300 Notifications

By Dr Colm Harney

In 2013, car-makers around the world discovered certain airbags produced by now-defunct Japanese company Takata could degrade over time, causing the airbag to blast metal shrapnel from its inflator when deployed in a crash.

It is estimated 100 million cars from more than two dozen brands originally fitted with certain Takata airbags have been recalled and fixed globally since 2013, although there are still vehicles on the road which have not had their potentially fatal devices replaced. In a media statement, the US National Highway Traffic Safety Administration (NHTSA) reported a driver was killed in Bowling Green, Texas, as a result of their 2002 Honda Accord’s Takata airbag inflator rupturing during a crash.

A media statement issued by Honda’s US division claims it attempted to contact the car’s owner more than 300 times since the recall campaign began, although the airbag was never replaced.

According to Honda, it mailed more than 40 notices to the owner's registered address, made more than 230 phone calls, and sent in excess of 40 email notifications.

The fatality is believed to be the 23rd in the US caused by a defective Takata airbag, among an estimated 35 deaths and 350 serious injuries worldwide. At least two people have been killed in Australia, with the fatal incidents occurring in 2017 and 2019 (Source – Drive.com.au 19 December 2022).

In the day-to-day practice of dentistry we issue risks and warnings all the time – from the relatively inconsequential warning we might issue to frequent poor attenders regarding their attendance/punctuality or they will be charged a non-attendance fee, to the potentially significant warnings we might issue in relation to a high value procedure with known significant material risks. The underlying issue here, of course, is communication, and critically in dental practice this would be the conversation of consent. The Dental Board of Australia Code of Conduct states that “informed consent is a person’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved” (Source: DBA Code of Conduct https://www.ahpra.gov.au/Resources/Codeof-conduct/Shared-Code-of-conduct. aspx). This includes financial consent, and the implication is that there is an obligation on the practitioner to ensure the patient has sufficient understanding.

So how should we approach a situation, like the Honda owner in the USA, where we believe that we have communicated the requisite information to gain consent but there is a sense that the patient is either not responding or giving us reason to doubt that they have full understanding?

I would suggest there are 4 key considerations on how to proceed for those times the dashboard warning lights flash but it’s not clear how to proceed. First is to pause, take a metaphorical deep breath and ‘listen’ to your gut instinct as it is probably telling you something important. I took a call recently from a dentist who was treating a patient for whom English was not their first language. The patient had significant bone loss apically around a non-vital lower premolar and wanted to keep their tooth, at least until some, as yet undetermined, time in the future when they were returning to their home country to get definitive treatment. The dentist was trying to explain that the tooth had a poor/nil prognosis, there was a strong suspicion of a root fracture and if the patient was going to spend time and money having a procedure then the dentist wanted a second opinion from an endodontist on the viability of the tooth. The patient declined and despite all risks and warnings being outlined the patient kept asking the dentist to treat the tooth. The patient refused to bring somebody to the appointment who might assist with understanding and even declined an offer of engaging an external translator.

In a discussion like this my points of reference are always to ask if the dentist is acting in the patient’s best interests and if they are able to meet the patient’s expectations. In this case, despite what the patient wanted, for the dentist to carry out root canal treatment on a tooth with a strong suspicion of root fracture, was likely to fail (perhaps catastrophically with a split once the tooth is opened), and cost the (financially sensitive) patient a significant amount of money – a strong objective case could be made that it was neither in the patients interests or likely to meet their expectations. The dentist would also be vulnerable to a potentially critical third party such as the regulator reviewing the information later on and making an adverse finding despite the best intentions of the dentist.

The second consideration is to always try and check understanding. It is not just enough to give a consent form before a procedure, while waiting for the anaesthetic to take, and ask for a signature. Neither is it enough to ask the patient if they understand because they may be embarrassed to say otherwise or just want to get things over to alleviate anxiety around a procedure. With the consent process, particularly if there is complexity, cost or potential for complication, I always ask the patient to give me a quick summary of what their understanding is. This is not requested in the tone of a final year viva exam but as a collaborative discussion where the dentist acknowledges any complexities/jargon and is willing to spend the time and resources to reach mutual understanding with the patient.

The third consideration, which follows from the second is to avail of any means to give alternative explanations. It is known that people respond and learn more effectively by different means – one simple way of classifying is auditory, visual and kinaesthetic. Using these categories means that it is beneficial not just to verbally explain a concept but also to give handouts/video clips and even tactile aids such as demonstration models where a patient can see and feel what a crown or veneer is rather than just attempting a verbal comparison to a ‘cap’ or a ‘false fingernail’. The final consideration is whether there is some reason that the patient does not have capacity to make the necessary decisions to consent to a procedure. Examples of this may be some form of cognitive impairment such as dementia or intoxication, age, or as in the example above the dentist and patient simply may not speak the same language as their primary means of communication.

So where does this leave us as healthcare professionals with the patient for whom we issue ‘300 notifications’ but still something goes wrong, and the patient says they didn’t understand the risks because if they had they would never have gone ahead?

All roads lead back to the records and documentation – if it can be demonstrated that all reasonable attempts were made to gain consent and the patient had capacity and understanding – then as the old adage goes in relation to claims, good records … good defence, poor records … poor defence, no records … no defence.

To close the loop on the automotive analogy, when an accident or adverse event occurs the records are like our airbag – when deployed effectively it will enable us to walk away from the wreckage and continue on our practicing journey relatively unscathed.

WADA Golf at Gosnells Golf Club

The second WADA Golf fixture for the year was held at the Gosnells Golf Club on Friday 24th March. We enjoyed classic Perth Autumn weather with a combination of heat, high humidity and Rain all in the same round of Golf. The course was in excellent condition once more and 23 keen golfers tried to conquer the course.

Scoring for the day was tight for most of the field except for the winner. Congratulations to Rod White for his victory on a fantastic score of 47 stableford points. Brad Potter (HealthLinc sponsor) took second with 35 points on a countback from Hugh Gillespie 3rd and Richard Williams 4th. Craig Lewis and Simon Tee took out 5th and 6th places with credible scores of 34 points.

• 1st Rod White

• 2nd Brad Potter

• 3RD Hugh Gillespie

The day was generously sponsored by Dentsply-Sirona. Leanne Patrick - Clinical Specialist North, from Dentsply joined us for the day. We subsequently enjoyed the company of Dentsply representatives Sarah Ahmedbegyi – Suresmile Manager, Thiya Rajaender – Implant Specialist and for a post-match catch up. Leanne kindly presented the Dentsply winner’s prize to Rod White. Our thanks to Dentsply-Sirona for their ongoing support of WADA Golf.

Nearest the pin prizes for the day, sponsored by our corporate partners.

Summary of results

NTP. 9th hole

NTP. 7th hole

NTP 11th Hole

T.Fenn Health Practice Brokers

M.Whitford Swan Valley Dental Laboratory

M.Whitford Dentsply Sirona

NTP 14th Hole Simon Tee Healthlinc

18th Hole Longest Drive Simon Tee Insight Dental Ceramics

NAGA award for the most golf played today – Jun Liew and Rick Lazar-Hard day at the ‘office’.

Finally, it was terrific to welcome Tom Hastie and Jun Liew as new members to WADA Golf and welcome back after some time Ben Campbell and Phil Robson. I encourage other interested dental golfers to dust off the clubs and join us for our next fixture at Hartfield Golf Club on Friday, 12th May. Good golfing, Frank Welten

WADA Golf Captain Dentistgolf@gmail.com