The Infected Tooth, the Refused Referral, and the Dismissal Letter
A 68-year-old man with atrial fibrillation, a mechanical mitral valve, and stage 3 chronic kidney disease presents to Dr. Okafor's office with a nonrestorable #19, a buccal swelling, trismus, and a temperature of 38.4 degrees C. He takes apixaban. Dr. Okafor recommends urgent extraction by an oral surgeon after medical management of the anticoagulant, plus antibiotics and possible hospital admission. The patient refuses to stop apixaban, refuses the hospital, and demands that Dr. Okafor extract the tooth immediately. He refuses to sign the consent form, saying, 'Just do it; I don't need paperwork.' Dr. Okafor dismisses him from the practice and sends a letter: 'You are no longer a patient here. Do not return.' Two days later the patient's new dentist requests the records. The office manager asks whether the dismissal was proper and whether the records must be released.
1. What informed-consent and documentation issues does this scenario present?
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Informed consent in Michigan requires a discussion of the diagnosis, the nature of the proposed treatment, its risks and benefits, reasonable alternatives including referral and antibiotics alone, and the consequences of refusing. The patient must have capacity and must voluntarily agree; a signature is evidence, not a substitute for the conversation. Here the patient has a serious infection and is on an anticoagulant, so the bleeding risk and the need for medical management are material. Saying 'just do it' does not cure the absence of a documented discussion. Dr. Okafor should document the patient's refusal to sign, the specific risks explained, the alternatives offered, the patient's questions and responses, and the fact that the patient refused referral. A witnessed note or a second staff member's signature helps. He should also document the medical consultation and the plan for antibiotics. Proceeding with an urgent extraction without addressing the anticoagulant would be below the standard of care.
2. Was the dismissal proper under Michigan law? What steps are required to terminate the relationship without abandoning the patient?
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Probably not. A dentist may terminate the relationship, but not by abandoning a patient with an active infection. Michigan law and the Board's rules require reasonable notice, a written explanation, continuation of emergency care, and referrals so the patient is not left without access to care. The letter 'do not return' is abrupt and does not provide referrals or a transition period. The patient's refusal of the recommended treatment does not justify dismissal without alternative arrangements. The practice should send a proper termination letter: state the reason, offer to provide emergency care for a defined period such as 30 days, list nearby oral surgery or hospital resources, and offer to forward records. Document the patient's refusal and the referrals. If the patient is still febrile or has trismus, the dentist should arrange urgent evaluation rather than simply dismiss. Abandonment can support a Board complaint and a malpractice claim.
3. Must the practice release the records? What retention and access rules apply?
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Yes, subject to proper authorization and allowable fees. Michigan's Medical Records Access Act gives a patient the right to inspect and obtain copies of his or her records, and HIPAA requires access within 30 days. The practice may charge a reasonable, statutorily limited fee for copies, but it may not withhold records because of an unpaid balance or because the patient was dismissed. The patient's new dentist should send a signed authorization; the practice should release the records promptly and keep a copy of what was sent. Michigan's dental records rule requires retention for at least seven years from the last treatment date, and longer for minors. HIPAA requires six years for certain records. Because this patient has a serious medical condition and the dismissal is disputed, the practice should preserve the entire chart, including the consent discussion, the termination letter, and the records request.