Ethical issues in managing the noncompliant child

Resident: Murphy
Date: 09/18/2009
Article title: Ethical issues in managing the noncompliant child
Author(s): Griffin, Ann. Lawrence Schneiderman
Journal: Pediatric Dentistry 14, #3 1992
Major topic: How to manage the child who doesn’t want to consent to treatment
Type of Article: Clinical Case Review

Main Purpose: To discuss the ethical dilemma involved with why we should or should not treat a child who needs treatment, but will no consent to treatment

Overview of method of research: Descriptions of procedures were provided to 120 parents by one of 4 methods: 1) Video 1 of technique during live appointment with an accompanying explanation before video is viewed, 2) video 2 of technique without explanation, 3) written presentation, and 4) oral presentation.

Findings: One of the first things we all learn in dental school is that you don’t do anything without an informed consent, no exceptions. A proper consent should include a description of recommended techniques, benefits of the procedure, alternative tx options, and risks for not doing any treatment. This article discusses the dilemma of having a child who needs emergency dental treatment, but is noncompliant. Patient autonomy is a fundamental right of all patients. Because a child may not be able to understand the consequences of their choices, parents sometimes need to override their refusal. While children may refuse the necessary treatment due to fear, parents may refuse treatment of their child due to monetary reasons or insurance reasons. All of these pressures can compliment treatment and cloud what our primary focus should be; providing the best care for the child.
This article reviews five areas of consideration 1.tx indications, 2. patient autonomy, 3. benefits vs. risks of tx and no tx, 4. parents wishes, and 5. allocations of reasons($$$$).

Is the treatment needed right now?
When a patient cannot be persuaded to agree to treatment, we must decide on how pressing the dental needs are. If treatment is delayed could the patient be harmed? The article reviewed the case of a 3 yo girl with small occlusal caries on two lower teeth. After much coaxing, the child would not allow the dentist to perform any tx. While the dentist may feel it necessary to try to complete some type of treatment, because the needs are not pressing, it is best to postpone the tx, and try another day.

When should we disregard Patient’s right to refusal?
As stated previously, each case, and each child is different. The term “consent” is reserved for individuals with the full capacity to make independent decisions. By the age of 14 or 15, most adolescents have the decision making ability of an average adult. Depending on the child’s maturity and their dental needs, it may not be our right to force them to consent to tx, whether or not we agree with their decision.

Weighing Benefits and Risks of management techniques:
If the decision has been made to proceed to tx without consent of the child, the proper management techniques benefits and risks must be considered. Behavior management (or as we say now, guidance) is an art, and each practitioner has a variety of techniques that could be used to calm the child. The main goal is to provide the best tx possible while not physically or emotionally harming the child.

Parental approval:
When a patient is not old enough to make an informed decision, their parent can give consent for them as a proxy. A legal guardian can also act as a proxy. With that said, parents do not always act in the best interest of their children. When this happens, healthcare providers may be better equipped to decide for a child rather than self interested, incompetent, or uninformed parents. If the parents refuse the proposed tx, the professional should due their due diligence to attempt to educate and overcome the ungrounded fears or misapprehensions.

Allocating resources:
Sometimes the best treatment for a child is to be seen under GA. While this is what’s best for them, it may not feasible due to lack of money or insurance companies denying treatment. Dental problems are considered less serious than other procedures requiring GA. Therefore, third party companies often limit their coverage. This limitation on available options isn’t in the best interest of the patients, and compromises care. It’s up to us to advocate for these kinds of patients.

Summary of conclusions: As professionals, it is up to us to use our best judgment and weigh all of the variables in a given case when deciding what is best for a child. If a child has a large abscess and is in pain, all efforts should be made to get that tooth taken out. If the child has a small occusal, pushing treatment isn’t indicated. Basically think everything through, communicate effectively with parents and patients, give the child the best tx possible for today, and for their future dental visits.

Assessment of article: Good article, results not surprising. More common sense than anything.