When Ethics Overcomes Bureaucracy

Claudia Ferdeghini

Ozar-Hasegawa Dental Ethics Award Submission

When Ethics overcomes Bureaucracy – Assistance to a vulnerable patient The goal of all healthcare institutions should be to eliminate barriers to quality care. I feel privileged to share a case where, as a student at University of Milano-Bicocca at Ospedale San Gerardo in Monza, with the support of my esteemed faculty, I had the opportunity to be a part of an uplifting experience which reaffirmed my conviction in my chosen profession. Dental care is often overlooked amongst the underserved populations until the need for treatment manifests as an emergency.

Vulnerable groups such as minors, refugees and immigrants oftentimes fail to be directed to the right resources and hence suffer a disproportionate amount of dental morbidity. The case discussed here involves a 16-year-old immigrant, Ms. G, who arrived in Italy with her parents 8 months ago who sought better economic opportunities for their family, and presently live in a Refugee Reception Center.

Ms. G was brought to the Dental Clinic by a social worker from the Refugee Reception Center for a dental emergency visit with the chief complaint of “severe tooth pain”. Ms. G does not speak Italian so we asked the social worker to be the translator between the patient and her parents and the clinical team. Medical and surgical history were reviewed and there were no diseases, conditions, allergies or medications reported. Vitals were stable and patient was cooperative and afebrile. Upon reviewing dental history, patient stated that she had received a dental filling in her home country but could not recall how long ago. She pointed to a lower right back tooth as the source of pain and described the pain as persistent and throbbing in character, which is made worse upon chewing.

Intraoral exam revealed that the patient had fair oral hygiene, tooth #c (upper right deciduous canine) was over-retained while #6 (upper right permanent canine) appeared to be unerupted, and tooth #30 (lower right first permanent molar) had an occlusal composite with signs of leakage and recurrent caries. #30 was tender upon palpation.

An Orthopantomograph (Fig. 1) was taken to obtain a baseline radiograph and on it, #6 was found to be impacted and #30 had a large periapical radiolucency.

Clinical and radiographic evaluations confirmed #30 has Acute Periapical Periodontitis secondary to recurrent caries, #6 is impacted and #c is over-retained.

Patient and parents were advised that the optimal treatment to address the patient’s pain from #30 would be to treat the tooth endodontically rather than to extract it. It was explained to the Fig. 1 patient and the parents that the tooth is of functional significance and is restorable. Patient was also advised extraction of #c to see if #6 spontaneously erupts into position, failing which orthodontic evaluation would be necessary. Treatment plan was thoroughly reviewed with the parents to confirm understanding of needs and recommendations. Considering the chief complaint of the patient, we prioritized addressing #30 to arrest progression of dental infection and avert further loss of tooth structure.

Informed consent was reviewed with parents who confirmed understanding and signed the document. The procedure was explained to the patient, with the help of the social worker, and she was put at ease by the dental team. Topical anesthetic was applied prior to administration of local Page. 1 of 5

Claudia Ferdeghini

Ozar-Hasegawa Dental Ethics Award Submission

anesthetic through inferior alveolar nerve block. Profound anesthesia was confirmed prior to isolating the operating field with rubber dam.

Defective occlusal composite on #30 was removed and pulp chamber was accessed occlusally to detect the pulp canals (Fig. 2).

A mesial buccal, a mesial lingual and a distal root canal were noted.

After initial access and instrumentation with hand files, rotary files were used. Pulp canals were disinfected with sodium hypochlorite and liquid EDTA. After a thorough debridement, paper points were used to dry the canal spaces. Root canal sealer was used to coat to walls following which gutta-percha was used to obturate (Fig. 3).

Radiographs were taken to confirm adequate fill and apical seal (Fig. 4). The occlusal access was sealed with IRM until patient can receive occlusal composite in two weeks.

The patient was comfortable throughout the procedure and she as well as her parents greatly appreciated the efforts put in by the dental team to properly diagnose, optimally treatment plan and diligently address the patient’s dental needs.

This case highlights how the dental team at University of MilanoBicocca at Ospedale San Gerardo upheld professional ethics within the framework of the six domains of quality in Healthcare outlined in the publication Crossing the Quality Chasm, A New Health System for the 21st Century (2001), which will be explored in the ensuing discussion:

Fig. 2

Fig. 3

Fig. 4

SAFETY: A clear line of communication between all parties- the patient, parents, social worker and the dental team, helped to identify a dental emergency. The patient’s chief complaint was empathically noted, the appropriate diagnostic tests- clinical and radiographic examinations, were obtained and the results analyzed using evidence-based approaches to arrive at the definitive diagnosis of Acute Periapical Periodontitis. Infection control protocols, PPE and personal safety standards were practiced to the fullest extent. This approach reflects the principle of veracity. The progressive nature of an active foci of infection is a cause for concern as it has the potential for resulting in bacteremia or septicemia, which can cause dental and systemic morbidity with potentially fatal consequences. The dental team’s efforts to provide the patient with the best possible care underscores the principle of beneficence. The optimal recommendation of endodontic treatment and definitive restoration, the alternate treatment of extraction and replacement, and the option to decline treatment, were all explained to the patient and the parents, highlighting the institutions adherence to the principle of patient autonomy. Patient was educated and counseled so they could make the right decision. The dental team upheld nonmaleficence in striving to partner with the patient and parents to eliminate barriers to information lest they act upon prior beliefs, and possible misinformation or bias, and opt to have the tooth extracted instead of having it endodontically treated.

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Claudia Ferdeghini

Ozar-Hasegawa Dental Ethics Award Submission

EFFECTIVENESS: The endodontic treatment was performed with adherence to the standards of care and in compliance with all clinical protocols. The patient’s chief complaint, “severe tooth pain”, was addressed with promptness in order to arrest progression of infection and further loss of tooth structure. Through an attitude of beneficence, the dental team’s approachability and empathy was also instrumental in educating the patient and the parents on the importance of preventative dental care and effective home care.

