Case study: Informed consent

3 september 2025 background an eight year australian terrier was taken to a veterinarian by its owner for a routine vaccination consult the dog received the chill protocol before the visit, which is a plan of prescribed medications to reduce stress and mildly sedate a limited physical examination was performed because the dog was difficult to handle and eventually needed to be muzzled the client mentioned that the dog had bad breath, and believed they had an infected incisor the veterinarian recommended booking a dental check up, which took place the following week before the check up, the dog’s owner administered 0 45ml of medatate the dog was muzzled and induced with alfaxan, and the veterinarian recommended a blood test, which showed a mild elevation of alkaline phosphatase and alanine transaminase the veterinarian examined the dog’s mouth and found it had advanced dental disease around all incisors and molars, as well as bone loss and abscesses the veterinarian contacted the owner to advise them that several teeth would need to be extracted, and that radiographs were required to determine if two additional teeth also required extraction verbal consent was given by the client results from the radiographs showed that both additional teeth had furcation and abscesses a local anaesthetic, bomacaine, was administered to the dog’s upper and lower jaw in total, 19 teeth were extracted through gum flapping, bone burring, and using dental elevators the gums were sutured, and clinical records noted that two teeth, 310 and 311, were missing metacam, clavulox, juroclav and paracetamol were dispensed for the client to give the dog at home later, the client requested copies of the dental radiographs from the veterinary clinic they said that the x rays they received for the two teeth confirmed their opinion that only three teeth needed removal, rather than 19 the complaint the client made a complaint to the vet council saying that they were not adequately informed that 19 teeth would have to be extracted they also complained that the veterinarian did not discuss that more than three teeth would need to be removed, and that the veterinarian did not give them an option to withdraw from the diagnostic investigations, or the proposed plan, so they could seek a second opinion how it was managed the code of professional conduct requires veterinarians to obtain a client's informed consent before proceeding with a proposed treatment or course of action this process involves the veterinarian providing information in a way that is understandable and allows the client to choose to follow the recommendations or not the consent process needs to be adequately documented in situations where either the condition of the animal or the treatment options change, further client consent is required this should involve a discussion between the veterinarian and client about the spectrum of care, which considers the client’s perspective and resources this discussion would allow the veterinarian to confirm both their own and the clients’ assumptions and understanding of the next steps the cac felt that the diagnostic recommendations and diagnostic pathway were appropriate the veterinarian provided a standard of care which would reasonably be expected of a competent veterinarian in their position in the cac's experience, it is not unusual for a dog of this age, breed, and clinical history to require the extraction of 19 teeth the cac identified some clear learnings for the profession from this case the cac noted that ideally, clients should be informed of the specific number of teeth that need to be extracted the standard practice for veterinarians in these situations would be to provide the client with a range of the number of teeth requiring extraction the cac also noted that there were no entries in the clinical records that documented the details of the telephone discussion regarding the number of teeth needing to be extracted other than a note that the dog’s owner was phoned and advised of the new estimate in the cac’s view, the discussion and new estimate should have been better documented in the clinical records the cac also commented that a veterinarian could consider emailing or texting the client to confirm what was discussed in the phone call the issues raised in the complaint stem from a lack of communication the veterinarian should have clearly communicated the specific number of teeth to be extracted or a provided a range of the number of teeth however, this particular case did not reach the threshold for further action under the veterinarians act in their response to the cac, the veterinarian shared insights into how this case could have been approached differently, and listed clinical improvements that have been made this included taking mouth photographs, re issuing consent forms with new estimates, full mouth x rays on dogs with grade 2 3 dentals and all cat dentals, and estimates being given for all dental patients the cac was satisfied that these reflections, and the steps that have been taken, mitigate the potential for this issue to happen again learnings for the profession in its finding, the cac reminded the profession that informed consent is an ongoing process veterinarians are responsible for ensuring their clients have, and understand, all of the relevant information needed to make an informed choice the veterinarian is also required to adequately document informed consent, including if verbal consent is given usually, this would be documented in clinical records other approaches include sending an email or text message to the client, or having them electronically sign an updated consent form regardless of the approach used to document the verbal consent, it is important that clients are given information about proposed treatment in a way that they can understand for more information about the vet council’s complaints process, click here