Adherence to credible CPGs can be beneficial and assist in providing quality care, though they do not necessarily establish a standard of care
Clinical practice guidelines, or CPGs, are statements that help patients and physicians make decisions about appropriate healthcare for specific clinical circumstances.1 CPGs are available on a variety of platforms, including peer-reviewed journals and healthcare organization websites.
When applied appropriately, a credible CPG can improve the quality of clinical care provided to patients. That said, physicians should always use their judgment to assess whether a CPG applies to a patient’s particular situation.
CPGs and clinical decisions
It is prudent for physicians to be aware of authoritative CPGs relevant to their practice. The most authoritative CPGs are typically based on evidence from randomized, controlled trials. Less reliable are those that are a collection of clinical opinions where evidence is absent or contradictory. 2
When considering treatment options for a patient, a physician might determine that the appropriate clinical decision is one that may seem contrary to a recognized and accepted CPG. In such instances, consulting with a colleague or relevant specialist is a good measure to take.
When deviating from an established CPG, a physician should document the rationale for doing so. A physician should also document discussions with the patient about the benefits and risks of different treatment options, including those advanced by established CPGs, and document the patient’s express consent for the chosen treatment.
CPGs and the standard of care
In legal proceedings where there is an allegation of negligence, it is the court’s role to determine whether the physician’s care fell below the accepted standard of care. Both parties will introduce evidence as to what the standard of care is in the case and whether the physician met that standard. Courts will generally not accept a CPG as determinative of a standard of care without expert evidence as to its applicability in the case in question. This evidence will be provided by medical experts retained by the parties to give an opinion on the medical standards at the time the care was provided.
A medical expert might refer to certain CPGs as being representative of the standard of care at the relevant time. A medical expert might also give an opinion about the degree to which a CPG has been accepted within the medical community. In both instances, it is the opinion of the expert, more than the CPG itself, that the court relies on in making its determinations.
Courts will not necessarily find a CPG to be determinative of a standard of care, even if the CPG is considered authoritative by some in the medical community. Evidence of the standard of care of a "prudent colleague" will often carry more weight than a CPG.
While decision makers in legal proceedings may not have the same knowledge as medical experts, they are aware of certain important realities regarding the scope and utility of CPGs. Courts generally understand that:
- a physician's decisions should not be measured against a standard of perfection or infallibility, and negative outcomes must be distinguished from acts of negligence (fault in Québec); 3
- adopting a respected school of thought different than one’s colleagues does not necessarily mean a physician's care would be considered an act of negligence (fault in Québec);
- there may be a lag in time between the publication of a CPG and its incorporation into clinical practice;
- a medical expert's opinion is provided after the clinical outcome is known, and this may affect how objectively the clinical care can be viewed.
Courts will take into consideration the greater context of the incident, weighing the entire body of evidence – including any CPGs provided by medical experts – to ascertain the standard of care that a similarly qualified physician would have provided in the same situation.
The bottom line
Courts may hear expert evidence of the relevance of a CPG to the issue before the court, but the CPG alone is not necessarily determinative of the standard of care. Nonetheless, if deviating from an established CPG in clinical work, it is wise to document the rationale and the patient’s informed consent. These steps can assist in defending the care should it come into question in the future.
Canadian Medical Association. CMA Joule;2021. Submit a guideline [cited 2021 Sep 28]. Available from: https://joulecma.ca/cpg/submit-guideline
Jutras D. Clinical practice guidelines as legal norms. CMAJ. 1993;148(6):905
Moffett P, Moore G. The standard of care: Legal history and definitions: The bad and good news. West J Emerg Med. 2011;12(1):109-112