Ethical issues in nursing home care: practice guidelines for difficult situations

Dental professionals encounter a number of challenging ethical and legal dilemmas when caring for nursing home residents. Questions may arise in determining a patient's capacity to make decisions, securing consent for treatment, choosing the most appropriate from among several treatment options, and when and how to use restraints. When securing consent for treatment, practitioners must consider both the patient's legal competence and his/her decision-making capacity, and adopt roles appropriate to the patient's circumstances. If legal competence has been retained but decision-making seems impaired, practitioners must involve others in the process of determining appropriate care. The capacity to consent to treatment can be assessed by questions designed to evaluate the patient's ability to understand relevant information, appreciate the situation and consequences, manipulate information rationally, and communicate choices. When faced with a choice of several treatment options and patient preferences are unclear or unknown, the principle of substituted judgment should be used to attempt to provide care in keeping with the patient's values. To maximize patient safety and dignity, ten guidelines are presented for the use of restraints to provide dental care for individuals with behavior problems.