ETHICS CASE

 

Dealing with non-compliant, abusive or aggressive patients in dental practice

 

 

Su Naidoo

BDS (Lon), LDS.RCS (Eng), MDPH (Lon), DDPH.RCS (Eng), MChD (Comm Dent), PhD (US), PG Dipl Int Research Ethics (UCT), DSc (UWC). Senior Professor and Principal Specialist, Faculty of Dentistry, University of the Western Cape, Department of Community Dentistry, Private Bag X1, Tygerberg 7505. E-mail: suenaidoo@uwc.ac.za

 

 

There is increasing concern as to how health professionals respond to patients who are considered non-compliant, abusive or difficult. What are their responsibilities to the patient? What are their responsibilities to other patients and staff? Can the patient be refused treatment? What are the responsibilities that providers, as employers, have in relation to staff who might be treating violent or non-compliant patients? What are the competing rights and responsibilities of patients and of the dental provider? Are the above questions influenced by the threat posed by the patient to the safety of staff and other patients? There are many instances in daily practice where patient behaviour, while being difficult and emotive, is not necessarily wrong or inappropriate in the context of the service being provided and the circumstances relating to their particular dental condition. This paper discusses issues relating to circumstances where serious issues arise regarding the behaviour of persons receiving dental treatment in the context where such behaviour is clearly inappropriate, aggressive or violent.

A dentist's primary concern is to do the best for their patients and this includes giving advice and providing treatment in accordance with the up-to-date evidence base and in the patient's best interests. The principle of respect for autonomy is not absolute and there will be instances where a patient's autonomous choice is in conflict with that of the dentist. Dentists have both legal and ethical responsibilities towards their patients and although there is no legal obligation for a dentist to provide a treatment requested by a patient that is not to their overall benefit, not doing so may cause problems.

The National Health Act¹ provides that health establishments must implement measures that minimize injury or damage to the person or property of health care workers. This means that it is a general duty of employers to provide a safe and healthy workplace, free from hazards and that their employees are protected from physical harm, their working environment made safe and free from any hazardous incidents. In this regard, employees are responsible for identifying hazards in the workplace; assessing the risk posed by each of these hazards and to control the risk. Where a patient is known to be or has a history of violent and abusive behaviours, the management and treatment of that patient may be characterised as a workplace hazard. An employer who fails to take steps to control the risk posed by such a patient may have breached their obligation to protect the health and safety of their employees. In addition, it may not only be employees who may be at risk from violent or abusive behaviour, but other patients in the practice could also be injured by another patient, or even suffer an adverse health outcome as a result of witnessing the behaviour of another patient. Dental practitioners must therefore provide a safe environment for those accessing their services and introduce practice policies and procedures to protect their patients.

Difficult patient behaviour can include behaviours ranging from non-compliance or self-harming to physical threats and abuse. A concern will be when a difficult patient's behaviour gradually escalates, usually along a continuum. The dentists' responsibility and the action taken will be dependent on where the patient's behaviour fits along the continuum. There are numerous actions that can be adopted by dental practitioners that can facilitate change or modify a patient's behaviour. These may include behavioural contracts, mediation, individual treatment plans, psychosocial intervention and shared care.

Behavioural contracts are contractual agreements developed by the practice, which are signed by the dentist and the patient. It sets out the guidelines under which the patient will be treated or continue to receive treatment. It should be sufficiently specific to allow for action taken by the practice and its staff to be clearly supported. Mediation is often very successful in achieving the resolution of these disputes. While it may be time-consuming and require wide consultation, it can lead to the negotiation of a mutually beneficial solution, rather than the imposition of requirements on the patient by the practice. Mediation differs from the introduction of behavioural contacts in that it does not involve language relating to acceptable or unacceptable behaviour, nor a discussion of consequences, but a deeper level of conflict resolution. The dentist must be able to first recognise that there is a problem and to determine the circumstances that may be contributing to a patient's behaviour, including medical, mental, financial and other factors. They should try to see the problem from the patient's point of view and both the practitioner and the patient should try to negotiate an acceptable way forward.² While behavioural contracts require patients to comply with existing requirements or policies, individual treatment plans are built on identifying the treatment which best meets the patient's needs. An individual treatment plan may involve a departure from or greater flexibility with the practice's policies. Psychosocial intervention is based on techniques such as active listening and teaching that may assist practitioners in determining the reasons for the patient's noncompliance or abuse and consequently taking the appropriate steps to prevent or manage the behaviour. This approach may include patient grievance policies and procedures, the use of behavioural contracts, and policies regarding treatment refusal, discontinuation or dismissal of the patient. The option of shared care can be considered as an approach not so much as an attempt to prevent or manage the patient's non-compliant behaviour, but to manage the impact of patient non-compliance on staff and other patients.

