Royal College of
Dental Surgeons of Ontario
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Informed refusal

Originally published in Issue 1 of Dispatch in 2017

One of the core values at the foundation of RCDSO’s Code of Ethics is respect for patient autonomy. This means that dentists have a duty to understand and respect the rights of patients to make informed decisions, based on their personal values and beliefs. It allows for dentists to inform, educate and advise their patients, but not to make treatment decisions for them. Dentists have a professional, legal and ethical obligation to involve their patients as full partners in the decision-making process.

When patients are engaged partners in the decision-making process, they tend to make better health choices and have more realistic expectations. In addition, they are more likely to accept and recognize the value of the treatment recommended by the dentist, and be satisfied with the treatment outcomes.

When seeking to obtain informed consent for proposed treatment, the dentist may have to deal with a patient’s decision not to proceed. In these situations, it is not enough to note the patient’s refusal; the dentist must secure the patient’s informed refusal.

A patient’s informed refusal must be based on an understanding of the facts and implications of not following the treatment recommendations. It is linked to the informed consent process, as a patient has the right to accept or reject treatment, regardless of its risks or benefits. Financial considerations are often a factor when a patient refuses treatment, but there are many others that may play a role in the decision, including inconvenience, fear, denial, previous experiences and/or religious beliefs. The dentist should take the time to discuss any questions or concerns that the patient may have about the recommended treatment and to understand the reasons for any refusal.

If a patient refuses recommended treatment, the dentist should thoroughly explain the risks and likely consequences associated with that refusal. This may include worsening of the patient’s condition and/or an inability to achieve a successful outcome in the future, resulting in the need for additional treatment and increased costs. This discussion, and the patient’s ultimate decision to accept or reject treatment recommendations, should be carefully documented in the patient’s record.

In some instances, the dentist may wish to use an informed refusal form or have the patient sign the chart to acknowledge that they have been informed of the risks and likely consequences associated with refusing treatment. Although this isn’t always necessary, in select cases, it may stress to the patient the seriousness of their condition and decision not to treat it.

If a patient refuses recommended treatment, the dentist should also consider whether this decision significantly compromises their ability to provide appropriate care, according to the standards of practice, and/or signals an irremediable breakdown of the patient-dentist relationship. In these circumstances, the dentist may decide to dismiss the patient from their practice. If the dentist concludes that dismissal is the best option, the patient should be informed in an appropriate fashion, preferably in writing.