Doing the Right Thing: Resolving Ethical Issues in Geriatric Dental Care

Editor's note: Tables 3 and 4 have not been included in the electronic version of this manuscript. The original copyright holder would not grant electronic rights to republish. Please see a printed copy of the CDA Journal for that information.

This article reviews key ethical concerns facing dental professionals caring for older adults and offers guidelines for resolving them. Approaches to securing informed consent for treatment and assessing decision making capacity are discussed. Next, the question of deciding among several treatment options when patient preferences are unknown is considered. Finally, guidelines are offered on restraint use for older adults with behavioral problems.

The "graying of America" is bringing more and more older patients into dental offices and more and more dental providers out into the community to reach those unable to access traditional dental practices. Along with the many challenges dental professionals will face in caring for this rapidly growing segment of the population, they will increasingly confront a number of difficult moral choices now more common in the health care of older adults. These ethical and legal issues have been recognized by physicians and other health care providers for some time.^1-4 Their relevance to the practice of dentistry is also a matter of growing concern.^5-7

When providing care for older adults, significant chronic illnesses and functional impairments are more prevalent, raising challenging questions about the appropriate intensity of care and choice of treatment when several options exist. The same chronic illnesses and impairments, especially those affecting cognitive function, also frequently provoke questions about the capacity of the patient to make treatment decisions and how to secure adequate informed consent. Dental providers caring for older adults may also face more behavior management issues due to adult-onset neurological problems such as dementia and stroke, which then lead to questions about the appropriate role of restraints in providing dental care.

This article reviews some key ethical concerns facing dental professionals caring for older adults and offers guidelines for resolving them. Approaches to securing informed consent for treatment and assessing decision making capacity are discussed. Next, the question of deciding among several treatment options when patient preferences are unknown is considered. Finally, guidelines are offered on restraint use for older adults with behavioral problems.

Securing Informed Consent

The process of informed consent is the primary mechanism for protecting patient autonomy in treatment decisions.⁶ Informed consent is a process that educates the patient about the nature of a particular health problem, treatment options, risks and benefits of those options (including costs and prognosis), and the consequences of not receiving treatment. It is important to note that informed consent involves a discussion that takes place between a patient and his or her health care provider. Informed consent forms that are now available can be helpful to guide such consent discussions but cannot replace them.

To secure informed consent, the patient must be informed, must have a free choice, and must be capable of making a decision.⁸ While these elements may not be difficult to address for most older adults who are relatively healthy, significant problems will arise for certain individuals with conditions frequently associated with advancing age. Common medical or mental problems -- such as dementia, stroke, psychiatric disorders, or sensory impairment --- can affect thought, perception, and communication, limiting the patient's capacity to understand or act upon choices. Some older individuals may also be inappropriately denied an opportunity to make choices because they are erroneously presumed to be incapable. For example, patients with Parkinson's disease or aphasia from a stroke may be excluded from health care decisions because their appearances or manners of communication create erroneous impressions of intellectual impairment. Dental professionals caring for older adults should be mindful of these potential limitations on patients' freedom to choose and must always try to involve patients in decision making to the greatest extent possible.

When a patient is unable to act independently, it does not mean that there is no need for informed consent but that its implementation must be different.⁹ To execute the consent process effectively for impaired patients, two concepts must be clearly understood -- "competence" and "decision making capacity." Competence is a legal designation that is determined exclusively within the legal system, while decision making capacity is a clinical concept assessed within the health care system.¹⁰ In geriatric care, the high prevalence of conditions potentially affecting the capacity to make decisions requires a careful approach to securing consent that accounts for both legal competence and decision making capacity. Table 1 summarizes the role of patients, guardians, proxies, and clinicians under varying conditions of legal competence and decision making capacity.

Competent Patients With Decision making Capacity

In obtaining consent for treatment, the first point to remember is that most older adults are both capable of making independent decisions about their care and legally competent to do so (Table 1, Box 1). In such cases, the patient should guide all treatment decisions. Occasionally, disabled or elderly patients are inappropriately "labeled" as incapable of making decisions. It is usually best to begin with the assumption that the patient is able to make decisions about care and look for evidence to the contrary, rather than the other way around.