Refusal or discontinuation of treatment

There may be legitimate reasons for refusal to treat a patient. However one must aware of the possibility of it being misconstrued as abandonment of the patient. Discontinuation of treatment is usually a last resort, and is only recommended after all other strategies have been implemented and have been shown to be unsuccessful. The National Health Act of 2003 No. 61 Chapter 2 Item 19: "Rights of health care workers" states that health care workers may refuse to treat a patient who is physically or verbally abusive or who sexually harasses him or her.¹ Refusal or discontinuation of treatment on account of non-compliance of the patient, posing a risk to the dental team, or if the patient is hostile, obnoxious or abusive to the dentist and staff becomes an option when the patient, who after having being informed about the practice's policies and requirements, breaches these requirements. The patient can then be refused treatment at the time, or the treatment may be discontinued. If all interventions are unsuccessful and the relationship remains adversarial, the best option would be to terminate it, formally inform the patient that treatment will no longer be provided and to find a mutually acceptable alternative. The dentist should provide a list of other suitably qualified practitioners in the area or refer the patient to another healthcare institution.

To avoid abandoning the patient, dentists may discontinue treatment after reasonable notice has been given to the patient by the dentist of his intention to discontinue treatment and that the patient has had a reasonable time to secure the services of another dentist or after all other dental treatment begun has been completed. Furthermore, the dentist (i) must ensure that the health of the patient is not compromised, (ii) the notification for termination be by registered or certified mail, providing at least 30 days as the termination date after the receipt of the letter, (iii) the letter should indicate what treatment the dentist will complete during the prescribed days, and (iv) what emergency care will be provided until the patient finds another dentist.

In summary, some of the steps that can be taken when dealing with non-compliant, abusive or aggressive patients include treating the patient on an individual basis if there is no specific policy; developing a 'treatment contract'; developing a more formal contract which the patient signs, setting out the expectations that the patient has to meet to enable him/her to continue to be treated; teaching the patient a home-based treatment; seeking restraining orders; referring the patient to another facility for treatment; hiring of security guards to be present while treatment is taking place and terminating the treatment.

It is essential that every practice should have clear policies on how to deal with non-compliant and abusive behaviour. At a minimum, these policies should be written; be provided to patients at the first consultation and be displayed prominently within the practice. In addition, policies should clearly identify, for both patients and staff what types of behaviour are considered unacceptable or inappropriate; what will happen when these behaviours occur; what will happen if these behaviours continue to occur; and the conditions under which treatment will be provided.

The entire dental team should be trained and aware of the practice policy and procedures and these should be enforced consistently. Staff should have access to training to ensure they have the necessary skills and confidence to implement any measures agreed upon, have strategies to deal with the behaviour that reduce rather than escalate conflict, and reduce stress upon themselves. Whenever violence or abuse is threatened, it will be necessary to investigate the patient's previous history of violence; personal factors i.e. relationship breakdown, death of family member, friend, loss of job; their access to weapons; and previous suicide attempts. All incidents should be clearly documented, and detailed notes made on the patient's chart. Documentation should include not only the clinical aspects of the patient's treatment, but all interactions in which verbal or physical abuse occurs. These notes should include the names of witnesses, the content of any threats made, and the steps taken by staff in response to the situation. The importance of reporting such incidents should be reiterated to all staff.

 

CONCLUDING REMARKS

Dentists have an ethical obligation to care for patients, but are permitted to terminate the difficult dentist-patient relationship, provided an alternative is available. There is no duty incumbent on dentist to treat people who are not their patients, except in medical emergencies.³ Creative approaches are usually required to handle difficult dentist-patient relationships. The dentist must be able to first recognise that there is a problem and to determine the circumstances that may be contributing to a patient's behaviour, including medical, mental, financial and other factors.

While recognising the fundamental importance of patient access and care, one must be cognisant of the personal strain placed on staff and the financial consequences of treating violent or abusive patients. There is also a need for practices to examine the circumstances that may be contributing to a patient's behaviour, including medical, mental and other factors. Interventions or other strategies should be considered that provide realistic solutions and options for both patients and staff and, if at all possible, reduce the potential for harm to either party. Every effort should be made to prevent the escalation of issues to such a level that denial of treatment is the only solution. While both patients and dental practices may have recourse to legal remedies, a range of other options, aimed at strengthening and continuing the treating relationship, also exist. Practices that offer a number of options, with trained staff, confident in the use of these strategies, will be better placed to respond to violent or abusive incidents, if and when they do occur.

The ethical principles of beneficence, respect for patient autonomy and do no harm should always be considered in the management of non-compliant, abusive or aggressive patients. It may not always be easy for a dentist to strike the right balance between a caring, supportive and patient-centered approach, but by acting ethically and professionally, they will find the elusive balance that will make patient care more rewarding and professionally satisfying.

Acknowledgement: With grateful thanks to Mr Punkaj Govan, Legal Advisor, SADA for his erudite and insightful comments.

 

References

1.South African Parliament. National Health Act No. 61 of 2003. Pretoria.         [ Links ]

2.Lo B. Refusal to care for patients. In: Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. Baltimore: Lippincott Williams & Wilkins, 2009:182-189. http://patients.about.com/od/doctorsandproviders/f/Can-My-Doctor-Dismiss-Me-As-A-Patient.htm (accessed 25 May 2016).         [ Links ]

3.Singh JA. Law and the health professional in South Africa. In: Moodley K, ed. Medical Ethics, Law and Human Rights: A South African Perspective. Pretoria: Van Schaik, 2011:109-142.         [ Links ]