© 200 8 Macmillan Publishers Limited. All rights reserved. Access to special care dentistry, part 3. Consent and capacity A. Dougall 1 and J. Fiske 2 VERIFIABLE CPD PAPER • The Mental Capacity Act 2005 sets out a legal framework on how to act where an adult is not considered to be competent to give informed consent. • Some conditions impact on the consent process and may lead to invalid consent if adjustments are not made to the way in which information is given and obtained. • Physical intervention may rarely be required in the dental setting and must be carried out within a legal and ethical framework. IN BRIEF PRACTICE This article considers what is meant by informed consent and the implications of the Mental Capacity Act in obtaining consent from vulnerable adults. It explores a number of conditions which impact on this task, namely dyslexia, literacy problems and learning disability. The focus on encouraging and facilitating autonomy and the use of the appropriate level of language in the consent giving process ensures that consent is valid. The use of appropriate methods to facilitate com- munication with individuals in order to be able to assess capacity and ensure that any treatment options that are chosen on their behalf are in their best interests are outlined. The use of physical intervention in special care dentistry in order to provide dental care safely for both the patient and the dental team is also considered. This article will consider what is meant by informed consent and the implica- tions of the Mental Capacity Act in obtaining consent. It will also explore the impact of a number of conditions on 1. Access 2. Communication 3. Consent 4. Education 5. Safety 6. Special care dentistry services for adolescents and young adults 7. Special care dentistry services for middle-aged people. Part 1 8. Special care dentistry services for middle-aged people. Part 2 9. Special care dentistry services for older people ACCESS TO SPECIAL CARE DENTISTRY 1 Lecturer and Consultant for Medically Compromised Patients, Division One/Special Care Dentistry, Dublin Dental School and Hospital, Lincoln Place, Dublin 2, Ire- land; 2* Chairperson of the Specialist Advisory Group in Special Care Dentistry/Senior Lecturer and Consultant in Special Care Dentistry, Department of Sedation and Special Care Dentistry, King’s College London Dental Institute, Floor 26, Guy’s Tower, London, SE1 9RT *Correspondence to: Dr Janice Fiske Email: Janice.Fiske@gstt.nhs.uk DOI: 10.1038/sj.bdj.2008.612 © British Dental Journal 2008; 205: 71-81 achieving consent, namely literacy, dyslexia and learning disability. It will focus on encouraging and facilitating autonomy in the consent giving process. INFORMED CONSENT Informed consent is required from all patients or, in the case of children, par- ents. Without it, dental treatment tech- nically and legally becomes assault. The model of informed consent comes from medical practice and is based on free- will, capacity and knowledge. Such knowledge needs to be sufficient for the person to come to a decision to refuse or agree to the proposed treatment. Hence, the patient, or parent/guardian, must understand the potential risks and ben- efits of the treatment and legally agree to accept those risks in writing. Further- more, the risks and possible side effects must be explained in easy to understand language, so that consent means that the consenting person understands what they are agreeing to and feels under no pressure to give a particular response. 1 Giving consent to a procedure does not necessarily waive the patient’s legal rights. The healthcare professional still has to follow through using the proper standard of care as the patient can still make a claim if the health provider func- tions incompetently. Informed consent can be complex to evaluate, because nei- ther expressions of consent, nor expres- sions of understanding of implications, necessarily mean that full adult consent was in fact given, or that full comprehen- sion of relevant issues has been internally digested. 1 Many times, consent is implied within the usual subtleties of commu- nication, rather than being explicitly negotiated verbally or in writing. Conse- quently, there is always a degree to which informed consent must be assumed or inferred, based upon observation, knowl- edge, or legal reliance. In medical or for- mal circumstances, explicit agreement by means of signature, which may usually be relied upon legally, is the norm. In the dental setting, implied consent is assumed if a patient sits in the dental chair and voluntarily opens their mouth for dental examination or treatment. It is prudent to obtain written consent for irreversible procedures, such as exodontia, and it is a requirement to obtain it for procedures being carried out with sedation or gen- eral anaesthesia. For many other proce- dures, implied and verbal consents are normal practice. Essentially, informed consent: 2 • Provides the patient with information about the procedure, including the risks, benefits and alternatives; also its nature and purpose BRITISH DENTAL JOURNAL VOLUME 205 NO. 2 JUL 26 2008 71