17 minute read
Patients Under the Influence
inviting the patient for an in-person consultation to determine the primary cause for delaying treatment. During this meeting, treatment alternatives and options for managing the patient’s dental anxiety should be discussed. As the team leader, the general dentist should use this time to address the patient’s concerns and then communicate those concerns with the specialists. Collectively, the dentists involved in the patient’s care can achieve a solution to manage the patient’s anxiety and provide treatment effectively.
Thoughtful Patient Selection
Effective communication and careful documentation at all points of service protect your practice’s reputation and mitigate risk. The answers to questions on your intake forms can guide your decision on whether to accept a new patient. Here are five critical points of communication and documentation that should be gathered before you consider adding a new patient to your practice.
• Whether the patient has had another recent dental provider.
If they have, make every effort to consult directly with that provider.
Request any notes or radiographs available. If the patient is unwilling to disclose the names of former dentists, consider refusing to accept the patient into your practice, as there might be critical information that the patient is withholding.
• The patient’s detailed medical
and dental histories. This is particularly important if you are unable to obtain records from another dentist on behalf of the patient.
Document past medical and dental procedures, current diagnoses and any medications. If patients complain about previous dental treatment, ask why. Through minimal investigation, you may be able to determine if the complaints are valid. • The patient’s lifestyle. To get a complete picture of health, inquire about and document aspects of the patient’s lifestyle that may impact their care. This includes travel plans and any impediments to consistent access to care.
• The patient’s anxiety level
toward dental care. Utilizing the Dental Anxiety Scale on patient intake forms is an appropriate way to open communication about fears and concerns that warrant additional consideration during treatment.
• The patient’s history of medications used to control
dental anxiety. Although it is within the scope of a dentist to prescribe anti-anxiety medications, it is best practice to determine if the patient’s physician may have prescribed these medications for them in the past.
Look out for these patient red flags: • Harboring unrealistic expectations. • Demonstrating a history of poor relationships with other dentists. • Acting in an abusive manner to staff. • The presence of a family member or a significant other who unreasonably dictates treatment. • Becoming angry, hostile, demanding or unreasonable; acting dissatisfied, unhappy or negative.
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Listen to your staff and allow them equal opportunity to weigh in on patient selection. Do not make exceptions — apply patient selection criteria consistently. If you feel you are unable to meet patient expectations or establish a good rapport with the patient or family member accompanying them, communicate these apprehensions. Provide specific examples to help demonstrate your point.
Adopt and adhere to your patient selection criteria to decline patients who make you feel uncomfortable. It is acceptable to inform the patient that you do not feel that the necessary and essential treatment rapport can be established to ensure a favorable outcome. If the patient insists, inform them that you do not feel that you are able to meet their expectations. When patient selection criteria are applied and the new patient clearly fits into one or more of the red flag categories, the best approach may be to courteously deny accepting the patient.
Cautious Patient Dismissal
Just as essential as screening incoming patients is knowing when to end the doctor-patient relationship. Once a patient-provider relationship is established, dentists have the right to withdraw from care; however, appropriate steps must be taken and documented to avoid liability and keep patients free from harm.
You may withdraw from treatment if the patient is given appropriate notice, usually 30 days, of the dentist’s intent to withdraw from care and provide an opportunity to find another practitioner. Some common indicators that a dentist may need to consider dismissing a patient from care are: • The patient is only interested in pain medication and does not schedule an appointment to address the pain or receive treatment. • The patient dictates treatment. • The patient is noncompliant with treatment recommendations. • The patient is inactive. Consider dismissal if the patient has not been seen in 24 months. • The patient demonstrates abusive behavior or makes inappropriate comments to the dental team or other patients. • The patient attempts to take dental care into their own hands through actions such as attempting to adjust restorations.
Adopt and adhere to your patient selection criteria to dismiss patients who make you feel uncomfortable.
To avoid claims of abandonment, the dismissal must be communicated in writing and only after the patient’s treatment is complete. If proper notice to end a doctor-patient relationship is not given or if the relationship ends before a dental problem is resolved, the dentist risks an abandonment allegation. While the legal definition of abandonment may vary from state to state, it generally means termination of the doctor-patient relationship without reasonable notice or opportunity for the patient to make other arrangements for dental care, which could result in harm to the patient.
There might be extreme situations in which you feel the safety of you, your staff or other patients is at risk. This warrants immediate withdrawal from care. Examples of such situations include a patient or family member who is threatening violence, making abusive comments or yelling. If you feel that safety is at risk, you are not obligated to complete the entire treatment plan.
Document the confrontation in the patient’s chart, including direct quotes. This could prove helpful in the event the patient seeks legal action. Send a certified dismissal letter referring the patient to a local dental society, clinic or dental school and provide their dental benefits plan (if applicable).
Inform your staff that you have withdrawn the patient’s care, and coach them on how to respond to the patient’s request for copies of records or an attempt to schedule an appointment. Confirm that any future appointments have been canceled and the patient is not inadvertently scheduled for future appointments.
