Rammya Mathew: Three questions I ask before using a guideline
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l358 (Published 28 January 2019) Cite this as: BMJ 2019;364:l358
All rapid responses
We welcome Rammya Mathew’s sensible guidance on how to resist ‘the slow creep of guideline centred decision making’, but feel that the questions & answers should be shared with the patient.
If on the face of it, there is a guideline for ‘my condition’ I should know why it doesn’t apply to me. If there is a guideline for ‘my condition’ but following it would not be pragmatic or feasible I should know why. Tell me these things then I may be able to help you better with the answer to your last question.
Competing interests: No competing interests
Rammya Mathew suggests some sensible questions that can help doctors avoid guideline-centred decision making. We share Dr Mathew’s concern that clinical guidelines should not over-rule clinical reasoning and what matters to the patient, and that doctors can, and indeed should, give themselves the freedom to step away from a guideline and do what they and the patient agree is right for them. Guidelines are intended to help with this. Guidelines should fit the patient, not the other way round.
NICE supports shared decision making through its guidance. All NICE guidelines begin with the following introductory text that seeks to ensure patient-centred application of the guideline: ‘The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.’
NICE is committed to the principles of shared decision making, and is in the early stages of developing a guideline on this topic. Applications for membership of the guideline committee are open until 15 February 2019, and we encourage interested readers to apply to SDMguideline@nice.nhs.uk
Competing interests: No competing interests
Mathew[1] recommends a three-point test to help decide if a clinical guideline is appropriate for the patient sat before you:
• Does the guideline apply to my patient?
• Is the advice pragmatic?
• Is it what my patient wants?
That the first question should always be asked goes without saying. One doesn’t whimsically apply NG84 (Sore throat (acute): antimicrobial prescribing)[2] to the patient with cellulitis. But how does one decide if a clinical guideline is pragmatic? Would an endocrinologist be best placed to make a judgment call on the practicality of CG167 (Myocardial infarction with ST-segment elevation: acute management)[3]? And are patients’ wants always their needs?
Clinical guidelines attempt to package the sum total of current knowledge, filling gaps with expert opinion, into conveniently practicable bite-size recommendations, hopefully tempered by an empathetic understanding of the complexities of real-world practice. They are intended to enhance clinical and cost effectiveness and quality of care, decrease variations in practice, and reduce the risk of preventable errors and adverse effects by making sense of sometimes imperfect, disorderly and, not infrequently, conflicting evidence.
While clinical practice need not be inflexibly bound by diktats, before dismissing the applicability of a relevant guideline one should consider the most important question of all: Why must my patient be the exception to the norm?
References
1 Mathew R. Three questions I ask before using a guideline. BMJ 2019;:l358. doi:10.1136/bmj.l358
2 Sore throat (acute): antimicrobial prescribing. NICE guideline [NG84]. London: : National Institute for Health and Care Excellence 2018. https://www.nice.org.uk/guidance/ng84
3 Myocardial infarction with ST-segment elevation: acute management. Clinical guideline [CG167]. London: National Institute for Health and Care Excellence 2013. https://www.nice.org.uk/guidance/cg167
Competing interests: No competing interests
Nice and pertinent article, but it misses one crucial&mandatory question. with clear answers.
This mandatory question shall be added to every single nowadays guidelines;
What are the Conflicts of Interests involved with each of the panel members
responsible&involved in writing that Clinical Guideline?
Competing interests: No competing interests
I completely agree with the text, but unfortunately I think there is a fourth, nasty question to be asked, especially when guidelines suggest super-expensive treatments that are so common in today oncology: are the authors of these guidelines free from conflicts of interest?
Competing interests: No competing interests
There is indeed danger when guidelines are translated into inflexible rules. This may be simpler but ignores the variability of clinical situations where treatment and management must be geared to the individual patient. There may then be good reasons for departing from a guideline but it is sensible to record the reason in the case notes.
A recommendation to avoid blood transfusion at night was made by the Serious Hazards of Transfusion haemovigilance scheme in their Annual Report for 2001/2 '‘transfusion should only take place at night if clinically essential’ (https://www.shotuk.org/shot-reports/).. This was because staffing tended to be less at night, and more errors were recorded. However this recommendation was misinterpreted in some hospitals as a rule never to transfuse at night. This resulted in clinically unacceptable delay in some cases of urgent and necessary transfusion contributing to death (Annual SHOT Report 2013 ( https://www.shotuk.org/shot-reports/)).
