Eying guidelines
Online posting: Oct. 15, 1996
Published in print: Dec. 15, 1996 (CMAJ 1996;155:1666)
Re: Clinical practice guidelines and the law, by Eike-Henner Kluge,
CMAJ 1996;155:574-6 [in brief / en bref]
The CMA, in collaboration with the National Partnership for
Quality in Health Care, has actively facilitated the development
of clinical practice guidelines (CPGs) in Canada during the last 4
years. This involvement has included commissioning a study by
Daniel Jutras into the legal aspects of guidelines[1] and
publishing Guidelines for Canadian Clinical Practice
Guidelines.[2] We therefore read Eike-Henner Kluge's article
on the topic in CMAJ with interest.
We are pleased to note Kluge's emphasis on the need for
clinicians to use CPGs flexibly, always keeping in mind the
uniqueness of each patient's condition, preferences and
environment. This concept is incorporated into our guidelines for
CPGs: "Clinical practice guidelines should be sufficiently
flexible to allow patients and physicians to exercise judgement
when choosing among available options." We find it refreshing
that a nonclinician appreciates the value of clinical judgement
in applying CPG recommendations to each patient's unique needs.
We are concerned, however, about Kluge's single-minded
approach to guidelines as simply tools for "reducing the cost of
health care . . . and freeing clinical practice from the threat
of litigation." In fact, the goal of CPGs is to improve the
quality of health care, which includes accessibility,
appropriateness, effectiveness, efficiency, safety, acceptability
and provider competence. Although some of these aspects of
quality will certainly impinge upon the cost of health care and
the threat of litigation, affecting cost and litigation is not
the goal of guidelines.
We are also concerned about Kluge's assertion that "guidelines
can set only minimal standards." If they are to be flexible and
to allow for physician and patient judgement, CPGs cannot be held
up as standards, minimal or otherwise. There is a logical
inconsistency between the flexibility inherent in a guideline and
the rigidity of a standard that must be followed. Jutras[1]
states clearly that guidelines are not developed to establish the
legal standard of care. They become a legal standard only through
legislation or through acceptance by the medical community as an
expected standard of behaviour. Otherwise, a CPG is perceived by
the legal system as simply one opinion about the standard of
care.
Ronald H. Wensel, MD, FRCPC
Chair
Committee on Quality of Care
Anne O. Carter, MD, MHSc, FRCPC
Associate Director
Research Directorate
David Walters, MA, MD, CCFP
Director
Health Care and Promotion
Professional Affairs Directorate
Susan Beardall, BScN, MHSc
Senior Project Manager
Quality of Care Program
Canadian Medical Association
Ottawa, Ont.
beards@cma.ca
References
- Jutras D. Clinical practice guidelines as legal norms.
CMAJ 1993;148:905-8.
- Guidelines for Canadian clinical practice
guidelines. Ottawa: Canadian Medical Association, 1994.
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