Blog Post

The 5 Essential Aspects of Informed Consent For Dental Practitioners

Jordan Uditsky • June 28, 2024

All dentists, on an intellectual level at least, understand the moral, ethical, and legal necessity of obtaining informed consent from a patient before embarking on a course of treatment. Unfortunately, there is often a disconnect between principle and practice when it comes to informed consent.

 

Part of the problem lay in a lack of consistency or the failure to establish and follow clear protocols when discussing a proposed procedure and securing a patient’s assent. Conversely and somewhat contradictorily, a failure to tailor informed consent efforts to a patient’s particular needs or limitations can lead to miscommunication and misunderstandings that leave the patient neither informed nor in a position to effectively consent.

 

However, perhaps the biggest stumbling block for dental practitioners regarding informed consent is the term itself. It implies that there are only two aspects to this fundamental duty: informing the patient, and obtaining their consent. This is a gross oversimplification of what dentists must do to both satisfy their obligations and insulate themselves from malpractice claims based on a lack of informed consent.

 

The reality is that informed consent is a multi-step process that involves conversation and documentation, education and evaluation, the patient and most of all, patience. Specifically, informed consent encompasses five separate and equally important components:

 

  • Disclosure
  • Comprehension
  • Voluntariness
  • Competence
  • Consent

 

Disclosure

 

The first step in informed consent is disclosure, where the dental professional provides the patient with all relevant information about the proposed treatment. This information should be comprehensive and include the nature of the procedure, its purpose, the expected benefits, potential risks, and possible complications. Additionally, the dentist should discuss alternative treatment options – including no treatment whatsoever – as well as the likely consequences of each course of action.

 

For example, if a patient needs a root canal, the dentist should explain what the procedure involves, why they believe it is necessary and appropriate, the expected outcome, and the risks, such as infection or failure to remedy the underlying issue. The dentist should then present root canal alternatives, such as extraction or antibiotic treatment, along with their respective pros and cons.

 

Comprehension

 

The most detailed and thorough explanation of a treatment, alternatives, and potential outcomes is as good as spouting incomprehensible jibberish if the patient does not understand what the dentist is telling them. And that lack of understanding can negate the existence of informed consent.

 

Comprehension means that the patient understands the information well enough to make an informed decision. This can be challenging, as dental procedures often involve complex medical terminology and concepts that may be unfamiliar to patients.

 

It is a challenge that we in the legal profession are familiar with. We frequently must discuss complicated or opaque legal issues with our clients. Doing so in “legalese” or using gratuitous Latin phrases that sound impressive but mean nothing to most people does little to inform our clients or make them comfortable with their representation. That is why I aspire to “accessible expertise” when speaking with clients about their matters.

 

For dentists, “accessible expertise” means using plain language and/or visual aids and repeating information as necessary. They should also encourage questions and provide clear, direct answers. Assessing comprehension might involve asking the patient to repeat the information in their own words or to explain their understanding of the treatment plan and its implications.

 

Special attention must also be paid to the language capabilities of the patient. If a patient has limited English language proficiency, the dentist must take steps to ensure that they receive accurate oral or written translations of the information being provided.

 

Voluntariness

 

Informed consent must be given voluntarily, free from coercion, manipulation, or undue influence. This means the patient’s decision to accept or decline treatment must be made independently, without pressure from the dentist, staff, or family members. Voluntariness is a critical aspect of respecting patient autonomy and ensuring that their choices reflect their own values and preferences.

 

For instance, a dentist should avoid using scare tactics to persuade a patient to undergo a particular procedure. Instead, they should provide balanced information and support the patient in making a decision that aligns with their own health goals and personal circumstances.

 

Competence

 

Competence refers to the patient’s ability to understand the information provided and make a rational decision based on that understanding. This element is particularly important when dealing with vulnerable populations, such as minors, elderly patients, or those with cognitive impairments. Competence is assessed by evaluating the patient’s ability to comprehend the nature and consequences of the proposed treatment and reason and deliberate about their choices.

 

For patients who are deemed incompetent, such as young children or individuals with severe cognitive impairments, the dentist must obtain informed consent from a legally authorized representative, such as a parent, guardian, or legal custodian. In such cases, the representative’s decision should reflect the best interests of the patient.

