and taking further radiology. The practitioner diagnosed mild chronic periodontitis. At that stage he did not think abutment teeth 13 and 16 required extraction. He recommended a conservative treatment plan of cleaning with re-assessment in 3 months’ time.

The patient returned 2-3 weeks later complaining of pain from the lower right area. Examination and assessment (including radiology) revealed an endodontic lesion at the 45 and a fracture of 46. The practitioner described his findings to the patient and discussed treatment options: endodontic re-treatment with crowns or extractions restored with implant supported crowns. The practitioner recommended extractions. Again, the practitioner spent a lot of time explaining his findings and the options and the discussion was recorded in the clinical record. He satisfied himself the patient understood the discussion and therefore had capacity to make decisions.

The upper bridge subsequently fractured. Radiology investigation revealed she was a suitable candidate for implants in the upper and lower jaws and the patient ultimately agreed to a treatment plan that provided for:

  • the extraction of teeth 13 and 16
  • the placement of 3 implants at the 13-16 site
  • the extraction of teeth 45 and 46
  • the placement of 3 implants at the 45-47 site

It was clearly explained to the patient that the cost of the treatment plan did not include the cost of the crowns which were to be placed by her GP dentist.

The extractions and implant placement proceeded without event. The patient was happy with all aspects of treatment. But someone else wasn’t happy, her son. The son was a lawyer.

The patient’s son sent a letter to the practitioner asserting that he had extracted two of his mother’s teeth “by mistake and without her authority”. He requested a “healthy discount” on the fees which he perceived were incurred in fixing a “mistake”.

The outcome:

The practitioner sent a detailed letter to the son explaining all the treatment steps and the associated decisions. He strongly denied the general assertion that the treatment was provided without the informed consent of the patient and noted that his mother had made no complaint and wanted to continue treatment with him.

The practitioner noted that his mother had paid all fees.

The practitioner stressed that he never had any doubt that the patient had capacity to consent to treatment and queried the son’s basis for asserting he had no authority to proceed. He queried whether the son had been appointed an enduring guardian authorised to make decisions about dental care on behalf of his mother.

The practitioner never heard from the son again.

The practitioner was in a strong position because of the comprehensive nature of his assessment, examination, treatment planning, communication and notes. He had communicated well with the referring GP dentist. In short he was able to “back himself” when it counted.

Lessons to be learned:

  • Practitioners must assess a patient’s mental state and cognition in order to be satisfied the patient has capacity to consent to treatment.
  • When dealing with patients of advanced age, always provide adequate time for the patient to absorb the information – don’t rush treatment.
  • Always document the discussions with the patient and note the consent of the patient.
  • If a patient does not have capacity to consent (for example due to dementia) then the practitioner needs to obtain consent from someone authorised to make decisions on behalf of the patient. Failure to obtain valid consent may leave the practitioner open to a claim for assault, battery and negligence.

Marianne Nicolle
Meridian Lawyers