Legal consent for treatment
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DENTAL practitioners in this country invariably assume that they are obligated to treat every patient who seeks their services. This is because they generally do not know that some patients are legally incapable of giving consent to therapy. More specifically, it is unethical, professionally prohibitive and immoral to treat anyone whose mental state cannot accommodate certain basic elements involving his or her treatment. The person may be too young to be intellectually competent to meet the criteria for independent consent, or may be mentally disabled. In such cases, they should be accompanied by an adult who would make relevant treatment decisions.

Before beginning dental therapy the patient must: (1) possess the ability to understand the specific procedure being contemplated and the risks and benefits associated with the treatment; (2) can retain an understanding of the overall proposed procedure, being able to describe the therapy and its associated significant risks and benefits
( in lay terms); (3) evidence the ability to choose( demonstrate a preference) between alternative therapies ( including the refusal of treatment); (4) choose a therapy based on rational reasons, and the expected outcome of that choice must be percipient( “right” and “responsible”); and (5) be able to appreciate and execute correctly post-procedural precautions.

There are numerous situations in which an apparently “normal” looking patient should be denied treatment based on his mental state. Dementia, depression and delirium are three common conditions encountered that may interfere with obtaining informed consent.

According to the population census, there were 28,342 Guyanese over the age of 65 years in 1992. These people are the most susceptible to mental illness, especially dementia. The essential features are a global progressive deterioration of intellectual functioning and changes in mood and behaviour to such an extent that they interfere with social or occupational functioning, and the patient’s ability and willingness to perform appropriate oral hygiene. During the early phase of the disease, patients frequently go to the physician with a confusing medical history consisting of multiple complaints of physical problems and psychiatric symptoms that do not conform to a specific disease process.

Delirium may mimic or be superimposed on dementia. Many conditions can cause delirium. Toxicity due to drugs, alcohol, and narcotics are probably the most reversible causes. Symptoms include clouded consciousness, often associated with delusions, illusions and vivid hallucinations. Other common causes are cardiovascular disease, liver disease, and kidney disease. Fatty plaques may break off from the walls of large blood vessels and partially occlude blood perfusion to the brain. With kidney and liver disease, there is an impaired ability to convert ammonia to urea and this build-up may result in encephalopathy(delirium/dementia).

Depression, like delirium, may mimic and/or coexist with dementia. Recent investigations suggest that a third of the patients with dementia have concurrent depression. Symptoms include sleep disturbances, fatigue, memory loss and retarded muscular reflexes.

Many mental diseases such as Alzheimer’s go unrecognised and untreated in this country. Once someone does not walk the streets nude or extremely unkempt, or behave very irrationally and violent, he or she is accepted by our society as normal. Professionals of the healing arts (dentistry and medicine) need to dedicate some time to initially psycho-analyse their patients before treating them. Failure to do so may result in more harm for such patients.

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