Are your patients in the BARN, or are you in the doghouse?

Whether restoring a single-surface restoration or providing a complex procedure, we, as doctors, are required to make sure ...

By William G. Leffler, DDS, JD

Whether restoring a single-surface restoration or providing a complex procedure, we, as doctors, are required to make sure our patients are able to make wise decisions about the care they are to receive. Having patients sign a form that goes into great depth about all the problems that could possibly occur does not necessarily meet the legal criteria of informed consent and may hinder their dental health decisions. Our patients may not understand everything on the form, may have difficulty reading the form, or may feel coerced into signing.

Informed consent involves a conversation between care provider and patient that addresses the reasons for treatment, reasonable risks, concerns, and alternative treatment options. It’s a mutually agreed upon plan for care.

Our practices are busy enough without lengthy forms and extra paperwork to add to our patients’ files. A simple method, which easily fits into our current systems, is called BARN. It’s a simple acronym for team members and dentists to incorporate informed consent into patients’ charts. The essential components of informed consent are:

B: Benefits
A: Alternatives
R: Risks
N: No treatment

The informed consent discussion should include all of the basic benefits of treatment. Any reasonable alternative treatments need to be reviewed. Obviously, the treatment that the dentist is recommending must be covered, and any risks that exist. Lastly, the patient needs to be informed about what could happen without treatment.

For example, consider a simple case where a small Class II carious lesion is diagnosed on the distal surface of a mandibular first molar. Obviously, the caries should be treated for preservation of health. For the sake of discussion, let’s say that a particular dentist usually prefers to restore this type of lesion with a DO amalgam. However, the patient may not necessarily want that treatment option. Other reasonable options exist — a metallic inlay, a ceramic inlay, a DO resin restoration, or remineralization techniques with no restoration. The patient should be informed of these alternatives. Applying the BARN system offers the dentist the opportunity to recommend the most appropriate treatment — for this patient — for this particular clinical situation. It also allows the patient to decide on the treatment that is best suited for him or her. The patient can now also understand what could happen if the carious lesion is not treated (i.e., progression of caries, possible pulpal involvement and infection, and eventual tooth loss, or extensive restorative therapy).

The discussion of informed consent for this example might go something like this:

Doctor: Mrs. Jones, please take a look at this X-ray of your tooth. I see that there is a cavity here that should be addressed.

Patient: Well, what should we do about it?

Doctor: Thank you for asking. First, the cavity should be treated because cavities compromise health. We can treat your cavity in several ways.

Patient: What do you mean?

Doctor: Well, cavities like yours can be repaired with a gold filling, a porcelain filling, a tooth-colored plastic filling, or a silver amalgam filling. Each filling type has strengths and weaknesses, which we can discuss further if you would like.

Patient: What would you do, Doctor?

Doctor: I’d recommend fixing your cavity with a silver filling because I’ve found them to be least costly for my patients, and I’ve been happy with the performance of this type of filling in my practice over the years. However, you should know that the use of amalgam is controversial because mercury is used to bind the parts of the filling together, and it is silver in color. If you prefer, I could use one of the other types of fillings. Do you have any questions?

Patient: What do you think about those white fillings instead?

Doctor: Well, would you like for the treatment to be done in one appointment, or do you mind coming in for a second visit for us to cement a ceramic filling?

Patient: Oh, I just want it done in one visit.

Doctor: Well, it seems that you may be interested in a tooth-colored resin. We can certainly fix your cavity with that type of restoration. While white fillings are tooth-colored, they may not last as long as the other filling types.

Patient: I really don’t want a silver filling. Let’s do the tooth-colored filling.

Doctor: Okay. We already discussed how resin fillings may not last as long as some of the others. Anytime a tooth is treated, it may need more extensive fixes in the future. We are treating the tooth because it is not healthy to begin with. Nothing we do can be as good as the original healthy tooth was, and sometimes we have to change the shape of the surrounding teeth a little bit to make the filling fit and function properly. In any case, once the filling is done, it is very important that you notify me as soon as possible if there are any symptoms with the tooth that develop so that we may address that before further injury to the tooth occurs.

Patient: Well, what if I just don’t have a filling done?

Doctor: Cavities usually get bigger and deeper without treatment. If this happens, you may develop pain and need to have root canal treatment or more extensive dentistry done to address the problem. Severe decay may even lead to your losing the tooth.

Patient: When can we schedule the filling?

Documentation of informed consent can be as simple as a note in the chart that says “Caries distal No. 19. Discussed BARN. Patient desires composite resin restoration.” It’s also nice to have take-home pamphlets or letters that cover all of the points you discussed. However, forms can be double-edged swords if they do not list all reasonable risks. If patients do not understand the language, they can hurt the argument for informed consent and put the dentist in the proverbial doghouse. Most malpractice carriers have informed consent documents that they may want you to use.

Providing informed consent for all dental procedures enables the patient to have autonomy about his or her treatment. The informed-consent discussion may be done with a trained staff member, but the patient must always have the opportunity to ask the dentist about the treatment being provided. This can be assured by simply asking the patient before any dental procedure, “Do you have any questions about what we’re going to do today?”

Proper and consistent practices for obtaining informed consent routinely make it very difficult for attorneys to build a case against a dentist for providing unwanted or inappropriate treatment. An informed consent discussion requires active participation of both the dentist and patient so it is hard to build an argument that the patient did not know what was going on. Using the BARN system for obtaining informed consent will usually keep you out of trouble and out of the deep legal doghouse. Informed consent is an interactive communication between dentist and patient to reach a common treatment strategy and outcome.

William G. Leffler, DDS, JD, is a general dentist and attorney in Massillon, Ohio. He is former chairman of the Council on Ethics, Bylaws, and Judicial Affairs of the ADA. Dr. Leffler is available for risk management lectures. He may be reached at n8xtg@aol.com.

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