Dr Kiran Keshwara, Dentolegal Consultant at Dental Protection, provides advice and guidance on those difficult conversations

Refusing to treat a patient is always a tough situation for a health professional, because we always want to be able to use our skills and clinical experience to help patients. People assume that they have a right to be seen by you whenever they ask, but this is not always the case.

There may be occasions when treating a patient isn’t always the best thing for them or for you. Each situation (and patient) should be judged on its merits and particular circumstances.

When might a healthcare professional refuse treatment? 

An obvious example is if the treatment that a patient wants you to provide them with is outside your scope of practice. The new guidelines for scope of practice, effective from 1 July 2020, state: “You must only perform dental treatments that you have been educated and trained in, and that you are competent in.”

In this statement, essentially the Dental Board is telling each registrant that they may only provide treatment that comes within the scope of their practitioner division (that’s hygienist, dentist, prosthetist etc); that they have sufficient training for; and, very importantly, that they are competent to provide. 

Using my clinical practice as an example, I don’t provide orthodontic treatment and consequently if a patient were to come in to see me and ask me to straighten their teeth, I would explain to them why I will not provide the treatment. I would then refer them either to one of my GDP colleagues or to a specialist who can then help the patient.

What if I don’t like the patient or have previously had issues with them?

This is definitely a tough situation to be in. It’s human nature to avoid conflict and if you’ve previously had issues with a patient, then naturally you’ll be reluctant to provide them with further treatment; this is where it can get a bit more complicated and, again, it’s a situation that has to be assessed on its merits.

For example, let’s say you last saw a patient two years ago. They were unhappy with a filling that you provided at the time and had to come back to see you a couple of times to rectify some issues. Maybe you had to replace the filling, or you gave the patient a refund as a gesture of goodwill and you don’t hear from the patient again. If the patient books in to see you again for a regular check-up, this would show that in the patient’s mind, they don’t have an issue with you; therefore you need to strongly consider whether you should refuse to see this patient.

That’s not to say you always have to see a patient.

If you have a patient that is verbally abusive and threatening, or has threatened you physically, this would be considered a significant breakdown in the professional relationship and so you would be well within your rights to refuse to treat the patient.

You may also simply not like the patient and this could be for a number of reasons. They are rude, they use language you don’t think is appropriate, they always turn up late or never pay their bills. In these circumstances, it is wise to remember that you have your own personal boundaries and it is not ok for anyone to breach them. You should clearly and respectfully set out what these boundaries are to a patient and, if the patient continues to cross these boundaries, you can refuse to treat them.

What other times would you refuse to treat a patient?

An example that most Dental Protection members would have experienced is when a patient attends and demands treatment from you. The treatment that they request may be entirely reasonable and in their best interests, so their request may be valid and based on the patient’s considerations and beliefs, and this is entirely reasonable. However, many times it is not in their best interests and you may consider refusing to provide the treatment.

A situation that I have come across a few times, especially when I was working in England in a very high-needs area, would be a patient coming in for the first time, having not seen a dentist for seven or eight years, and asking me to extract all their teeth and giving them dentures. I’d examine the patient and, while I would agree that two or three of their teeth could not be saved and needed to be extracted, their remaining teeth would be fine and either needed a simple clean or small restorations. I did not believe extracting all the teeth and providing dentures was the right thing for the patient and would have to refuse to provide this treatment. This was always a difficult conversation with patients. 

Managing difficult conversations with patients

With difficult situations, communication is often the most important factor; it’s not the decision to refuse treatment but the way this is conveyed to the patient that makes the difference.

I would explain my findings to the patient and explain to them that aside from the very broken down teeth, the rest of their teeth could be saved. I would further go on to explain that dentures (or any of the other options) are not the route to a lifetime of having no dental issues and would stress the difficulties in wearing dentures, the need to try to get used to them, how they would affect speech and taste and that the dentures would need replacing over time.  

Many times, the patient would listen and understand what I was explaining to them, and most of them would appreciate the advice, as they would not have considered the risks and negative aspects of the treatment that they were requesting.

Once I had a patient demanding that I provide the treatment, with the classic line of “they’re my teeth, you have to do what I say”. I had to explain to the patient that yes, they are most definitely your teeth but I do not believe that the treatment you are requesting is in your best interest, and therefore I am not comfortable providing the treatment. I offered to refer the patient to another dentist for a second opinion.  

If you ever find yourself in this sort of situation, I would recommend that you offer the patient a referral for a second opinion, or offer to send the patient records to the practitioner of their choice.

Other tips on handling difficult situations

If you are certain that you will not provide treatment a patient is asking for, there are a few things to keep in mind during your discussion.

Firstly, I believe it’s very important to be very clear in your refusal to treat. Say no. Being vague or letting the patient convince you otherwise is never going to be in your best interests – it will lead to more confusion for the patient.

As explained before, simply saying “No” and walking out the room is never the way to handle this situation, so it is important to explain why you are refusing to provide the treatment. Many patients will be more reasonable in face-to-face discussions with you and this can help build trust.

As always, offering the patient alternatives, and explaining the pros and cons of these alternatives, is necessary and if you feel that the patient is adamant that they want the treatment, always offer to refer them for a second opinion. 

What is the guidance on refusing to treat patients?

The Dental Board of Australia’s Code Of Conduct document advises us that, along with the scope of practice issues that we had discussed, a clinician should:

• recognise the limits to their own skills and competence and refer a patient to another practitioner when this is in the best interests of the patient, and
• be aware of their right to not provide or participate directly in treatments to which they object conscientiously, informing patients and, if relevant, colleagues of the objection, and not using that objection to impede access to treatments that are legal, and
• ·not allowing moral or religious views to deny patients or clients access to healthcare, recognising that practitioners are free to decline to provide or participate in that care personally.

Similarly, the Health Care Complaints Commission of New South Wales advises that: “A practitioner is obliged to see a patient when a person’s life is in danger and they require urgent emergency treatment.”

It goes on to say that in non-emergency situations, a health practitioner may decline to see a patient for reasons such as:

• They don’t have any free appointments available and taking on a new patient would compromise the care they can provide to existing patients.
• They don’t feel they have the right expertise to help.
• There has been a breakdown in the relationship between the practitioner and the patient.
• There is a risk that professional boundaries could be crossed.

Are there any situations where you can’t refuse to treat a patient?

It is always important to remember that as a healthcare professional, you cannot discriminate and refuse to see a patient based on their race, religion, gender, sexual preferences or physical or mental disabilities. The only exception to this is when it is not possible to see a patient – for example, if you have a bariatric patient who exceeds the safe limit of the dental chair.

Another example could be if you have concerns that the patient has behavioural issues, generally out of their control, which could make communication, consent and provision of treatment difficult. In all such circumstances, it is important that you offer the patient a referral pathway to an appropriate clinician.

We can’t just abandon patients, especially mid-treatment. You need to ensure continuity of care, so make sure that you appropriately hand over or refer them.

Final tips

Refusing to treat a patient, for whatever reason, is always a difficult situation to be in and I think most clinicians will face something like this at some point in their career.

Each situation needs to be carefully considered; communication with your patient is very important and I would suggest that this isn’t delegated to a staff member. It is always a good idea to give Dental Protection a call so that we can discuss the issue and help you to communicate your thoughts and decision to a patient.

For a more in-depth discussion with Dr Kiran Keshwara and Dr Annalene Weston on this topic, listen to our podcast episode “Saying no to patients, Can we? Should we? And how do we do it?” available now.