Legally Competent Patients With Impaired Decision Making Capacity

Among the most challenging situations faced by practitioners caring for older adults are those in which a patient's decision making capacity seems impaired due to an acquired mental problem, but the patient has not been legally declared incompetent (Table 1, Box 2).¹¹ This can be especially troubling when the patient is refusing or resisting care. Refusals of care, resistance, and combativeness could be either manifestations of mental impairment or expressions of an authentic desire to refuse treatment. Although they may appear irrational, they do not constitute proof of impaired decision making.¹² Even when there is evidence of mental impairment that has affected memory, judgment, and reasoning, such deficits are not always absolute and some patient involvement in treatment decisions may be possible and should be encouraged.¹³ Unfortunately, however, it is still not unusual to witness discussions in which a health provider ignores an impaired patient who is present, while explaining treatment options and seeking approval from others who also may be in attendance.¹⁴

When decision making seems impaired but the patient has retained legal competence, it is important for the clinician to establish how surrogate decisions should be made and who should serve as a proxy decision maker. It is generally necessary to involve family or other concerned parties in the consent process when a patient's decision making capacity is in doubt.^15,16 Advance directives and durable powers of attorney are increasingly common and can specify a surrogate decision maker.¹⁷ Most states have statutes or court decisions that empower family members to make decisions on behalf of impaired patients leaving no advance directives.¹⁸ Such statutes may also specify the sequence in which family members should be solicited for input (e.g., spouse, children, siblings), so practitioners should become familiar with any applicable laws or legal precedents in their states (Table 2). Consultation with the patient's primary care physician can also be important to obtain information about the patient's decision making capacity and to learn how other health care decisions have been or will be made.

When there is severe conflict or indecision among health professionals and surrogates over appropriate treatment of an impaired individual despite substantial efforts to achieve consensus, two options should be considered. First, in nursing homes, hospitals, or other institutional settings, an ethics committee may be available to assist in deliberations and help promote a resolution.¹⁹ Second, if all other avenues have been exhausted, the matter can be brought to the legal system for a decision, although the need for this approach should be extremely rare.

Legally Incompetent Patients

Patients whose decision making capacity is significantly impaired and who have been formally declared by the courts as unable to manage their own affairs are designated as "incompetent" and have a guardian appointed for them. Examples may include individuals with moderate-to-severe psychiatric disorders, with mental retardation, or in persistent vegetative states. As indicated in Table 1, Box 3, when a patient has been declared legally incompetent, the dental provider must ultimately obtain authorization for treatment from the patient's legal guardian. One exception to this guideline, however, is the immediate need for care due to a serious emergency. Fortunately, situations in which the need for treatment is urgent and a guardian cannot be contacted first are rare in dentistry. Yet when such an occasion does arise, all states recognize that it is reasonable for health professionals to act in the best interest of the patient.¹⁵

Assessing Capacity to Consent for Treatment

Since informed consent is critically dependent on the patient's capacity to consent to treatment, discerning whether a given patient possesses this ability takes on special importance. While legal standards vary from jurisdiction to jurisdiction, there is general agreement that a patient is considered capable of making a treatment decision if he or she can:

* Understand relevant information;

* Appreciate the situation and its consequences;

* Manipulate information rationally; and

* Communicate choices.²⁰

Clinicians usually assess these skills intuitively before accepting patients' treatment decisions; and, unless the patient displays behavior to the contrary, he or she is usually presumed capable of deciding about treatment. In dealing with the older adult population in which cognitive impairment is more prevalent and often variable in nature, it can be useful to employ a more structured approach for assessment of decision making capacity.

Table 3 (see printed copy of Journal) summarizes the four elements of the capacity to consent to treatment and suggests some assessment questions that have been adapted from Appelbaum and Grisso.^7,20 For the dentist, these questions are meant only for the purpose of screening for problems in decision making and as a signal that the patient may need assistance in the consent process. Evidence of impaired decision making capacity should prompt discussions with family, caregivers, the physician, or others who know the patient. Evidence of a new onset of decisional incapacity suggests the need for a medical consultation to verify whether a problem exists and facilitate future care planning. While implementing this entire structured assessment may not be practical nor necessary in every treatment situation, it may still be wise to ask at least a few appropriate questions of most patients, impaired or not, to verify decisions about treatment and detect decision making problems. However, when the impact of the patient's decision about treatment will be substantial (e.g., on comfort, function, appearance, or finances) the more concern there should be about the patient's capacity to make an informed decision, and the more thoroughly practitioners should screen for problems in decision making. Dental professionals should also bear in mind that recent research now indicates that word fluency appears to be a key predictor of the capacity of a patient to formulate rational reasons for a health care decisions.²¹

It is important to remember that even if a patient displays some limitation in decision making capacity, not all treatment-related decisions may be out of reach since cognitive impairment may not affect all areas of intellectual function uniformly. For example, an individual who no longer can manage finances may still be able to indicate whether he or she would prefer to save a tooth or have it extracted, although assistance may be necessary to make financial arrangements. When attempting to involve cognitively impaired patients in treatment decisions, it is usually necessary to allow extra time for the patient to fully comprehend treatment information. When memory is impaired, frequent reminders will likely be needed for the patient to recall the issues at hand. The presence of a caregiver is often beneficial so that they can repeat and reinforce the information given. Confirmation of treatment decisions after a period of time can also be helpful to ensure authenticity, although it is again dependent on memory.

