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Make the discussion meaningful

Consent should help a patient understand and decide about proposed care. In a busy dental practice, it is useful to ask whether the patient could explain, in their own words, what is being proposed and why.

In Samira Kohli v. Dr. Prabha Manchanda, (2008) 2 SCC 1, the Supreme Court described valid consent in terms of capacity, voluntariness and adequate information. The information should address the treatment’s nature and purpose, benefits, alternatives, substantial risks and consequences of refusal. The Court also explained that consent to one procedure does not ordinarily authorise a different procedure; a limited exception concerns urgent necessity where delay to obtain consent would be unreasonable. [1]

These principles provide a foundation. The following checklist is a practical recommendation for dental teams rather than a quotation of a universal statutory form.

A useful consultation checklist

Identify the proposed procedure, tooth or anatomical site. Explain the diagnosis or working diagnosis and any important uncertainty. Discuss realistic benefits, relevant risks, reasonable alternatives and what may happen if treatment is deferred or refused.

Give the patient time to ask questions. Use language they understand. Where an interpreter is needed, record who assisted and how communication took place. Where appropriate, asking the patient to summarise the plan can reveal misunderstandings before treatment begins.

For invasive procedures, a procedure-specific written record is a prudent part of this process. Its content should reflect the actual discussion. Avoid relying on a generic clause purporting to authorise every possible intervention.

When the plan changes

Pause to consider whether the proposed change falls within the consent already obtained. Where practicable, discuss a material change before proceeding and record the patient’s decision. Urgency, capacity and the clinical circumstances require individual assessment.

Record decisions clearly

The clinical notes should identify the discussion, questions, decisions and any refusal. If recommended care is declined, record the recommendation, the information explained and the follow-up advice.

A patient’s signature does not establish that every relevant conversation occurred. Equally, consent does not excuse negligent treatment. In Kusum Sharma v. Batra Hospital, the Supreme Court discussed the continuing expectation of reasonable professional skill and care. [2]

The practical aim is a patient who understands the decision and a record that accurately reflects how it was made.

Sources

[1] Supreme Court of India. Samira Kohli v. Dr. Prabha Manchanda & Anr., (2008) 2 SCC 1, judgment dated 16 January 2008, particularly paragraph 32. Judgment text: https://indiankanoon.org/doc/438423/

[2] Supreme Court of India. Kusum Sharma & Ors. v. Batra Hospital & Medical Research Centre & Ors., (2010) 3 SCC 480, judgment dated 10 February 2010. Judgment text: https://indiankanoon.org/doc/29738758/

Educational discussion of Indian legal principles. Particular disputes require assessment of the complete facts and applicable law.

Begin with the diagnosis and the specimen details

A histopathology report records the examination of submitted tissue. Before interpreting individual terms, check your name, the specimen site and the procedure described. Then review the diagnosis with your treating clinician.

Typical sections include a description of the tissue received, the microscopic findings and the diagnostic conclusion. Additional tests may be reported separately or in an addendum. The final interpretation combines the tissue findings with relevant clinical information. [1]

Understand the limits of the sample

Ask whether the procedure sampled part of the lesion or removed it in its entirety. This helps explain what the report can establish and what still requires clinical assessment.

A useful question is: “Does this result adequately explain what was seen during the examination and on imaging?” If the answer is uncertain, the treating clinician and pathologist may need to discuss the case.

Grade and stage describe different things

When cancer is diagnosed, grade refers to microscopic features of the tumour cells and tissue. Stage describes the extent of the cancer, including its size and spread. A biopsy report does not always provide everything needed to determine the complete stage. [2,3]

Avoid interpreting a word such as “well differentiated” as a complete statement about severity or treatment. Ask how the microscopic diagnosis fits with examination, imaging and other findings.

What margin information means

In an appropriate surgical specimen, the pathologist may assess whether tumour reaches the tissue edges. This is margin assessment. Its relevance depends on the procedure and the specimen; a small diagnostic biopsy should not be read as though it were necessarily a definitive cancer excision. [1,4]

Questions worth taking to the appointment

• What is the diagnosis in plain language?
• Is the result final, or are further tests pending?
• Does the tissue result fit the clinical findings?
• What is the next step, and how soon should it happen?
• Is specialist review or a second opinion appropriate?

Keep the complete report rather than only a cropped photograph of the diagnosis line. Comments and addenda can contain information relevant to the next decision.

The report becomes most useful when it is explained in the context of your case and followed by an agreed plan.

Sources

[1] National Cancer Institute. Surgical Pathology Reports. https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis/pathology-reports-fact-sheet

[2] National Cancer Institute. Tumor Grade. https://www.cancer.gov/about-cancer/diagnosis-staging/diagnosis/tumor-grade

[3] National Cancer Institute. Cancer Staging. https://www.cancer.gov/about-cancer/diagnosis-staging/staging

[4] National Cancer Institute, SEER Training Modules. Pathological Exams. https://training.seer.cancer.gov/staging/sources/pathologic.html