 

Consent

 

The final step in the informed consent journey is obtaining the actual consent from the patient. This consent can be given verbally, in writing, or through implied actions, depending on the nature of the procedure and the circumstances. Written consent is typically required for more invasive or risky procedures, while verbal or implied consent might suffice for routine or minor treatments.

 

When obtaining written consent, dentists should use a form that is clear, comprehensive, and devoid of unnecessary complexity. It should summarize all the information provided and include a statement confirming that the patient has had the opportunity to ask questions and that their questions have been answered to their satisfaction. The patient (or their representative) should sign and date the form, and the dentist should also sign it as a witness to the consent process.

 

Practical Implementation Of Informed Consent Protocols

 

Satisfying all of the conditions necessary to ensure informed consent, as essential as it is, can tax a dentist’s schedule and patience. To make this process as efficient as it is effective, consider adopting some or all of the following practices and protocols:

 

  • Have Educational Materials At The Ready: Maintain a library of brochures, pamphlets, or links to videos that explain common dental procedures, their benefits, risks, and alternatives. These materials can serve as a foundation for further discussion and help reinforce and increase comprehension of verbal explanations.
  • Interactive Communication: Engage in two-way communication with patients. Encourage them to ask questions and express their concerns. Use open-ended questions to gauge their understanding and clarify any misconceptions.
  • Maintain Meticulous Documentation: Maintain thorough records of the informed consent process. Document the information provided, the patient’s questions and responses, and the consent given. This documentation is essential for legal protection and continuity of care.
  • Use a Tailored Approach: Adapt the informed consent process to the individual needs of each patient. Consider factors such as age, language proficiency, cultural background, and cognitive abilities. Use interpreters or translation services when necessary to ensure comprehension.
  • Train and Educate Staff: Ensure that all dental staff are trained in the principles and practices of informed consent. Regular training sessions can help staff stay updated on best practices and legal requirements.
  • Allocate Sufficient Time: Schedule adequate time for patient consultations to ensure that informed consent discussions are not rushed.

 

If you have questions or concerns about informed consent and would like to discuss them (in clear, plain language), please contact Jordan Uditsky at Grogan, Hesse & Uditsky, P.C. We focus a substantial part of our practice on providing exceptional legal services for dentists and dental practices, as well as orthodontists, periodontists, endodontists, pediatric dentists, and oral surgeons. We bring unique insights and deep commitment to protecting the interests of dental professionals and their practices and welcome the opportunity to work with you.

 

Jordan Uditsky, an accomplished businessman and seasoned attorney, combines his experience as a legal counselor and successful entrepreneur to advise dentists and other business owners in the Chicago area. Jordan grew up in a dental family, with his father, grandfather, and sister each owning their own dental practices, and this blend of legal, business, and personal experience provides Jordan with unique insight into his clients’ needs, concerns, and goals. 

