Mutual discussions with doctors/failure to follow guidelines

[diogenes]

Good practice formally demands adequate discussions between doctor and patient in deciding on treatment. This website shows the protocol:

gmc-uk.org/ethical-guidance...

An excerpt:

From Good Medical Practice Consent: patients and doctors making decisions together

The doctor uses specialist knowledge and experience and clinical

judgement, and the patient’s views and understanding of their

condition, to identify which investigations or treatments are likely

to result in overall benefit for the patient. The doctor explains the

options to the patient, setting out the potential benefits, risks,

burdens and side effects of each option, including the option to

have no treatment. The doctor may recommend a particular option

which they believe to be best for the patient, but they must not put

pressure on the patient to accept their advice.

The patient weighs up the potential benefits, risks and burdens

of the various options as well as any non-clinical issues that are

relevant to them. The patient decides whether to accept any of the

options and, if so, which one. They also have the right to accept

or refuse an option for a reason that may seem irrational to the

doctor, or for no reason at all.

If the patient asks for a treatment that the doctor considers would

not be of overall benefit to them, the doctor should discuss the

issues with the patient and explore the reasons for their request. If,

after discussion, the doctor still considers that the treatment would

not be of overall benefit to the patient, they do not have to provide

the treatment. But they should explain their reasons to the patient,

and explain any other options that are available, including the

option to seek a second opinion.

It seems that there are far too few instances recorded here of patients having that kind of (mandatory according to guidelines) interaction with the GP. I think that all patients having an appointment with their GP/endo should carry this excerpt with them, if things go awry.

[Musicmonkey]

Mmmm..... 😣

[fibrolinda]

Thank you diogenes I've been searching for this on and off for many months. Sounds good doesn't it, working as a team, if only 😕

[helvella]

I fully agree that what is demanded and what happens appear to be in different universes.

Over time, I increasingly feel that use of good practice guidelines, ethical standards, and similar might end up being more effective than direct attack using science and research.

One example, many have strong disagreement with the idea of an anonymous laboratory person deciding on which tests should actually be performed. Their lack of any direct connection to the patient means that decisions are made without any understanding of the clinical issues. If, or perhaps when, their decisions have a negative impact on a patient, how does that audit trail of responsibility run? Can't help thinking that a few high profile court cases in which a lab person is brought to book would concentrate minds - but that really isn't the right way for things to happen. It is a "when all else fails" situation - and is far too late after damage has happened.

[Baobabs]

Ideology is a beautiful thing!

[UrsaP]

Brilliant. Thanks for sharing.

[SilverAvocado]

Just before I got sick I was working in a project about consent (and children's assent) for clinical trials.

What I learned about consent when I became a patient makes a mockery of all the theoretical stuff. The whole way that medical treatment is structured, like a flow chart, means that if a patient withdraws their consent and drops out of the one (or v limited) trajectory provided for them, there isn't support of any kind. I think that for choice to be meaningful, the whole system has to be restructured.

Doctors would have to be empowered to make meaningful decisions themselves, in order to collaborate with the patient to make a decision, for one thing.

[diogenes Remembering in reply to SilverAvocado]

I fully agree with the need to restructure how doctors and patients can interact. My only concern was to give patients the knowledge that, however inadequate, there are present guidelines to help GP/endo/patient relationships and that the professionals should constantly be made aware of them and the need to adhere to the recommendations. Rather than the casual lofty dismissals that seem to happen far too often.

[holyshedballs in reply to SilverAvocado]

They are empowered, the empowerment is in the Good Medical Practice Code of Practice on Informed Consent.

[SilverAvocado in reply to holyshedballs]

Aaah! I wrote a long response to this but the internet swallowed it!

The main issue I was flagging up is that the doctor themselves usually won't be making a decision between a range of treatments, choosing something specific to the full complexity of this patient's symptoms and history. They will just be offering the one thing that the guidelines flag up as the gross response to any patient at all like this.

It means that the patient's choice amounts to either accepting that or getting nothing. That's not a meaningful decision, and its pretty shaky consent, as well.

[holyshedballs in reply to SilverAvocado]

That's the point of the guidelines. Doctors SHOULD know about the range of options. To stick to one document produced by one group of people without taking into account other treatments would be against the guidelines.

So if a doctor doesn't know about the Lowe/Peatfield/Skinner/Myhill method - and s/he should - then s/he MUST listen to the patient who does have that knowledge.

That is what the guidelines say, and if doctors don't do that, they are not complying with the guidelines.

As you correctly say, it is not informed consent and contrary to the guidelines and now it is confirmed by the courts as negligent.

That is what is so powerful about the Montgomery court case. It confirms that lack of informed consent, by not doctors not following the steps in the guidance, which causes harm, is negligent.

[nightingale-56]

Thanks for posting this diogenes . I shall certainly keep this by me when I next have to 'argue' my special needs son's case with our present unknowledgeable GP, who is determined to over-ride our very pleasant Endo, who gives reasonably good advice. Hope I don't need to bring it out when we have three appointments this coming week.

[Katepots]

I don’t think they’ve read it!😳

[holyshedballs in reply to Katepots]

They should do and patients should take that list of actions in with them to check that the doctor is sticking to Good Medical Practice.

[holyshedballs]

Diogenes/all,

The Whole of the guidelines is important

but

the really important message in the guidelines are

The doctor uses specialist knowledge and experience and clinical

Judgement, and the patient’s views and understanding of their

condition, to identify which investigations or treatments are likely

to result in overall benefit for the patient.

To me this means that when we inform the doctors of our knowledge, they have to listen and use the knowledge we impart to identify treatments. This should then generate further options i.e. treatment within the "reference " range or T3.

Really, in my view, the doctors should know about alternative treatments, even if they don't agree with them. They should discuss the alternative treatments with the patients.

The medical negligence case of Montgomery v Lanarkshire Health Board [2015] SC 11 [2015] 1 AC 1430 said that if a doctor doesn't follow the guidelines for informed consent and harm results from not following the guidelines s/he is negligent in law.

This is very important because none of the doctors i have seen have followed the guidelines.

The Montgomery case is binding now so it is much easier to bring a case of negligence. Better to inform a doctor of this so that they diagnose and treat properly in the first place.

[holyshedballs]

There is another piece of case law (Bolam) that states that a doctor has to follow a course of medical action e.g. treatment of hypothyroidism that is supported by a body of medical opinion. So the BTA is a body of medical opinion. BUT crucially, so is the course of medical action supported by Drs Lowe/Peatfield/Skinner/Myhill. The Courts have said that a body of medical opinion can beas few as 4 doctors, so these doctors represent a body of medical opinion. If we accept that 2 are deceased, we can still add: Holtorft, Hoeteghe, Tietlebaum, Arem, Starr, Hoermann et al..

To some degree, Montgomery has rejected the Bolam test.

F v R (1983) 33 SASR 189 Full Court Supreme Court (SA, Australia) states that the ultimate question, however, is not whether the defendant’s conduct accords with the practices of his profession or some part of it, but whether it conforms to the standard of reasonable care demanded by the law.

Further, another piece of case law (Bolitho) states that the procedures of a body of medical opinion MUST be logical. I believe that the practice promoted by the BTA is clearly not logical based on the evidence collated by Drs Lowe/Peatfield/Skinner/Myhill et al.

this neatly ties in with Montgomery and the Informed Consent Code of Practice. In my view, if doctors stick to the BTA statement (NB not guidance) then they are negligent.

All the ducks are in place, we just need someone to take a case. or start a crowdfunding page to pay for the legal costs when someone takes a case on.

[lady_eve]

Amen to that.