The anaesthetist was, however, concerned about the possible risk of bleeding with this particular patient and did not believe that it was in the patient's interests to administer heparin. Aware of the NICE guidelines recommending its use (Venous thromboembolism - reducing the risk, NICE, January 2010) and concerned that he could be criticised if he failed to follow them, he rang the MDU helpline for advice.
The MDU is often asked about the medico-legal implications of guidelines and whether doctors are bound to follow them, or if there can be circumstances where, after due consideration of the individual patient's circumstances, it may be appropriate to depart from guidelines.
Guidelines inform clinical practice but don't dictate it. They do not replace the knowledge and skills of clinicians. However, doctors are expected to be familiar with any nationally recognised guidelines that are relevant to their specialty. For an anaesthetist, this could include guidelines produced by NICE, The Royal College of Anaesthetists, The Association of Anaesthetists of Great Britain and Ireland as well as guidance from the GMC. Doctors also need to be aware of local guidelines relevant to their hospital/ department.
In fact, NICE explains, in a document on the legal context of its guidance (2004) that: "Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgment. However, NICE 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".
While doctors have a duty to be "familiar with relevant guidelines and developments that affect your work" (GMC, Good Medical Practice, paragraph 12) this does not mean you cannot depart from guidance in specific situations when you consider it is in the patient’s interests to do so.
You must be prepared to explain and justify your decisions and actions, especially if you depart from guidelines produced by a nationally recognised body, such as NICE. It is also important to keep a record of the reasons for your decision and your discussions with the patient.
The MDU adviser explained to the member that if he decided it was not in his patient's interests to comply with the relevant guidance, he would need to discuss his opinion about the best course of action with the patient.
In seeking consent from the patient, he would need to explain why he believed it was in the patient's best interests to depart from the NICE guidance, including an explanation of the possible outcomes if heparin was administered. The details of the reasons for the decision, including any discussion with the patient, should be noted in the clinical records.
Doctors are often concerned as to what might happen if something goes wrong and there is a clinical negligence claim following treatment where it was necessary to depart from guidelines.
While the fact that a doctor can demonstrate he or she followed widely accepted guidance, supported by expert opinion, can help towards the successful defence of a claim, it is equally possible to mount a successful defence of doctors who do not follow guidelines because it is not in their patients' interests.
This page was correct at publication on 21/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.