6: Treatment accommodations

6

Treatment accommodations

Debra Cinotti, DDS

INTRODUCTION

Treatment accommodations for dental patients with developmental disorders (DDs) can be viewed as adaptations or modifications of customary practices to provide oral health care. The objective of incorporating accommodations is to provide quality treatment in a safe and effective manner, as well as providing a nonthreatening environment whenever feasible, thereby augmenting access to oral health care.

Patients with DDs experience access-to-care issues in part because the health care provider is intimidated by or lacks knowledge about meeting the treatment needs of persons with DD. One initiative set forth to increase the number of oral health care providers trained to provide treatment to persons with DD is a change in the educational standards for predoctoral dental students adopted by the Commission on Dental Accreditation (CODA). CODA “serves the public by establishing, maintaining and applying standards that ensure the quality and continuous improvement of dental and dental-related education and reflect the evolving practice of dentistry. The scope of the Commission on Dental Accreditation encompasses dental, advanced dental and allied dental education programs” (ADA 2010). CODA has modified its standards to mandate that the dental graduate “must be competent in assessing the treatment needs of patients with special needs” (ADA 2010).

While these educational changes are commendable for future oral health care providers, the current provider workforce can also become skilled, knowledgeable, and comfortable in the delivery of quality care to persons with DDs. It is important to remember that the Americans with Disabilities Act (AwDA) requires “reasonable modifications in policies, practices, and procedures” enabling persons with disabilities equal opportunity to receive the goods and services available to others. Specifically, doctors’ offices, classified as places of public accommodation, are covered by regulations set forth in Title 3 of the AwDA. Becoming familiar with Title 3 of the AwDA will assist health care providers to understand their obligation to provide health care to individuals with DD (U.S. Department of Justice 2011).

Becoming learned in the types of treatment accommodations considered for the DD patient facilitates the dental provider’s ability to deliver safe and effective oral health care to these individuals. Earlier chapters discussed obtaining pertinent information (such as medical, dental, and social histories) prior to treatment as well as how to determine if treatment accommodations are necessary. This chapter will focus on what types of accommodations may be necessary for the DD patient, as learned from information obtained from the caregiver interview as well as patient experiences from previous dental/medical visits. Accommodations may be necessary to commence treatment as well as provide treatment. Take into consideration the intellectual capacity, behavioral challenges, mobility constraints, neuromuscular limitations, uncontrolled body movements, and medical profile of a patient that would benefit from adjustments to routine procedures (NIDCR 2011). For example, how does the dental provider obtain informed consent from a patient with DD? What accommodations should be taken to control stimuli in the dental office, such as noise? What accommodations are available for consideration to support the physically challenged patient’s ability to receive care? Each of these circumstances will be discussed, providing the dental practitioner with useful means to enhance his or her knowledge of the delivery of care to the DD patient.

ACQUISITION OF INFORMED CONSENT

Informed consent in health care refers to an agreement by the patient to receive specified procedures after receiving detailed information about the nature of the proposed procedures, other treatment options available, and the risks and benefits associated with these procedures (ADA 2010). As described in the Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing & Allied Health, informed consent is based on the principles of autonomy and privacy and must satisfy seven different criteria: “(1) competence to understand and to decide, (2) voluntary decision making, (3) disclosure of material information, (4) recommendation of a plan, (5) comprehension of terms (3) and (4), (6) decision in favor of a plan, and (7) authorization of the plan” (Miller-Keane 2003). In addition, the individual providing consent must be of a certain age (ADA 2010). Informed consent is obtained before services are rendered. However, it is important to note that the laws and requirements governing informed consent are state driven and may be different for different types of procedures (Stein 2007).

