Patients could also feel under pressure to accept treatment if they are already in the dental chair or on the treatment couch, thus invalidating consent
Before the first lecture in our postgraduate certificate programme in non-surgical facial aesthetics, a topic of conversation came up regarding giving patients cooling off periods in dentistry. This was a concept I had not considered in a formal manner before. As a general dental practitioner, I was used to providing treatment that was advisable, often necessary and sometimes in a somewhat urgent situation, such as relief of pain or treatment of infection. I always considered I was using a ‘best practice’ approach (General Dental Council [GDC], 2013; General Medical Council [GMC], 2013). I used to give patients time to think about their treatment options and whether they were happy with our agreed treatment plan, but it was not something I would formally offer every patient with every item of treatment. This was very different to the clinical situation I would find myself in when providing non-surgical facial aesthetic treatments, which is typically a cosmetic choice to be made by the patient. I became aware of advice aimed at aesthetic practitioners regarding this aspect of consent. With regard to non-surgical facial aesthetic treatments, the Joint Council of Cosmetic Practitioners (JCCP) advise the following:
‘25. You must give the patient the time and information they need to reach a voluntary and informed decision about whether to go ahead with an intervention.
26. The amount of time patients need for reflection and the amount and type of information they will need depend on several factors’
(JCCP, 2019)
The subject of valid consent is a key aspect of medical and dental law and ethics, and the Department of Health and Social Care advise case law has proven that touching a patient without valid consent may constitute battery, and if there is subsequent harm there may be a negligence aspect to a case against the healthcare professional (Gov.uk, 2009). This positions consent within the UK's legal framework. Valid consent is that which is given voluntarily, is informed, and is given by a patient with the capacity to do so. My consideration is the specific aspect of offering a cooling off period within the process of obtaining valid consent, and whether the cooling off period that should be offered differs between non-surgical facial aesthetic patients and dental patients.
The GDC and Dental Defence Union (DDU) advise giving dental patients cooling off periods, though neither specify the length of time that should be given, both stating ‘a reasonable length of time’ (GDC, 2013) (DDU, 2018).
The GMC produced guidance for doctors who provide cosmetic interventions following the Keogh review into the regulation of cosmetic interventions, commissioned in response to the PIP breast implant scandal (Assets.publishing.service.gov.uk, 2013) (GMC, 2016). They advise a cooling off period should be offered during the consent process, but again do not specify a length of time. This advice applies to aesthetic non-surgical procedures and is supported by the Royal College of Surgeons (Professional Standards for Cosmetic Surgery, 2016), the JCCP and Cosmetic Practice Standards Authority (JCCP, 2019) and Care Quality Commission (CQC) (CQC, 2016).
So, it is clear with the above guidance in mind that valid consent is legally required, and for consent to be valid it is necessary that the patient should be given time to reflect on the information given during consultation, to fully consider the implications of the treatment, associated risks and to consider their expectations (GMC, 2008, 2016; GDC, 2013; JCCP, 2019). This is applicable in both dental and non-surgical aesthetic situations. There are often large volumes of information given (Nordfalk et al, 2019). Much of this information will be new to the patient and we cannot assume they will be able to process it all immediately, nor come to a decision as to the most suitable way to proceed (Graham and Brookey, 2008). Risks and benefits of the procedure need to be considered.
A patient could also feel under pressure to accept treatment if they are already in the dental chair or on the treatment couch, thus invalidating consent. Ultimately, we do not want patients to make a last-minute decision they could end up regretting. In 2011, Groupon offered and were forced to remove an offer on breast implant surgery with a strict time constraint for customers to take the deal (Sweney, 2011). This highlighted the issues of trivialising cosmetic procedures and putting pressure on patients to make quick decisions.
Cosmetic procedures, particularly non-surgical, have become ‘normalised’ and patients risk trivialising the risks associated with them so they must be given full information and the time to reflect on it, where the benefits of such procedures are purely cosmetic (Assets.publishing.service.gov.uk, 2013; Cook and Dwyer, 2016; Griffiths and Mullock, 2017).
A cooling off period will also allow the patient to consider their choice of practitioner. This was examined in two notable judgements. There were similar findings in Chester v Ashfar 2004 and Chappel v Hart 1998, evidencing that the patients in both cases, if given all warnings, would have had the operation at a different time and possibly with another surgeon (Scott, 1998; House of Lords, 2004).
In application to the practice of dentistry and non-surgical facial aesthetics, we can conclude that a cooling off period is a vital part of the process of obtaining valid consent, with the reasons discussed above, but that the length of time to be offered to a patient is open to interpretation. Analysis of the risk-benefit balance of every procedure needs to be assessed and will differ between individual patients and between procedures. I maintain that many dental clinical situations and decisions will be weighted differently to aesthetic procedures on the risk-benefit analysis; however, my attitude to this question has now altered and offering a cooling off period will become habitually ingrained into my consultation process, whether for dental or non-surgical aesthetic treatments.