Choosing Among Treatment Options

In guiding patients through decisions about what dental care is most appropriate for them, practitioners customarily consider factors such as patients' stated preferences, medical status, and financial resources. However, matters become more complicated if the patient's preferences are unclear or unknown due to problems in cognition, communication, or other disabilities more frequently encountered in the older adult population. At such times, questions frequently arise about the appropriate intensity of care and choice of treatment when several options exist. Because of concern in recent years about ensuring that treatment decisions are as patient-centered as possible in such situations, there has been great interest in promoting strategies that maximally protect patient autonomy. In this regard, two alternative care standards are frequently mentioned -- the "substituted judgment standard" and the "best interest standard." Knowing when to apply which of these standards is important for dental professionals.

The Best Interests Standard

The best interests standard calls for decisions about treatment that reflect what other reasonable people would do under similar circumstances.⁹ The values standard that is used in this case is not the patient's own but that of others facing the same situation. The best interests standard has traditionally guided the thinking of health professionals for many years but creates the risk of paternalistic decisions as well as decisions that do not account well for differences in individual circumstances as well as in patient goals and values about health care. Therefore, in recent years, the best interest standard has given way to more patient-centered approaches. Clearly, however, there are times when it is still reasonable to approach care using the best interests standard, such as when pressing dental problems arise (e.g., acute pain or infection), and patient decision making is impaired. However, it is still rarely justifiable in dentistry to initiate any treatment without some attempt to solicit input from others who have an interest in the patient's welfare when the patient themselves cannot express a preference about care.

Substituted Judgment Standard

The substituted judgment standard dictates that decisions be made in accordance with what the patient would have decided if he or she could have expressed it directly. This approach fosters decisions that reflect individual patient choice and has gained favor in recent years as society has moved toward greater emphasis on patient self-determination.⁹ The focus is on clarifying the patient's goals and values about oral health care and making decisions consistent with them. Therefore, when elective dental treatment is under consideration or there are several treatment options and patient preferences are unclear, those involved in decision making should attempt to make decisions based on what the patient would have chosen.

To establish this, input from the patient's family; others in close, loving relationships with the patient; and informal and formal caregivers is helpful to understand patient goals and values concerning dental care.²² Frequently, such information can be gathered from previous dental records and current oral findings. For example, a history of regular preventive dental visits, extensive restorations, and prosthodontics all suggest that the patient placed a high value on oral health and suggest that future dental care decisions should be consistent with those values. On the other hand, a history of only emergency care, evidence of multiple missing teeth without replacement, and minimal preventive care suggests that the person was unwilling or unable to devote resources to dental care, which in turn might dictate a more basic approach to treatment planning. Of course, good clinical judgment must always be factored into such decisions. For example, even if a patient previously chose sophisticated crown and bridge procedures to maintain his or her dentition, the onset of advanced dementia would likely preclude such an approach and suggest simpler forms of therapy. It is also possible that the patient who previously selected the simplest treatment approaches because of monetary concerns might choose more sophisticated therapy if financial support for care somehow became available.

Using Restraints

In the world of geriatric health care, restraint use has become a matter of major concern in recent years because of its implications for patient autonomy, dignity, and well-being. "Physical restraints" include tying a patient down with any of a variety of devices, including either soft or leather straps around the wrists or ankles, as well as sheets or belts wrapped around the chest or waist. Holding a patient down by hand also constitutes physical restraint, and it could be argued that some mouth props used in dental treatment are also a form of physical restraint, since they limit a patient's ability to voluntarily close the mouth. A "chemical restraint" is any medication that subdues behavior, including sedatives (oral, intramuscular, or intravenous), neuroleptics (e.g., haloperidol, thioridazine), nitrous oxide analgesia, and general anesthesia. The high frequency of behavioral problems in older adults with late-onset neurological diseases frequently leads to questions about when and how to appropriately manage patients who are uncooperative during therapeutic or personal hygiene procedures, including dental interventions.

