10.4 Alternative Treatments and Shared Decisions When Several People Are Involved
Key Takeaways
ADA Code Section 1.A requires informing the patient of the proposed treatment and any reasonable alternatives.
CDA Code Section 9 obliges a dentist to tell the patient all available treatment options, even those outside an insurer's contracted services or providers.
Before arranging patient credit, a California Medi-Cal provider's written treatment plan must say whether Medi-Cal covers an alternative medically necessary service (B&P § 654.3(h)(3)).
California Civil Code § 56.1007 lets a dentist share relevant information with family involved in care when the patient agrees or does not object.
When a patient lacks capacity, the surrogate decides by the patient's known wishes or best interest, not by the surrogate's own preferences (Probate Code § 4714).
The duty to present alternatives (K2051)
| Source | What it requires |
|---|---|
| Cobbs v. Grant | Reasonable disclosure of the available choices for proposed therapy (legal standard) |
| ADA Section 1.A | Inform the patient of the proposed treatment "and any reasonable alternatives" |
| CDA Advisory Opinion 1.D.1 | Fully explain proposed treatment, reasonable alternatives, and the risks of not treating |
| CDA Section 9 | When care needs services beyond the dentist's scope, inform the patient of all available treatment options and refer. If the patient's condition needs care beyond the payer's contracted services or providers, inform the patient of all options so they can decide whether to stay in the plan or accept an outside referral at their own expense |
A reasonable alternative is one a competent dentist would consider acceptable for this patient. Typical sets include:
- Missing tooth: implant, fixed bridge, removable partial denture, or no replacement.
- Deep caries: direct restoration, indirect restoration, root canal plus crown, extraction, or, in some cases, arrest and monitoring.
- Periodontitis: nonsurgical therapy, surgery, referral to a periodontist, or palliative maintenance.
Insurance and program limits
Insurance pays for some options and not others. That limits payment, not what the dentist should disclose:
- Tell the patient about the clinically best option and the covered one, and let them choose (CDA Section 9).
- For Medi-Cal patients considering financing, the written treatment plan must say whether Medi-Cal would cover an alternative, medically necessary service, and that the patient may ask for Medi-Cal-covered services only (B&P § 654.3(h)(3)).
- Never describe a covered alternative as "not an option" just because you prefer the other.
Referral as an alternative
Referral to a specialist is itself an alternative the patient should hear about when the case is complex (ADA 2.B). Chapter 11 covers referral duties.
When several people are involved (K2052)
Decisions often include a parent and child, divorced parents, an adult child and an elderly parent, a spouse who pays, an interpreter, a physician whose clearance is needed, or an insurer. Methods that keep decisions ethical and lawful:
- Identify the decision-maker. An adult with capacity decides for themselves, even if a relative pays or disagrees. For minors and adults who lack capacity, identify the legal decision-maker (Chapter 8).
- Confirm permission before sharing. With an adult patient, get their agreement, or give them a chance to object, before discussing care with family (Civil Code § 56.1007). Don't assume the person in the waiting room is entitled to details.
- Address the patient directly, even when others speak for them. Ask the patient's preferences first, then invite others' questions.
- Give everyone the same information. Use the same written estimate and options sheet for all parties to avoid "he said, she said" disputes.
- Surface disagreements. If a daughter wants extractions and dentures for her father while he wants to keep his teeth, and he has capacity, his choice controls. If he lacks capacity, the surrogate must follow his known wishes or best interest (Probate Code § 4714), not their own convenience.
- Coordinate clinical input. When a physician's input is needed, for example about anticoagulation or bisphosphonates, obtain it and share it with the patient. The patient still chooses among options.
- Separate payment from choice. A family member who pays may choose what they are willing to pay for, but may not direct care for a competent adult. Offer the alternatives within the available budget.
- Document who took part, what options were discussed, and who made the final decision.
Tools that help shared decisions
- Option grids: a one-page table listing each option's steps, visits, longevity, risks, maintenance, and cost helps patients compare side by side.
- Models and images: showing the patient their own radiographs and intraoral photos, with an explanation, makes the findings concrete.
- Time to decide: for elective, costly, or irreversible care, offer a second visit instead of pressing for a decision the same day.
A good chart note for a shared decision reads: "Discussed implant, three-unit bridge, RPD, and no replacement with the patient and her daughter (the patient asked her daughter to attend). Reviewed costs and insurance coverage for each. The patient chose the RPD. Teach-back confirmed understanding."
Worked scenario
A 17-year-old needs replacement of a congenitally missing lateral incisor. His mother wants an implant now. His father, who shares joint legal custody, wants a resin-bonded bridge until growth is complete. The orthodontist advises waiting.
- Explain every option (implant after growth completes, a resin-bonded bridge, a removable interim appliance, or orthodontic space closure) with its risks, including placing an implant before growth is complete.
- Include the teen as the patient and invite his preferences.
- Legally, either parent may consent to routine care (Family Code § 3083). For an elective, irreversible choice with active disagreement, the ethical course is to postpone until the parents and patient agree, using a reversible interim option in the meantime.
- Document the discussion and the plan.
A patient's insurer covers a removable partial denture but not an implant. The dentist believes an implant is the best option. What is the ethical approach?
Explain both options with their benefits, risks, and costs, including which is covered, and let the patient decide
Present only the covered partial denture to avoid disappointing the patient
Present only the implant, because the dentist should recommend the best care
Bill the implant under the partial denture code so the patient receives benefits
An adult patient with capacity wants to keep his teeth with periodontal therapy. His adult son, who is paying, insists on full extractions and dentures. Whose decision controls?
The son's, because he is paying
The dentist's, because the family disagrees
The patient's, because an adult with capacity decides his own treatment, though the son may decide what he will pay for
Neither; the dentist must wait for a court order
Before discussing a patient's diagnosis with the spouse in the waiting room, what should the dentist do?
Share freely, because spouses are always personal representatives
Refuse to share anything with any family member under any circumstances
Share only billing information, without asking the patient
Ask the patient whether the spouse may be included, or give the patient a chance to object, before sharing information
Sections you finish are checked off in the contents.