Departing from guidelines

Guidelines are becoming an increasingly common feature of modern medical practice. A recent case highlights difficulties that doctors can encounter when they depart from guidelines without adequate reasons for doing so. [Risk Alert]

Guidelines are becoming an increasingly common feature of modern medical practice. A recent case highlights difficulties that doctors can encounter when they depart from guidelines without adequate reasons for doing so.

A 56-year-old man attended his general practitioner with significantly raised blood pressure (systolic greater than 200mmHg and diastolic greater than 120mmHg). The GP arranged for a review of the blood pressure one week later when similar readings were obtained. The GP decided to give the patient lifestyle advice but undertook no further investigations. The patient was reviewed a month later and commenced on hypotensive treatment. Unfortunately, the patient stopped treatment because of side-effects and it was decided to review the situation after attempts at reducing weight and reducing alcohol consumption. The patient was then lost to follow-up and did not re-attend the GP.

Some months later the patient suffered a stroke leaving him with significant neurological loss. The patient sued on the basis that the management of his hypertension had not been in-keeping with current guidance.

As part of the investigation of the case we discussed the member's approach to the management of hypertension, particularly in light of guidance that was available from organisations such as the British Hypertension Society (see www.bhsoc.org).

The doctor was of the view that these guidelines were unduly aggressive and he was anxious that he did not over treat otherwise healthy patients. Unfortunately, he found it difficult to persuade our expert that there was a logical basis for his significant departure from the advice contained in these authoritative guidelines, and it was decided that the case was not defensible on the grounds of liability.

ACTION: be aware of relevant guidelines for common conditions in your area of practice. If your routine practice deviates significantly from these your practice should be reviewed. If following review the decision is made not to follow guidelines there should be a logical basis for your decision and patients should be advised of the fact that you hold a different view from mainstream practice.

Rob Hendry, MDDUS medical adviser