In his second article on clinical guidance, Dr Gerard Panting considers when it is legitimate for doctors to follow their own judgement instead of a guideline
When it comes to consent, it may be possible to lay down hard and fast rules about what doctors should or should not do in given circumstances. However, it is impossible to legislate for all potential outcomes when dealing with clinical situations.
There may be absolute contraindications to using certain medication, such as allergy, the patient’s refusal to tolerate the side-effects of certain drugs, potential interaction with the patient’s current medication or the possibility of exacerbating existing conditions.
In all these circumstances it is the doctor’s job to exercise judgement and inform the patient about the alternatives, the pros and cons of each and, all things considered, advise him or her on the best option.
However, despite the difficulty in covering all the angles, clinical guidelines abound and they are often very lengthy.
A choice of guidance
The Scottish Intercollegiate Guidelines Network (SIGN) publishes guidelines on the treatment and management of cancer, CHD and stroke, child health, dentistry, diabetes, ENT, mental health, obstetrics and gynaecology, orthopaedics, vascular disease, respiratory medicine, sexually transmitted disease, surgery and other miscellaneous areas.
Under the respiratory medicine section, the British Guideline on the Management of Asthma, jointly produced by SIGN and The British Thoracic Society,1 can be found. This document runs to 82 pages with references, and includes a number of annexes on, for example, the management of acute severe asthma in adults in general practice.
Annex 1 helps differentiate between moderate asthma, acute severe asthma and life-threatening asthma, and under each category sets out the preferred management, including the immediate treatment.
For example, patients with moderate asthma whose PEF is greater than 50% of best or predicted and whose speech is normal, with respiration less than 25 breaths/minute and pulse less than 110 beats/minute, are recommended to be treated at home or in the surgery and their response to treatment assessed.
The recommended treatment is a high dose beta2 agonist bronchodilator, ideally delivered by oxygen-driven nebuliser, or by spacer or air-driven nebuliser.
If PEF is greater than 50-75% of predicted or best, the guideline recommends prednisolone 40-50 mg with the usual treatment continued or stepped up.
If response to the first nebulised treatment is good, the recommendation is to maintain or step up the usual treatment and continue prednisolone.
Admission to hospital in this category is recommended if there are lifethreatening features, previous near-fatal asthma or features of acute severe asthma are present after the initial treatment.
Doctors should have a lower threshold for admission if the attack occurs in the afternoon or evening, if there have been recent nocturnal symptoms, hospital admission, previous severe attacks or if the patient is unable to assess his or her own condition or there are concerns over social circumstances.
Equally comprehensive guidance is set out for the other two categories – acute severe asthma and life-threatening asthma.
Alternative asthma guidance
PRODIGY also issues guidance on the treatment of asthma which includes a section on the management of acute asthma.2
The categorisation of moderate, acute severe and life-threatening asthma according to PEF is the same as the SIGN/BTS guideline, but the PRODIGY guidance combines management recommendations for adults and older children, whereas the SIGN/BTS guideline considers adults and children separately.
Guidance on diabetes
Some guidelines are more complicated still. Take, for example, the NICE guideline for type 2 diabetes on management of blood glucose.
This guideline was developed by the Royal College of General Practitioners’ Effective Clinical Practice Programme based at the University of Sheffield, in collaboration with Diabetes UK, the Royal College of Physicians and the Royal College of Nursing.3
The guideline runs to 235 pages and is predictably comprehensive, but it is only one of five interrelated guidelines that deal with different aspects of type 2 diabetes. The others cover foot care, retinopathy, renal care and lipid and blood pressure management.
The entire series of guidelines is referred to as the national guideline, the aim of which is to assist healthcare professionals in their management of patients with type 2 diabetes in primary and secondary care. The guideline is evidence based where appropriate evidence is available, but otherwise relies on consensus methods.
The principal recommendations are related to measurement, targets, self-monitoring, lifestyle intervention, patient education, general therapy issues and the use of drugs.
For example, it is recommended that individuals with type 2 diabetes should have ongoing structured evaluation of microvascular and cardiovascular risk and the development of complications. There are specific recommendations about the measurement of HbA1c, depending upon such factors as the level of control and change in therapy.
When it comes to lifestyle interventions, the guideline states that weight loss and increased physical activity should be encouraged in the overweight and obese and that healthcare professionals should work with individuals to find approaches to lifestyle change that are likely to be adhered to and give the best chance of success. Having said that, the guideline then concedes that the evidence for effectiveness of lifestyle interventions in type 2 diabetes is limited.
Can you justify an alternative approach?
These are just two examples of guidelines addressing particular, quite discrete, issues that GPs face, along with the full gamut of acute and chronic illnesses in children and adults. There is ready access to vast amounts of information from numerous sources. Guidance from the major institutions such as SIGN, NICE and PRODIGY is well researched, evidence-based and undoubtedly contains excellent advice.
In the event of a complaint, claim or disciplinary action, it is easy for those examining the patient’s management to compare the record of care provided against the guidance for the ailment under scrutiny including, for example, the lifestyle issues raised in the NICE guidelines on type 2 diabetes.
If the guideline has not been adhered to, the question for the doctor will be how do you justify doing something different? Unless that question can be answered by reference to some other authoritative source, the defence is at risk.
The NICE guidelines open the door to this argument by explicitly stating that it is only one type of healthcare information that healthcare professionals may use when making decisions about patient care, and that there is an assumption that healthcare professionals using it will also employ their clinical knowledge and judgement in making decisions about caring for individual patients.
The guideline explicitly states:
"It may not always be appropriate to apply either specific recommendations or the general messages in this document to each individual or in every circumstance. The availability of resources may also influence decisions about patient care, including the adoption of recommendations.”
It goes on to say:
"For pharmacological interventions, licensing issues and precautions/contraindications should be considered. Information on precautions and indications for particular pharmacological interventions is available through the ABPI Compendium, summaries of product characteristics (www.emc.vhn.net).”
- Scottish Intercollegiate Guidelines Network and the British Thoracic Society. British Guideline on the Management of Asthma: a national clinical guideline. Thorax 2003;58(Suppl 1). www.sign.ac.uk
- PRODIGY Guidance Asthma. London: DoH, 2001. www.prodigy.nhs.uk
- Royal College of General Practitioners. Clinical Guidelines for Type 2 Diabetes – Management of blood glucose. London: NICE, 2002. www.nice.org.uk
- Royal Pharmaceutical Society: www.rpsgb.org.uk