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There are many reasons why a dentist may want to sell their practice - retirement, relocation, a desire to step back from the responsibilities of ownership, or an offer too good to refuse. Whatever the motivation, one goal is always the same: maximizing the financial benefits of the transaction. Those benefits – today and far into the future - depend on many factors, but few have as much impact as how the Internal Revenue Service treats the gains you realize from the sale of your practice. How you structure the sale, the nature of the entity you’re selling, the specific assets involved in the sale, and any special considerations like earnouts or deferred payments will determine how much winds up in your pocket vs. how much you’ll be sending to Uncle Sam. Here are some fundamental tax considerations to understand if you are looking to sell your dental practice in 2025: What Type of Entity Are You Selling? As noted in the title of this post, how you structure the sale of your practice is as important as the nature and value of the practice you’re selling. However, the entity structure you chose when you formed your practice still has a significant impact on how you’ll be taxed when you walk away. If you organized your practice as a C corporation, all proceeds from the sale of the corporation’s assets will be taxed on the corporate level. This means these proceeds may be taxed twice: once at the corporate level and again when you distribute those monies to yourself. If, however, your practice is a regular partnership (such as a limited liability company or a limited liability partnership) or an S Corporation, you may pay tax on both ordinary and/or capital gains income on your personal income tax return, depending on the structure of the sale. Capital Gains v. Ordinary Income If you make a profit when you sell an asset, you make a capital gain. But not all such gains are subject to capital gains tax. Sometimes, the IRS taxes profits as ordinary income at the taxpayer’s individual rate. Since the current individual rate is around 37 percent, sellers would rather pay the currently lower capital gains rate (the maximum of which is 20%) to the extent possible. Notably, the capital gains tax only applies to profits on assets held for more than 12 months. Unless a dental practice goes from zero to 60 or acquisition to sale in less than a year, which is rarely the case, the sale will implicate the capital gains tax. Accordingly, structuring your deal to maximize the amounts taxed as capital gains vs. ordinary income is one of the most significant considerations in minimizing your tax liabilities. This depends, to a large degree, on how you allocate and treat the assets you are selling. Asset Allocation Most sales of dental practices are structured as asset sales, meaning the purchaser is acquiring specific assets of the practice rather than its stock. Dental practices are comprised of several different kinds of assets—equipment, supplies, real property, goodwill—and separate accounting and tax rules apply to each type of asset. Tangible Assets : These include equipment, furniture, office and medical supplies, and other physical assets. Typically, tangible assets are treated as depreciated property, so gains on the sale of these assets are usually subject to recapture rules, where depreciation deductions taken in prior years may be "recaptured" and taxed as ordinary income. Accounts Receivable : Any outstanding accounts receivable can be part of the sale. For cash-basis taxpayers (the most common for dental practices), accounts receivable are taxed as ordinary income since they represent payments for services already rendered but not yet received. Goodwill and Intangible Assets : The goodwill of your dental practice, which includes the value of your brand, client base, and reputation, is generally taxed at the capital gains rate. This is advantageous because the long-term capital gains rate is often lower than the ordinary income rate. Other intangible assets may also qualify for capital gains treatment, depending on how they are classified. If you have taken depreciation deductions on your practice’s equipment or real property, the IRS requires that depreciation be "recaptured" and taxed as ordinary income up to the amount of prior depreciation. While this applies to equipment and other depreciable assets, goodwill, and certain intangibles do not face depreciation recapture. Earnouts: Deferred Purchase Price Payment or Compensation? From the IRS’ perspective, how and when you receive payment for the sale of your practice will determine its tax treatment. If those payments come in the form of earnouts, the key issue is whether the IRS views each payment as a deferred purchase price payment or the payment of compensation. Earnout provisions are often included in practice sale agreements and provide for contingent additional payments from the buyer to the seller upon the practice meeting specified financial targets or other milestones in the future. Earnout payments are generally treated as part of a deferred purchase price so long as the seller is not performing services for the buyer and the practice after the consummation of the sale. The earnout payments may be treated as compensation income if the seller provides services for the buyer or target company after the acquisition or, in some cases, if the purchase agreement includes a non-competition provision. If the IRS treats earnout payments as deferred purchase price payments (for a non-corporate seller), they will be capital gains, which, as noted, are taxed at a much lower rate than ordinary income. However, if the IRS determines that the earnout constitutes compensation to the seller, the IRS will consider it ordinary income that can be subject to tax rates as high as 37 percent, along with employment taxes (such as Social Security and Medicare taxes). Accordingly, the sale agreement should specifically refer to earnout payments as part of the purchase price to support the treatment of such payments as capital gains rather than ordinary income. However, what you call the payments in the documentation is far from determinative, as the IRS will look beyond the language of the agreement to consider several substantive factors when deciding how earnout payments should be classified. This is where careful structuring and documentation can play an outcome-determinative role in how these substantial sums will be treated for tax purposes. You put a lot into your dental practice over the years. How much you take out and whether your sale will reap the benefits you anticipate depends on how well your professional team of attorneys, accounting professionals, and financial advisors do their jobs when crafting your transaction. That is one of many reasons why you should consult with an experienced dental practice sale and acquisition attorney to discuss and understand your options. We Focus on You So You Can Focus on Your Patients At Grogan Hesse & Uditsky, P.C., we focus a substantial part of our practice on providing exceptional legal services for dentists and dental practices, as well as orthodontists, periodontists, endodontists, pediatric dentists, and oral surgeons. We bring unique insights and deep commitment to protecting the interests of dental professionals and their practices and welcome the opportunity to work with you. Please call us at (630) 833-5533 or contact us online to arrange for your free initial consultation. Jordan Uditsky, an accomplished businessman and seasoned attorney, combines his experience as a legal counselor and successful entrepreneur to advise dentists and other business owners in the Chicago area. Jordan grew up in a dental family, with his father, grandfather, and sister each owning their own dental practices. This blend of legal, business, and personal experience provides Jordan with unique insight into his clients’ needs, concerns, and goals.
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