Informed Owner Consent

I am in Ontario, so when it comes to practice standards and legal aspects of veterinary practice, I write about the situation in Ontario. Things may differ slightly from one jurisdiction to another but the general principles of Informed Owner Consent (IOC) ought to apply anytime there is a Veterinary-Client-Patient relationship (VCPr). The College of Veterinarians of Ontario has two publications on their website that pertain to IOC:

The Professional Practice Standards bulletin on IOC outlines the expectations of a veterinarian practicing in Ontario. Here is a direct link to a pdf of that – https://vetdentedu.ca/wp-content/uploads/2023/04/CVO_informedconsent_PPS.pdf.

The CVO has also put out a Guide to the Standard (FAQs) on IOC and the pdf of that can be found here – https://vetdentedu.ca/wp-content/uploads/2023/04/CVO_informedconsent_FAQs.pdf

Details of expected treatment plan

Some years ago I was contacted by a local general practitioner who was in a conflict with a client. The DVM contacted me looking for vindication and moral support. Apparently, the client had done a ”drop-off” at the clinic early in the morning and had signed a form consenting to “a dental”. Later in the day, when the client went to collect their pet, they were dismayed to learn that several teeth had been extracted. They had only expected a dental cleaning.

My colleague had called me thinking I would be in their corner, but I really could not defend their actions. They indicated that the extracted teeth were so loose that they basically fell out as the calculus was being removed but that was irrelevant. The medical-appropriateness of the treatment is not the issue. The issue was that the DVM did not have IOC to proceed with anything specific, let alone several extractions. At no point in the process of recommending dental treatment or admitting the patient for its procedure did the DVM (or anyone else at the clinic) inform the owners that a dental procedure in a small dog with marked calculus accumulations might reasonably be expected to involve extractions. The owner was not informed of the diagnostic plan, the likely treatment plan, the risks and benefits of proceeding or anything else. They consented to “a dental” which is like consenting to “a surgical”. That amounts to uninformed owner consent and is not worth the paper it is written on.

Once the patient was anesthetized and the extent of disease detected, there was an opportunity to contact the owner to disclose the findings, outline a medically-appropriate treatment plan (and revised estimate of costs) to obtain IOC to proceed but that opportunity was missed.

I have no idea how this was all panned out. Hopefully some open communication (with contrition from the DVM) smoothed things over and they were able to re-establish a relationship based on mutual trust and respect. However, an ounce of prevention…

So, when it comes to scheduling a dental procedure, do NOT call it “a dental” as that is an exceptionally vague term that invites misunderstanding. And don’t call it a “Prophy” because that is short for prophylaxis, which means prevention and we know that by the time we get our patients in for dental care, we areusually way past prevention. There is active and established disease that requires accurate assessment and appropriate treatment. The term many of us have adopted is COHAT which stands for Comprehensive Oral Health Assessment and Treatment.

It is important to document and discuss with the owners the findings of the conscious examination that led to the recommendation for professional dental care. The known, suspected and statistically likely problems need to be outlined to the owners (like, you know a 10-year-old cat is statistically likely to have at least some tooth resorption and you know that a 6-month-old Yorkie is likely to have persistent primary teeth and dental crowding). From this, a tentative treatment plan and estimate can be generated AND a plan MUST be in place to contact the owner intra-operatively to disclose the findings of the Comprehensive Oral Health Assessment, to present the revised Treatment plan based on those findings along with the updated estimate in order to obtain the necessary IOC to proceed.

Who Does What

Another issue raised in the CVO document on IOC is the imperative to inform owners that some task may be performed by support staff. Owners might assume that all aspects of the dental procedure, including the oral hygiene procedure (OHP), are performed by the attending DVM and in some clinics this might be the case. I have always done my own OHPs because it gives me the opportunity to spend some time getting to know each and every tooth in greater detail and I often find subtle things that might have otherwise gone unnoticed.

If some portions of the dental procedure are going to be carried out by anyone other than the licensed attending DVM, the owners must be made aware of this in order for them to provide IOC. You might do up a document entitled “Who Does What” that outlines what parts of the procedure are definitely going to be done by the DVM (detailed dental examination, interpretation of the dental radiographs, all extractions and oral surgery, root planing…) and what parts might be delegated to support staff (placement of IV catheters, coronal scaling and polishing, monitoring of anesthesia…). Have this printed up and have the owners read it over. On the consent form, maybe have them initial a box stating that they have seen and read this document.