In 1987, an ad hoc committee of the Academy of Dentistry for the Handicapped published guidelines for the use of restraints to provide dental care for handicapped individuals.²³ This committee concluded that the definition of restraint differed from state to state. It recommended that restraints only be used when absolutely necessary, that the least restrictive form of restraint be used, and that restraints not be employed as punishment or for the convenience of the staff. The use of restraint was deemed acceptable dental practice when appropriately used for the behavior control of patients with developmentally disabling conditions. Clear documentation of restraint use was stressed, as were guidelines that physical restraints should cause no physical injury, and that informed consent should be obtained in accordance with state guidelines.

It is important to note that the committee's recommendations were largely concerned with the management of developmentally disabled individuals using physical restraints. However, resistance (e.g., pulling away, closing the mouth) and combativeness (striking out) may also be frequently encountered in older adults with acquired neurological disorders such as Alzheimer's disease, Parkinson's disease, or stroke -- conditions that can unpredictably affect memory, perception, judgment, and reasoning. Inability to cooperate for dental treatment can also occur in adults with severe psychiatric disorders, as well as a variety of neuromuscular disturbances such as cerebral palsy, multiple sclerosis, and tardive dyskinesia.

In geriatrics, physical restraints are frowned upon due to the large body of literature detailing the hazards of their use in older individuals.^24,25 Older adults may have fragile skin, bones, and blood vessels that can be easily traumatized by physical restraints. The stress associated with the use of physical restraints may exacerbate other underlying chronic medical problems, such as cardiovascular disease. Further, physical restraints may induce psychological trauma, and the resultant agitation may render their use counterproductive.²⁶

Restraint Guidelines

Using the Academy of Dentistry for the Handicapped ad hoc committee's recommendations as a starting point, updated guidelines have now been developed (Table 4, see printed copy of Journal).⁷ In addition to the original guidelines developed by the academy, Guideline 5 stresses the need to consider the likely outcome of the dental treatment for which the restraint will be used. Restraint use should be reserved for those situations in which the patient is likely to gain some substantial benefit, such as restoration of lost oral comfort or function. Guidelines 6 and 7 address the need for informed consent, both for the planned dental treatment and for the use of restraint. Restraint use for dental treatment would not normally be expected by an average, reasonable person, so it is not encompassed within any implied consent for dental care and must be addressed separately in the consent process.²⁷

Guideline 8 emphasizes that the choice of restraint be selected based on the proposed dental treatment without blind reliance on orders developed for other situations. For example, there may be a tendency to request the administration of neuroleptics (e.g., haloperidol), originally ordered for psychotic episodes, as premedication before dental treatment simply because those orders already exist and seem more convenient to employ. However, if patient anxiety during treatment is the real issue, then a short-acting benzodiazepine such as lorazepam or oxazepam might be a better choice. Behavior management techniques for dental care should take into account any other currently employed strategies for that individual but should not be solely limited to those strategies if others might be more effective.

Guideline 9 stresses the need for training in the appropriate use of any restraint. While more stringent state dental licensure requirements have reinforced this concept where nitrous oxide analgesia, conscious sedation, and general anesthesia are concerned, practitioners may not realize the need for training in the use of other types of restraints, especially physical restraints. Other professionals, such as institutional nursing staff members, are trained and regularly updated in the proper use of such devices. No less should be expected from any dental personnel using them. Finally, Guideline 10 addresses the need for clear documentation. A number of state institutional guidelines,²³ as well as federal nursing home regulations,²⁸ mandate that a reason for restraint use be specified, along with the type and duration of use. It is reasonable to expect that this same information be made part of the dental treatment record when such behavior management approaches have been used in conjunction with dental care.

Summary

Dental professionals encounter a number of challenging moral dilemmas when caring for older adults, especially those with chronic illnesses and functional impairments. In securing consent for treatment, practitioners must consider both legal competence and decision making capacity and adopt roles appropriate to the patient's individual circumstances. If legal competence has been retained but decision making seems impaired, practitioners must involve others in the process of determining appropriate care. The capacity to consent for treatment can be assessed by asking some simple questions designed to evaluate the patient's ability to understand relevant information, appreciate their situation and its consequences, manipulate information rationally, and communicate choices. When faced with a choice of several treatment options and patient preferences are unclear or unknown, the principle of substituted judgment should be employed whenever possible to promote care in keeping with the patient's goals and values. To maximize patient safety and dignity, guidelines are provided for the use of restraints to provide dental care for individuals with significant behavior problems.

