Release from Liability Forms

First, let’s look at a slightly different version of this scenario. What if the patient had a tooth that needed a root canal and crown, but he refused to proceed with this treatment? Would you withhold other treatment unless he agreed to proceed with the endodontic treatment? The larger question is what are the reasons, concerns, fears, etc, that are keeping the patient from proceeding with diagnosed treatment? I would ask the following questions of patients who decline treatment:

1. What is your objection to proceeding with the recommendation for treatment?
2. Do you trust that we have your best interests in mind when we make a diagnosis for specific treatment?

I would advise teams to prepare themselves through roll-playing during team meetings on how best to engage patients in nonthreatening dialogue about their refusal of treatment.The dentist should participate in the conversation in which the patient articulates his or her objections to treatment as well. You may find that you are simply at an impasse and it would be in the patient’s best interest to seek care from another dental practice, or you may discover that his/her objection to treatment is actually a challenge that you can manage. Second, how do you proceed? I think the answer will become obvious once you thoroughly explore the patient's genuine objections. For example, if the patient refuses treatment because he doesn’t think he needs it or doesn’t value keeping his teeth, then you may “negotiate” by agreeing to provide an alternative treatment. This is similar to a palliative treatment in medicine that keeps the patient comfortable but does not treat an underlying disease. In this case, a preventive prophylaxis that removes biofilm and stain might be an option, but I would want verbal and written clarification for the patient, and his acknowledgement that preventive care is not a substitute for therapeutic care and the risk of tooth loss, oral malodor, and other problems are increased without appropriate treatment to halt disease progression. It has been my experience that sometimes a frank conversation with a patient along with good listening skills to understand the objections creates a dialogue in which the objections can be overcome. On the other hand, there are situations in which the demands of a patient may not fit into your practice philosophy, or they may be unrealistic in which case a decision to dismiss the patient may be the best option. For example, if the patient is a smoker, has diabetes, and a history of heart disease, and simply doesn’t want to pay the extra cost for therapeutic care, continuing to provide preventive care really is not a good substitute because his or her risk for disease progression and adverse health consequences is high. Regardless of your decision on how to proceed with each circumstance, you must keep in mind that patients need what they need, regardless of whether they proceed with treatment recommendations. I am a strong advocate of clear verbal communication and practicing good listening skills to explore all possible solutions.