Refusing to treat a patient is always a challenging decision for a health professional, because we want to be able to use our skills and clinical experience to help patients. However, there may be occasions when treating a patient is not always the best thing for them or for you and each situation (and patient) should be judged on its merits and particular circumstances.
Scope of practice
A clear example is if the treatment that a patient wants you to provide them with is outside your scope of practice. The General Dental Council (GDC) Standards for the Dental Team 2013 emphasise this in Standard 6.3, “You must delegate and refer appropriately and effectively” and 6.3.3, “You should refer patients on if the treatment required is outside your scope of practice or competence. You should be clear about the procedure for doing this.”
In this statement, the GDC is effectively guiding the registrant that they may only provide treatment that comes within the scope of their practitioner category (that is dental hygienist, dentist, dental therapist and so on); that they have sufficient training for; and, very importantly, that they are competent to provide.
For instance, in my clinical practice, I do not provide orthodontic treatment and consequently if a patient were to ask me to straighten their teeth, I would explain to them why I could 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, while keeping 6.3.5 in mind, “If you need to refer a patient to someone else for treatment, you must explain the referral process to the patient and make sure that it is recorded in their notes.”
Difficult or abusive patients
It is human nature to avoid conflict and negative interactions with a patient can be challenging. If you have previously had issues with a patient, then naturally you would want to avoid a similar situation and may be reluctant to provide them with further treatment. This is where it can get complicated and, again, it is a situation that has to be assessed on its merits.
For example, if you saw a patient two years ago and they were unhappy with a filling that you provided and had to come back to see you to rectify their concerns. You may have replaced the filling, or perhaps gave the patient a refund as a gesture of goodwill. If the patient books in to see you again for a regular check-up, this would show that in the patient’s mind, they have no issue with you; therefore you need to strongly consider whether you should refuse to see this patient.
That is 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 do not 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 okay 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.
Other examples
An example that many dentists will have experienced is when a patient attends and demands treatment. 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. 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 in a very high-needs area in the UK, would be a patient coming in for the first time, having not seen a dentist for a number of years, asking for all their teeth to be extracted and replaced with dentures. On examination of the patient, while I would agree that some of their teeth could not be saved and needed to be extracted, their remaining teeth would be salvageable with simple restorative treatment. Having formed the opinion that extracting all the teeth and providing dentures was not the right thing for the patient, one would have to refuse to provide this treatment. It is important to explain to the patient why you were not agreeing to provide the specific treatment requested and what alternatives they have available, including the option to seek a second opinion.
Guidance
As a baseline, we must put patients’ interests before our own or those of any colleague, business or organisation. However, Standard 1.7.8 states, “In rare circumstances, the trust between you and a patient may break down, and you may find it necessary to end the professional relationship. You should not stop providing a service to a patient solely because of a complaint the patient has made about you or your team.”
It goes on to say, “Before you end a professional relationship with a patient, you must be satisfied that your decision is fair and you must be able to justify your decision. You should write to the patient to tell them your decision and your reasons for it. You should take steps to ensure that arrangements are made promptly for the continuing care of the patient.”
When treatment cannot be refused
It is always important to remember that as a healthcare professional, you cannot discriminate and refuse to see a patient based on factors such as 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 to offer the patient a referral pathway to an appropriate clinician.
We also cannot abandon patients, especially mid-treatment. You need to ensure continuity of care, so make sure that you appropriately hand over or refer them. As well as the ethical obligations, it will also be important to consider any potential contractual elements that may have a bearing in terms of obligations to make alternative arrangements or on appropriate communication of the decision to decline further treatment.
Risk of complaint
If for some reason, you go against your instincts and provide treatment to a patient, there is always the chance that something will go wrong and the patient will make a complaint. My experience is that even if a patient is demanding treatment, when something goes wrong, a patient could argue that they were not fully aware of all the risks involved in a particular treatment and so consent was not properly obtained.
The regulatory bodies and the courts expect professionals to provide their patients appropriate advice and treatment.
The best way to avoid this situation is to refuse treatment in the first instance, and the members we speak to in similar situations often regret having proceeded with treatment. However, if you are compelled to provide treatment, for example, to help alleviate a patient’s pain, you should have a clear discussion with the patient about the limitations of the treatment you are providing and appropriately set their expectations. As always, detailed records of this discussion and the patient's understanding and agreement to treatment, may help to reduce the chances of a negative outcome for you.
Final tips
Refusing to treat a patient, for whatever reason, is always a challenging aspect of clinical practice that most professionals will encounter at some point. Each situation needs to be carefully considered; communication with your patient is very important and, given the delicate nature of the conversation, should not be delegated to a staff member.