Another example was a case reported as an inappropriate treatment. The decision was to reverse warfarin therapy before urgent surgery when the INR was below the guideline cut-off for treatment. The treating doctor gave a good explanation why this was necessary and reasonable treatment in the best interests of that particular patient at that time.
Guidelines should never be used as an excuse not to think. There is a world of difference between a standard operating procedure in the laboratory (for example for coagulation tests) where it is essential to follow the steps exactly in order to obtain the right result, and a guideline which is so written that we may know the best evidence and use that in planning the management of individual (and variable) patients.
The British Society for Haematology guidelines are regularly reviewed and updated as necessary. This may result in changes to the guidance as new evidence is reported. It is important to recognise when 'guidelines' are not sufficiently evidence-based, then depending more on 'expert opinion'. Their value then may be to demonstrate where more evidence must be gathered. This was the main fruit of the 1996 guidelines for immune thrombocytopenic purpura. The recommendations for children were controversial demonstrating a transatlantic difference of opinion due to the paucity of evidence. George, J. N., S. H. Woolf, et al. (1996). "Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology." Blood 88(1): 3-40.
Competing interests: No competing interests
Re: Rammya Mathew: Three questions I ask before using a guideline
Whilst fully supporting patient choice, it is important to review the strategy outlined in “Three questions I ask before using a guideline” [1] for deciding when to ‘walk away’ from guideline recommendations. Of the three factors the author considers, surely nobody would disagree with considering how applicable guidelines are to their patient. Since the strongest recommendations in guidelines are based on high quality evidence from trial populations that may not be fully represent the population with a condition, they may not be generalisable to all. Guidelines should acknowledge this and include alternative recommendations where possible [2]; clinicians should consider these limitations when providing advice. Secondly, considering whether the advice is pragmatic clearly makes sense and the example used of mindlessly pursuing guideline-recommended investigations is one that resonates with us all.
However, it is the third of the trinity of considerations that warrants exploration: “Is it what my patient wants?”. All people with capacity have the right to refuse treatment, and patient choice is an essential part of good decision-making, but we must balance personal choice with our obligation to use our limited resources most effectively. Considered within the four pillars of medical ethics [3] one would hope guidelines have addressed already the question of beneficence vs non-maleficence, but it must be the duty of clinicians to consider this also, and it is important for all to engage in guideline writing or consultation processes. The crux is justice vs autonomy; the balance of personal choice against wisest resource use is at the heart of clinical decision-making.
Using examples from our field of sexual health and HIV we can apply “is this what my patient wants” to different scenarios. Guideline recommended first-line syphilis treatment, two large volume intramuscular injections, is not be the first choice of many yet, as the most effective treatment, is the one we recommend – here beneficence outweighs autonomy. Current HIV treatment, usually a combination of three drugs, requires lifelong daily pills; some combinations are available as single tablets. Single tablets are popular, but when they are priced significantly higher than generic alternatives, requiring 2 or more pills, our experience is that most patients are happy to support saving NHS finances with a slightly less convenient option.
Conversely, HIV care in England must follow NHS England commissioning policies that may differ from specialty clinical guidelines; offering fair access to new treatments on ever restricted budgets is a a difficult balance. This, as in many medical situations, requires patients to trust clinicians are making clinically appropriate decisions, even if these deviate from preferred options in guidelines.
Guidelines are often seen as a reference for doctors, yet they also play an important role for patients to understand whether their treatment is at an appropriate minimum standard of care. All patients have the right to understand their treatment options in order to make informed decisions about their care, particularly if their clinician is advising treatment outside evidence-based recommendations.
It’s hard being a gatekeeper but we must not shy away from these challenges. Guidelines should not be followed slavishly but nor should they be ignored based on patient preference alone – this truly risks an injustice to others.
1. Mathew R. Three questions I ask before using a guideline. BMJ 2019;364:l358
2. https://www.bhiva.org/HIV-1-treatment-guidelines accessed 8th February 2019
3. Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th. New York: Oxford University Press; 2001.
Competing interests: No competing interests