DENTAL CONSENT


Dental adviser Doug Hamilton tests the waters aſter a landmark legal ruling on shared decision making in consent


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UE perhaps to the generally torpid nature of medical law, the seminal case of Montgomery v Lanarkshire Health Board has prompted many fevered commentaries and


opinion pieces. Te facts surrounding this ruling are probably well known. Nevertheless, it is worth reminding ourselves, very briefly, of the decision which, although it related to an obstetrics claim, has impacted upon the consenting practices of virtually all healthcare professionals. Te claimant in the case – Mrs Montgomery – experienced


complications during the birth of her son. Te baby’s head failed to descend properly due to shoulder dystocia – a rare complication where the baby’s shoulder lodges behind the mother’s pubic bone and essentially becomes stuck. Tis led to a 12-minute delay between the baby’s head appearing and delivery during which time the cord was completely or partially occluded. Sadly, the baby


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suffered significant cerebral palsy. Mrs Montgomery was only just over five feet tall and diabetic.


She alleged negligence, saying that, before the birth, she should have been warned about the possibility of shoulder dystocia. Initially Mrs Montgomery lost her case at trial and later on


appeal, but she went to the Supreme Court and won. Te Supreme Court clearly recoiled from the ‘paternalistic’,


though doubtless well-intentioned, attitude of the treating physician. As a result, the prevailing ‘prudent doctor’ standard was abandoned. It is no longer a matter of what the reasonable clinician thinks the patient ought to know. Instead, healthcare professionals are now required to treat their patients “…so far as possible as adults who are capable of…. accepting responsibility for the taking of risks affecting their own lives...” Whilst few would dispute its wisdom, one might still question whether this doctrine is required, or even workable, in every healthcare environment. Take, for example, an NHS dental practice. Financial survival depends to an extent


on reasonably fast care delivery. Many of the procedures are


routine and are relatively low-risk. GDPs will oſten be well acquainted with their regular patients. Must there always be a comprehensive exploration of the patient’s wishes prior to treatment at every dental appointment?


Risk of endocarditis Consider the hypothetical patient who pitches up in the middle of a typically busy session with a painful upper 1st molar. Te patient expects speedy and efficient pain relief. Te tooth is heavily compromised. Te patient in question has never shown the slightest interest in conservative dentistry. Tere is no obvious risk of maxillary sinus involvement. Might the practitioner in these circumstances simply confirm that an extraction would be acceptable before proceeding? To make the case more “interesting”, imagine our patient


has had a previous episode of infective endocarditis (IE). (To be clear, this is a dento-legal thought experiment and not a clinical article.) Probably, at some point in the past, this patient would have received prophylactic antibiotics prior to invasive dental procedures. However, following the publication of the relevant NICE guidelines in 2008, this practice would have been discontinued. It is difficult to imagine a dentist who continues to work within NICE guidelines being criticised. However, practitioners will have read recent reviews by NICE and another authoritative body, the European Society for Cardiology, of their


SUMMONS


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