Following the Signs: Standards of Medical Practice
Just as an automobile driver must follow the signs and not drive at any speed selected by the driver and must obey signs that demand caution and attention, physicians practicing medicine must also follow signs along the road of diagnosis and treatment. The signs represent the standards of medical practice which are supposed to guide the physician safely and effectively as he or she manages a patient. They represent what is currently acceptable. Examples of such standards currently would be how heart attack patients are diagnosed and treated, how death by neurologic criteria (so-called “brain death”) is established, how a case of suspected thrombophlebitis is worked up and treated and, in general what treatments are appropriate for what illnesses. If a physician fails to obey the standards and an accident occurs, as with a driver ignoring the red light, there may be legal consequences.
Where do these standards of medical practice come from and who enforces them? Interestingly, some standards may have arisen many years ago, derived from physician experience and hearsay leading to informal consensus as an accepted practice and never have been changed. Some standards, especially in modern times, have been based on clinical studies which provided evidence based conclusions. Some standards are set by professional organizations, often for their own sub-specialties in medicine or surgery. Some standards represent a consensus by society or laws set by legislation or by state medical boards. Insurance companies and health maintenance organizations also set standards of practice that they expect their patient’s physicians to follow. Also, there has been suggested that some standards may have been introduced by pharmaceutical and medical instrument companies for the company's financial interest but not necessarily in the interest of the doctor or the patient. Standards of medical practice also include not only those related to diagnosis and treatment but also ethical and professional behavior as set by physician associations such as the American Medical Association.
From a legal point of view, standards are not expected to be followed to the same extent everywhere. Some standards may be dependent on where the physician practices and what resources are available. A physician treating an acute stroke patient in a rural area away from medical centers may not be able to meet all the criteria set for treating a patient in a major city. Standards also may vary with the type of practice a physician is engaged. The standards for a general physician who has had no specialty training will be different than a physician with specialty training. Further the standards may be different between the various specialties. In fact, in court cases, it requires an expert witness who is familiar with the specific standards for the physician defendant to establish which standards were followed and which were not. Some standards may not be the same in all countries since the laws, resources and cultural settings may be different.
With regard to who enforces the standards of practice, beyond the courts, it is the various state medical licensure boards in the United States and the other similar organization in other countries. As with traffic signs, the physician must be able to defend his or her practice decision if the standards are not followed. ..Maurice.
GRAPHICS AND THEIR RELATION TO THE CONTEXT OF THE THREAD:
(Photographs taken by me in a neighborhood in Arroyo Grande, California 9-14-2008.)
END- Standards of practice which dictate that further attempts at curative therapy will be fruitless and that these attempts should be terminated but that comfort care should be continued.
SLOW- Standards of practice which dictate that there is valid concerns regarding the benefit vs risks of a procedure or treatment and that to continue to follow the same course should be carefully reconsidered.
STOP- Standards of practice which dictate that no value has been established for a procedure or treatment for the patient's condition (often requested by patient or family) and that it should not be further considered and if started should be stopped.
posted by Maurice Bernstein, M.D. @ 10:32:00 PM
4 comments
4 Comments:
If a person has a heart condition that can be helped with standard therapy (pacemaker) and yet demands an experimental surgery which could restore his heart but has only 1% chance of his surviving it, would you say that this falls into the "STOP" category? I view it as medical futility to attempt a highly risky and very expensive surgery when a standard therapy exists (because rather than "improve" the person's condition it might actually do harm by killing him), and also as an infraction of the Non-Maleficence (First do no harm)principle. Ultimately, my question is: can a patient demand such treatment against the best judgment of the doctor? My belief is that he cannot, or at least that he should not. There has to be some place where the medical experience and skilled knowledge may trump the autonomy of the patient. Could you clarify this for me? Aline
Aline, physicians are not required to obey any request by the patient, particularly if the request is inconsistent with the medical literature, standards of practice, known to be ineffective or would pose an unusually high risk to the patient if the request was granted.
Finally, in some states such as California, there are laws which permit a physician not to grant a request by a patient if the physician's moral conscience is against the request. Whatever the circumstances, in order to avoid abandoning the patient, refusal to comply does require an attempt made by the physician to refer the patient to another physician who would comply. As in California, if after a good effort attempt, no other physician is found, the patient's request can remain not granted. ..Maurice.
Maurice, if physicians are not required to obey any request by a patient, does that also extend to the religious beliefs of a patient? for instance, Jehova Witness Faith followers and their refusal for blood transfusion. SPH
Specifically, with regard to Jehova's Witness followers, the general consensus is to obey their refusal of blood if the patient is an adult even if the refusal is life threatening. Alternate, patient accepted, supportive treatment may be offered. However, in the case of a minor, particularly one who is too young to be able to understand and participate in that religion and practices and who requires blood for life support, a court order requiring the transfusion is an option followed.
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