Author/

Stephen K. Shuman, DDS, MS, is an associate professor and director of the Oral Health Services for Older Adults Program in the Department of Preventive Sciences at the University of Minnesota School of Dentistry. He is also dental director of the Amherst Wilder Foundation Senior Dental Program in St. Paul, Minn., and the Presbyterian Dental Program at Presbyterian Homes of Arden Hills in Arden Hills, Minn.

References/

1. Beauchamp TL, Childress JF, Principles of Biomedical Ethics, 2nd ed. Oxford University Press, New York, 1983.

2. Cassel CK, Riesenberg DE, et al. Geriatric Medicine, 2nd ed. Springer-Verlag, New York 1990.

3. Rule JT, Veatch RM, Ethical Questions in Dentistry, Quintessence Publishing Co., Chicago 1993.

4. Kane RL, Ouslander JG, Abrass IB, Essentials of Clinical Geriatrics, 3rd ed. McGraw-Hill, New York, pp 474-5, 1994.

5. Wetle T, Ethical issues in geriatric dentistry. Gerodontology 6:73-8, 1987.

6. Odom JG, Odom SS, Jolly DE, Informed consent and the geriatric dental patient. Spec Care Dent 12:202-6, 1992.

7. Shuman SK, Bebeau MJ, Ethical and legal issues in special patient care. Dent Clin N Am 38:553-75, 1994.

8. Marsh FH, Informed consent and the elderly patient. Clin Geriatr Med 2:501-10, 1986.

9. Marsh FH, Refusal of treatment. Clin Geriatr Med 2:511-20, 1986.

10. Appelbaum PS, Lidz CW, Meisel A, Informed Consent: Legal Theory and Clinical Practice. Oxford University Press, New York, 1987.

11. Burtner AP, Defensive strategies for the institutional dentist. Spec Care Dent 11:137-9, 1991.

12. Ruark JE, Raffin TA, Initiating and withdrawing life support. N Engl J Med 318:25-30, 1988.

13. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forgo Life-Sustaining Treatment. Washington, DC, US Government Printing Office, 1983, p 123.

14. Dolinsky EH, Dolinsky HB, Infantilization of elderly patients by health care providers. Spec Care Dent 4:150-3, 1984.

15. Litch CS, Liggett ML. Consent for dental therapy in severely ill patients. J Dent Educ 56:298-311, 1992.

16. Hirsch AC, Gert B. Ethics in dental practice. J Am Dent Assoc 113:599-603, 1986.

17. Emanuel LL, Barry MJ, et al, Advance directives for medical care: A case for greater use. N Engl J Med 324:889-95, 1991.

18. Fade AE. Advance directives: Keeping up with changing legislation. Today’s OR Nurse 16:23-6, 1994.

19. Olson E, Chichin E, et al, Early experiences of an ethics consult team. J Am Geriatr Soc 42:437-41, 1994.

20. Appelbaum PS, Grisso T. Assessing patients' capacities to consent to treatment. N Engl J Med 319:1635-8, 1988.

21. Marson DC, Cody HA, et al, Neuropsychologic predictors of competency in Alzheimer's Disease using a rational reasons legal standard. Arch Neurol 52:955-9, 1995.

22. Shuman SK, Ethics and the patient with dementia. J Am Dent Assoc 119:747-8, 1989.

23. Fenton SJ, Fenton LI, et al. ADH ad hoc committee report: the use of restraints in the delivery of dental care to the handicapped -- legal, ethical, and medical considerations. Spec Care Dent 7:253-6, 1987.

24. Evans LK, Strumpf NE, Tying down the elderly: a review of the literature on physical restraint. J Am Geriatr Soc 37:65-74, 1989

25. Evans LK, Strumpf NE, Myths about elder restraint. Image: J Nurs Scholarship 22:124-8, 1990.

26. Mion LC, Frengley JD, et al, A further exploration of the use of physical restraints in hospitalized patients. J Am Geriatr Soc 37:949-56, 1989.

27. Klein A. Physical restraint, informed consent, and the child patient. ASDC J Dent Child 55:121-2, 1988.

28. Department of Health and Human Services, Health Care Financing Administration. Medicare and Medicaid programs; Omnibus nursing home requirements. Federal Register, Wednesday, February 5, 1992; 57(24):4516-20.

To request a printed copy of this article, please contact/Stephen K. Shuman, DDS, MS, University of Minnesota School of Dentistry, 15-136 Moos Tower, 515 Delaware St., SE, Minneapolis, MN 55455.