Departing from guidelines

KEEPING up with the latest clinical guidelines can prove a challenge for even the most diligent of healthcare professionals, with new advice released on what can often seem like a daily basis.

Bodies such as the National Institute for Health and Clinical Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) are tasked with making recommendations based on the best available evidence of the most effective care.

Practitioners are then expected to take this guidance into account when making clinical decisions.

But is it ever appropriate for a doctor or dentist to exercise their clinical judgement and choose to depart from this guidance?

MDDUS has handled a number of calls on this topic and advises doctors and dentists to exercise caution before departing from guidance, particularly where practice would depart significantly from agreed guidance.

It is important to make clear that clinical guidelines are not legally binding and are designed to inform clinical practice rather than dictate it. NICE says its guidance is designed to help healthcare professionals ensure the care they provide “is of the best possible quality and offers the best value for money.”

NICE goes on to say that its guidance “does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian/carer.”

One example of a situation where a doctor could justifiably depart from accepted guidelines would be where a patient is likely to suffer a serious adverse reaction to a recommended drug. In these circumstances, it would be appropriate to prescribe an alternative.

But NICE cautions: “Any health professional who is considering departing from NICE guidance may wish to discuss the issue fully with the patient and/or their guardian or carers and should keep a record of his/her reasons for taking such a decision in the patient's notes.”

Practitioners have a professional duty to be aware of relevant guidelines in their field of practice. There should be a logical basis for any decision to depart from guidelines and practitioners should be prepared to justify their chosen course of action. In some cases, it may be advisable to seek the advice of a specialist.

The matter should always be discussed in full with the patient, being sure to make them aware if your proposed treatment differs from standard guidance. You should explain the reasons behind your decision and why you believe the proposed course of treatment is in their best interests.

Defending any claim of negligence related to a departure from guidelines will rest on the quality of the consultations and records and will be dependent on a responsible independent expert’s support of the chosen course of action.

ACTION: Carefully consider any decision to depart from clinical guidelines and be prepared to justify your actions. Always discuss any decision with the patient and record fully your reasons for departing from the guidelines.