When treating a DD patient, first determine the “decisional capacity” of that patient. Not all persons with DD lack ability to make informed decisions. Furthermore, an individual’s ability to comprehend may vary with the complexity of the decision to be made. For example, a person may be able to comprehend and consent to an initial examination but not comprehend the risks and benefits of a proposed surgical intervention. Therefore, it is important to establish the patient’s ability to fully understand the information provided. “The capacity to make health care decisions has been defined as the ability to understand the information about a proposed care plan, appreciate the consequences of a decision, and reach and communicate an informed decision“ (Beltran 1996). As Beltran so aptly stated, “There is a need to balance protection from harm with the patient’s right to self-determination. This balancing requires skilled listening, the proper level of advocacy from caregivers, and pragmatic models of shared decision making” (Mosby’s Medical Dictionary 2009). A DD patient with full decisional capacity should provide informed consent for him- or herself. A DD patient with diminished capacity will either require assistance or depend completely on another person to provide informed consent. This other person should be the patient’s guardian or surrogate decision maker (an identified individual or organization appointed to assist or make decisions regarding the welfare of the DD patient, when the patient does not have a guardian). Once again, laws determining guardianship of a person with developmental disabilities vary from state to state. State law may require that when an individual becomes of “legal” age, a court order is necessary to (1) determine diminished decision-making capacity and the need to appoint guardianship, and (2) grant approval for those seeking the role of guardian.

Once it is determined who will give informed consent, the dental provider should determine if the current policies and procedures routinely followed in the office are acceptable for the patient with limited decision-making capabilities. Often, implied informed consent is accepted for the initial examination visit. Implied informed consent is when a patient permits care without a formal agreement between the patient and health care provider. When a patient calls and schedules an appointment, it is implied that the patient has consented to the treatment visit (Ferguson et al. 1996). However, for the patient who is dependent on a guardian or surrogate to provide informed consent, it is recommended to obtain written informed consent for all forms of treatment, including general routine care, utilization of behavioral guidance aids, and surgical treatments.

Patients who reside in a facility and not with a guardian may be escorted for treatment with a caretaker who does not have authority to provide informed consent. To obtain informed consent for these individuals consider the following options:

1. If a patient’s guardian lives within distance of the providing dental care facility, require the guardian to attend the visits requiring consent for treatment.
2. If a patient’s guardian lives a far distance from the dental care facility (which is a common occurrence), obtain informed consent from the guardian/surrogate prior to the appointment. Informed consent should be obtained for the initial examination, diagnosis, and treatment planning visit, including informed consent for behavioral guidance aids. These consent forms should include specific information describing the nature of the treatment, alternative treatments available, and associated risks and benefits. After the initial examination and diagnosis visit, the proposed treatment plan would require informed consent as well. To help facilitate this process, another option for these individuals is to formulate a memorandum of understanding (MOU) between the residential facility, the patient’s guardian, and the dental care provider (Ferguson 2005). The MOU may serve as a contract of informed consent allowing designated treatment to be rendered based on specific criteria described in the MOU. The MOU document would have to include all information required of informed consent.
    With respect to consent for behavioral guidance aids, a separate informed consent form may be obtained. This form should describe the protocol utilized to determine if behavioral aids will be used, as well as a description of these aids and the associated risks and benefits with use. The form should also define the time period for which the consent is valid and the opportunities and procedures to withdraw the consent prior to the expiration date. An “extended” informed consent for utilization of behavioral guidance aids enables the dental care provider to perform treatment with these aids over multiple visits. This facilitates care especially for patients residing in a residential facility and not accompanied to the dental visits by a guardian or surrogate individual authorized to provide informed consent. It goes without saying that the standards for utilizing behavioral guidance must be followed.
    In summary, informed consent is essential for any patient and may require special consideration for individuals with developmental disabilities. However, the process does not have to be a difficult one. If the DD patient has full decision-making capacity, follow standard procedure to obtain informed consent. If the DD patient has limited decision-making capacity, have the guardian present to assist the patient in giving informed consent. Obtain both signatures on the informed consent. If the patient has no decision-making capacity, identify the guardian/surrogate and obtain informed consent from that individual.

ACCOMMODATIONS TO MANAGE GENERAL OFFICE STIMULI

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Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 6: Treatment accommodations
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