PATIENT-CENTEREDNESS: The endeavor is to do what is in the best interest of the patient through identifying, and then systematically eliminating, all barriers to dental care. This was possible through a concerted effort to address the following Access to information, communication and education in a language she is comfortable with and through a social worker that she is familiar with.  Respect for patient’s values, preferences and expressed needs as reflected in the efforts to educate the patient and parents and make them active stakeholders in the clinical decisionmaking process.  Physical and emotional support through ensuring that the minor patient is comfortable in the clinical environment while undergoing a lengthy clinical procedure that she has not had a previous experience of.  Involvement of family and caregivers, particularly with our patient being a minor, to ensure that all administrative protocols are followed, consent is obtained, post-op instructions are reviewed and follow-up visits are scheduled.

TIMELINESS: In this particular case, Ms. G had not been a patient of record prior to presenting at our facility with the dental emergency that necessitated the endodontic treatment. The consequences of delaying the appointment on account of inadequate documentation or other bureaucratic reasons, in light of an active infection, could have been detrimental as previously discussed. The patient’s treatment was underway even as administrative ‘check boxes’ were been worked upon on the side to ensure that the patient did not suffer any further than she already had on account of the infected tooth.

Here, the dental team’s beneficence and nonmaleficence is evident.

EFFICIENCY: Under the National Health System in Italy, resources are monitored and utilization is reviewed in order to ensure efficiency within the healthcare system which serves all Italians and legal non-Italian residents through federal funding. Healthcare facilities and institutions that operate under the National Health System are audited to ensure transparency in practices and compliance with protocols. The clinical team and the administrative team at the dental department at Ospedale San Gerardo worked cohesively to make resources available for this case without incurring legal trespasses. Being aware of the dental needs of vulnerable groups such as refugees and non-legal immigrants, the institution has provided sensitivity training to its personnel to identify vulnerable individuals with needs. A pool of dental supplies was created through the contributions of clinical faculty who receive samples from dental products manufacturers and it is through this forethought that Ms. G was able to receive the treatment that adhered to the standards of endodontic care and treatment. Through the domain that highlights efficiency, the principles of nonmaleficence, beneficence, justice and veracity shine through.

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Claudia Ferdeghini

Ozar-Hasegawa Dental Ethics Award Submission

EQUITY: The National Health System serves all Italian citizens, and legal non-Italian residents who have a Permesso di Soggiorno (residency permit), who additionally also have to furnish documentation such as the Carta d'identità (identity card), Codice fiscale (a fiscal code equivalent to the Social Security Number in the USA) or driver’s license in order to attest to their legal status of residency.

Documented refugees and legal immigrants are usually given a temporary individual access code called STP, which covers emergency hospital and outpatient care but not any dental treatments.

Owing to their current status of residency in Italy, Ms. G’s family could not be a beneficiary of the National Health System and the families financial situation precluded private practice care.

In light of Ms. G’s clinical presentation, all services that did not consume the institutions physical resources- such as maintaining electronic dental records, taking digital radiographs, rendering clinical car and providing support, were written off in toto. Resources and supplies used for the clinical procedure were drawn from the pool of faculty contributions that they received from dental supplies and equipment manufacturers. In essence, the patient received optimal clinical care and in doing so, there were no administrative breaches. The patient’s chief complaint (resulting from #30) was addressed and the other treatment recommendations (extraction of #c to allow for eruption of #6, possible orthodontic consultation, and preventative dental care) were also thoroughly explained to the patient and parents. The dental team at University of Milano-Bicocca at Ospedale San Gerardo upheld the principle of justice through providing Ms. G with the same care as any other conventional beneficiary of the institution’s resources would have received.

DISCUSSION: Italy, in recent years, has witnessed a steady stream of immigrants from non-EU countries, which has stirred a widespread social debate on the economic, social, cultural and healthcare implications.

These topics, which resonated deeply with the general population, generated considerable political mileage which resulted in the creation of bureaucratic systems to ensure utilization is monitored and resources are carefully allocated. In healthcare, this has caused many problems in addressing the needs of vulnerable patient groups such as refugees and immigrants who, despite needing treatment for evident dental problems, find the winding bureaucracy to be a barrier. Most of these patients cannot afford the alternative route of paying private practice fees and are heavily dependent on state sponsored healthcare systems. Many fear being caught, reported to the authorities and deported even, if they try to avail health services, if found to be residing in the country illegally.

We witnessed these situations several times during the past few years at our facility and collectively resolved to develop a pragmatic response that balances our professional and moral obligations towards the underserved and vulnerable, while also complying with national and regional regulations. To this end, we abide by the rule that all patients treated at our facility are registered in our electronic dental records systems, so as to maintain their clinical charts, but share the information with the law enforcement authorities only when specifically requested by the authorities.

We have mobilized supplies and resources donated to the faculty by dental companies and suppliers to ensure that we meet the needs of this patient population without drawing from the conventionally allocated supplies and resources. The students are highly motivated to meet the dental needs of the underserved and vulnerable and are supported in this endeavor by their dedicated faculty and by a very enthusiastic staff of auxiliaries.

The quality of care that each and every patient receives at University of Milano Bicocca at Ospedale San Gerardo consistently meets the highest standards of care, regardless of their nationality.

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Claudia Ferdeghini

Ozar-Hasegawa Dental Ethics Award Submission

REFERENCES 1. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001.

2. McCarley DH. ADA Principles of Ethics and Code of Professional Conduct. Tex Dent J. 2011 Aug;128(8):728-32.

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