7 minute read
Dentistry and the Chemically Impaired Patient
Lifeline Liability
When a patient arrives for dental care in a suspected state of chemical impairment, it’s time to hit the “pause button.” Step back and assess the situation objectively. Even if the substance a patient has indulged in is legal, medicinal or prescribed, there are significant standard of care issues involved in dealing with a patient under the influence.
Should you treat a chemically impaired patient?
The short answer to this question is a simple and emphatic “no.” TDIC’s Risk Management experts strongly discourage dentists from providing care to patients who exhibit signs of impairment from alcohol or drugs. Patients who are impaired due to the use of alcohol or drugs cannot fully participate in informed consent discussions. This means that any consent forms signed while a patient is intoxicated may be considered invalid. In addition to the issue of consent, the clinical risks of treating intoxicated patients include: • They cannot provide accurate medical histories. • They are more likely to forget postoperative care instructions. • They cannot be given certain medications due to potential interactions with the substance they have already ingested. • They are more likely to become belligerent, abusive and in some cases, violent during treatment.
These risks also apply to impaired caregivers of patients who, due to age, infirmity or disability, are unable to provide consent for themselves.
Preventing patients from arriving impaired to appointments
One of the best steps practice owners can take to ensure patients arrive sober to their appointments is having an office policy regarding patient drug and alcohol use. The policy should clearly outline that chemically impaired patients will not be treated, and any patient who presents while under the influence of alcohol, drugs or other mind-altering substances, including prescription drugs, will be asked to reschedule and return when they are not impaired.
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Identifying chemically impaired patients
Despite your best efforts to communicate an office policy of providing treatment to sober patients only, you may still encounter patients whom you suspect are under the influence of alcohol or drugs. Some obvious physical signs of impairment are: • Breath odor • Bloodshot eyes or flushed face • Slurred or louder than typical speech • Damp or clammy skin • Lack of coordination and balance • Difficulty making decisions • Inappropriate comments or behavior
Patients who exhibit signs of being impaired, such as slurred speech or unsteady gait, should be asked whether their behavior could be caused by an underlying medical condition. Some conditions, including diabetic ketosis, mimic the signs of intoxication, and you may be observing a patient in need of immediate medical attention.
TDIC recommends that all dental team members should be trained to identify patients under the influence of drugs or alcohol and be educated on the office’s protocol for handling them.
Best practices for dealing with inebriated patients
Once you’ve established that the patient is impaired by drugs or alcohol — rather than exhibiting signs of a medical condition — rely on established office protocol for rescheduling the patient, getting them safely home and documenting the interaction. It’s imperative to remain calm and objective at all points of communication and documentation, particularly if the patient is not willing to admit that they are not in a state to safely receive treatment. State the known facts: observable actions and comments made by the patient. Do not editorialize or speculate. Avoid attaching unnecessary or demeaning labels to the patient, such as addict, drunk or junkie.
When developing office protocols regarding intoxicated patients, consider: • If possible, obtain information on the substance taken, the amount and when it was ingested. Give consideration as to how accurate the patient’s responses might be. • Recommend rescheduling the appointment. n Advise the patient that their intoxication limits your ability to accurately access and treat them. n Share a copy of your office policy on substance use prior to treatments. If necessary, remind them of their previous acknowledgment of the policy and agreement to uphold it. n Remind the patient of the necessity of not using substances prior to a visit and the ramifications that drug or alcohol use could have on the success of treatment if they indulge after treatment is rendered.
• Rely on in-office safety procedures in case potential behavior issues arise, such as belligerence or aggression. n Have parameters in place for when to contact law enforcement or what code words staff should use to alert one another of a potentially dangerous situation.
• Determine if the intoxicated patient needs assistance leaving the office.
The potential for practice liability does not end with a rescheduled appointment. The observation of an impaired patient leaving the office becomes the responsibility of the dentist to determine that the patient has a reasonably safe exit. If a patient is too impaired to undergo dental treatment, they are more than likely too impaired to drive safely. The dentist is legally obliged to warn the patient of the danger of driving or operating equipment while impaired but has no authority to restrict an impaired patient from leaving the office. While dentists are not liable if an impaired patient causes an accident after leaving their practice,
TDIC’s experts encourage providers to do the following: n Offer alternative methods of transportation. n Encourage the patient to remain on the premises until alternative transportation can be arranged. n If the patient is unable to do so themselves, call their emergency contact, a taxi or other ride share service to get them home safely. n Call the police if an intoxicated patient refuses your attempts to prevent them from driving. • Document all patient discussions thoroughly. Include patient comments (quotes are recommended) and any noncompliance along with the advice, instructions and educational resources that you provided within the documentation.
n Again, when documenting observations that lead you to believe the patient is impaired, deal only with the facts and not your perceptions.
Following up with impaired patients
The topic of substance abuse and misuse can be thorny. As a health care provider, you are in a unique position to identify problems early on and have crucial conversations with patients about their overall well-being. If a patient shows signs of substance abuse or misuse, including having to reschedule appointments due to impairment, it is time to communicate your concern with them.
This could take place during an office visit later or when they are not impaired or on the phone. For example, you may choose to reach out personally to a patient to remind them of their rescheduled appointment and your office policy on substance use. Express your concern for their safety and wellbeing as well as your desire to help. It is appropriate to ask if they chose using a chemical substance to cope with dental pain or anxiety and discuss alternate options for helping them be comfortable at their appointment.
If the patient’s problem appears to extend beyond the scope of what you can do for them as a dentist, offer referrals to medical or substance abuse professionals. Communication with the patient’s medical providers when coordinating the delivery of dental treatment may be required for the safety and well-being of the patient.
Your expression of care and willingness to communicate concerns honestly may be just the encouragement the patient needs to seek help.
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