A dentist who is dismissing a patient should never refuse to provide a subsequent treating dentist with a copy of a dental record simply because the patient has not paid for services. Such withholding of records or dental information increases liability exposure should the patient suffer an injury because another doctor did not have access to their dental record.
TDIC recommends that their policyholders call the Risk Management Advice Line with any questions about patient dismissal or similar situations. Analysts will assess the situation to recommend whether dismissal is warranted. If dismissal is determined to be in the best interest of patient and provider, analysts can review letters and offer information about what to include and exclude in a patient dismissal letter.
Patients Under the Influence
Many patients suffer from dental anxiety, and they each have their own way of addressing their unease. Anxiety management techniques run the gamut, from conscious sedation to deep breathing to simply toughing it out. Sometimes, patients use alcohol or recreational drugs to relax. When patients self-medicate to ease anxiety or simply enjoy a three-martini lunch, dentists are left with the uncomfortable dilemma of whether to provide treatment.
TDIC reports numerous calls to its Risk Management Advice Line regarding the treatment of chemically impaired patients. In one case, a patient presented to his appointment visibly intoxicated. In fact, he admitted to office staff that he had indeed been drinking. Staff rescheduled him to come in at a time when he was sober, but he arrived at the second appointment intoxicated as well.
The dentist contacted the Advice Line for guidance on how to proceed and whether he could be held liable if the patient was driving and should cause an accident after leaving the practice. The analyst advised the dentist that he could be held liable if a personal injury claim was brought against him for failing to take reasonable actions to prevent the patient from driving.
TDIC’s Risk Management analysts urge dental staff to take proactive measures in these situations. Attempt to prevent the patient from driving and encourage them to remain on the premises until alternate transportation can be arranged.
These measures are often easier said than done. Should a patient refuse to hand over the keys and insist on getting behind the wheel, the police should be notified. As mandated reporters, dentists are obligated to notify the appropriate authorities when they feel a patient may be a danger to themselves or others.
Documentation is key in these cases and can protect the dental practice if any claim is filed. It is important to note every detail, including the patient’s behavior and comments and actions taken to prevent the patient from driving.
It’s not just patients driving under the influence that can cause liability concerns for dentists. There are clinical risks as well. Dentists should not treat chemically impaired patients for the following reasons: • They cannot provide accurate medical histories. • They cannot fully participate in informed consent discussions; therefore, any consent forms signed while a patient is intoxicated may be considered invalid. • They are more likely to forget postoperative care instructions.
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• They cannot be given certain medications due to potential interactions. • They are more likely to become belligerent, abusive and, in some cases, violent during treatment.
Intoxication and Dental Patients
Patients who exhibit signs of being impaired, such as slurred speech, lack of coordination and 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, so it is essential to document only the known facts: observable actions and comments made by the patient. Do not editorialize.
TDIC recommends practice owners develop a policy regarding the treatment of intoxicated patients.
The policy should clearly outline that an intoxicated patient will not be treated, and any patient who presents while under the influence of alcohol, drugs or other intoxicating substances, including prescription drugs, will be asked to reschedule and return when they are no longer impaired. Staff will encourage the patient to remain on-site and make alternative transportation arrangements, such as calling a taxi or ride-share service or will notify the emergency contact listed on the health history form and ask them to pick up the patient. If the patient becomes belligerent or abusive, security or law enforcement will be notified.
Risk Management Advice Line analysts also report calls from dentists inquiring about the risks associated with providing alcohol to patients to help them “take the edge off” and lessen their dental anxiety. Of course, providing alcohol to patients is different than prescribing a sedative. Business liquor licenses vary by state, but there are regulatory processes that must be adhered to — even if the alcohol is being provided for free.
Additionally, serving drinks to patients prior to treatment carries significant legal risks beyond licensure considerations. Claims could range from slip-and-fall injuries to sexual harassment to questions of informed consent should a patient not understand or recall discussions about the risks, benefits and alternatives related to treatment. In addition, dentists could be held liable should an underage child ingest alcohol while their parent is in the operatory, or if staff members indulge in alcohol while the dentist is busy at work.
Alcohol isn’t the only intoxicant that has been making an appearance in the dental office. In another case reported to TDIC, a patient was suspected of using recreational drugs prior to arrival. She was being treated for temporomandibular disorder and the dentist had fabricated an appliance for her. The treatment involved several visits, but at every visit, the dentist and staff suspected that the patient was under the influence of drugs. She was disoriented and had impaired coordination and trouble speaking coherently. On a few occasions, there
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was evidence of a white, powdery substance on her nose.
At each visit, the patient’s behavior became increasingly unstable. Although she needed additional treatment, the dentist wasn’t willing to proceed due to his concerns about her abnormal behavior. The doctor contacted TDIC’s Risk Management Advice Line for guidance. The Risk Management analyst advised the dentist to reschedule the appointment and to explain to the patient that if there was no improvement in her behavior, he would have no choice but to dismiss her from care following a formal dismissal protocol.
As health care facilities, dental practices should always remain professional, and dentists should proceed with caution when patients are suspected of using substances that can impair their judgment. Failing to do so can set the stage for a liability claim.
Anxiety relieving medications
Oral anti-anxiety relieving medications such as diazepam (Valium) are prescribed by dentists or a patient’s primary care physician to help ease dental anxiety prior to dental treatment. Generally, a short-acting, small, single dose is taken one hour before the dental appointment.
Regardless of who prescribes the oral sedative, there must be a logical connection between the drug prescribed and the diagnosis or clinical indication.
Before prescribing, dentists must have current knowledge of the patient’s health status and clinical condition, acquired by obtaining a medical history and conducting an appropriate clinical examination, to make a diagnosis or differential diagnosis, or otherwise establishing a clinical indication for the use of a drug. A patient may have previous medical conditions that may be affected by the administration of the oral sedatives. The patient may also be taking some medications that may have adverse interactions with the sedation.
In all cases, check a patient’s history in CURES when prescribing, ordering, administering, furnishing, or dispensing a controlled substance.
It is imperative to meter dosing rather than just giving the patient a prescription for a larger quantity to use at their discretion before each visit. In all cases, check a patient's history in your state's Prescription Drug Monitoring Program when prescribing, ordering, administering, furnishing or dispensing a controlled substance.
Things to consider before prescribing: • Having an informed-consent discussion to explain to the patient any possible side effects of premedication and risks associated with the procedure. • Providing patient education and asserting that the prescription must be taken as directed by the dentist or physician. • Advising the patient of the need to arrange transportation to and from the office. • Avoiding adverse drug interactions. • Using the patient’s medical history, age, level of anxiety, history of taking anxiety medications and your own familiarity with the sedative to determine the level of sedation that would be appropriate for the recommended procedure.
Compromised decision-making
Once a patient is under the influence of a substance, their decision-making processes are usually impaired, and it can be difficult to have productive discussions about changes to treatment or financing it. The dentist must thoughtfully discern whether to move forward with the treatment that was planned with the patient beforehand or reschedule for another time when the patient has full cognitive function.
Strive to apply these five principles in your efforts to mitigate and de-escalate conflict.
1. Be clear.
Overgeneralization can increase drama.
Instead of saying:
“You’re always rescheduling appointments at the last minute.”
Instead of saying:
“I'm concerned that you've rescheduled your last three appointment less than 24 hours before your scheduled visit.”
Specific, fact-based examples of the behavior creating conflict are more effective than overgeneralized statements.
With patients, clarity comes with listening to concerns firsthand, not deflecting issues or delegating them to staff. Patients, just like everyone else, want to feel heard. Allow them to voice their concerns without interrupting or speculating on what may be driving the issue. • Listen attentively to the patient. • Repeat back your understanding of their concern so there is no misunderstanding about the source of conflict.
2. Be empathetic.
Whether at home, in the practice or out in the world, we tend to judge others by their actions and ourselves by our intentions. While the intention doesn’t excuse the action, an attempt to see both sides will facilitate more productive, solution-oriented discussions.
Instead of saying:
“You’ll have to find another provider if you continue to miss appointments.”
Try saying:
“I want to provide you the best care possible, but I’m concerned the appointments you’ve missed are delaying important treatment steps. Let’s figure out together if there’s a way we can make sure your appointments are scheduled for times that work better for you.”
Empathy also extends to saying thanks to patients for being punctual, compliant with treatment and communicating their needs, in addition to offering sincere apologies when you’re in the wrong.
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3. Be patient.
Living with unresolved conflict can be stressful but rushing to a solution rarely bears long-term gain. When a patient has made a demand or offered a solution that you may not be able to accept in its current form, explain that you will need time to consider their request and make your decision.
However, if a patient’s demand is unreasonable, it is fair to answer at the time. Give a measured response that keeps the discussion open to reasonable demands.
Instead of saying:
“Absolutely not.”
Try saying:
“I don’t feel it’s reasonable to ask me to make adjustments that would create a disruption for my practice as well as other patients or employees.”
4. Be objective.
How the message is being delivered and who it is delivered by often determines how we’ll engage. When struggling to approach or engage in a conflict, start with the facts. View the situation as an opportunity to analyze the point of conflict, share your observations and listen to the other perspective before pursuing a resolution.
Instead of saying:
“You’re being unreasonable.”
Try saying:
“I can see you have concerns about our cancellation policy. Would it help if I explained how canceled appointments might negatively affect your treatment outcomes?”
5. Be curious.
Empathy doesn’t mean making assumptions about others’ experiences. Listen first and ask the patient or employee questions to understand their perspective. Your curiosity can help de-escalate rapid escalation of conflict.
Instead of saying:
“You’ve got to stop coming late to appointments.”
Try saying:
“I’ve observed that you’re on time for your regular cleaning appointments but not for the appointments to treat your injured tooth. Is there a chance you may be feeling anxious about the treatment plan we’ve discussed?”
Once you’ve heard the other person’s side, invite their input in finding a solution.
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Liability Lifeline is published by: The Dentists Insurance Company 1201 K Street, 14th Floor Sacramento, California 95814
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Idaho State Dental Association
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TDIC reports information from sources considered reliable but cannot guarantee its accuracy.
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