How Patients Can Exit from Clinical Guidelines
Patients and clinicians can deviate from guidelines at any time because guidelines are explicitly not mandatory, not legally binding standards of care, and are designed to inform—not dictate—clinical decisions that must account for individual patient circumstances. 1
Guidelines Are Not Mandatory Standards
Guidelines serve as educational tools and reference points, not as rigid protocols that must be followed. The American Psychiatric Association explicitly states that guidelines "should not be considered as a statement of the standard of care or inclusive of all proper treatments or methods of care" and "do not mandate any particular course of medical care." 1
NICE and other guideline organizations have clearly stated that guidelines are "not in any way mandatory" and are designed to help "healthcare professionals and patients make informed choices." 1
The APA cautions against the use of guidelines in litigation, emphasizing that adherence to guidelines will not ensure successful outcomes for every individual, and guidelines do not account for individual variation among patients. 1
When Deviation from Guidelines Is Appropriate
Deviation is justified when patient-specific factors make guideline recommendations inapplicable, including differences in disease prevalence, risk factors, comorbidities, patient values, or sociocultural preferences. 1
Clinicians should deviate when patient preferences and values differ from those assumed in the guideline. The ultimate recommendation must be made "in light of the psychiatric evaluation, other clinical data, and the diagnostic and treatment options available" and should "incorporate the patient's personal and sociocultural preferences and values." 1
Guidelines have limited applicability to patients with multiple comorbid conditions. Research shows that 85% of guidelines address comorbidity, but only provide an average of 3 recommendations per guideline for these complex patients, with 78% focusing on concordant (related) rather than discordant (unrelated) comorbidities. 2
Legal Protection for Deviation
Under the Bolam and Bolitho legal tests, clinicians are not negligent if their practice is upheld by a responsible body of professionals, even if it deviates from guidelines. The standard of care in law requires only that the logic underlying the clinical decision be explained, not that guidelines be followed. 1
"Failure to adhere to these guidelines should not necessarily be considered negligent, nor should adherence to these recommendations constitute a defence against a claim of negligence." 1
Clinicians should be prepared to justify major deviations from relevant guidelines, but this justification can be based on patient-specific factors, clinical judgment, or more recent evidence not incorporated in the guideline. 1, 3
Practical Steps for Exiting Guidelines
Document the clinical reasoning for deviation, including patient-specific factors such as comorbidities, contraindications, patient preferences, or more recent evidence that supersedes guideline recommendations. 1
Engage in shared decision-making with the patient, explaining why the guideline recommendation may not be optimal for their specific situation and discussing alternative approaches. 1
Consider whether the guideline is outdated, as guidelines cannot be updated for every new piece of evidence and may not reflect the most current research. For example, large trials published after guideline development may provide superior evidence. 1
Assess whether local resources, expertise, or practice patterns make guideline implementation impractical or inappropriate for your specific clinical setting. 1
Critical Caveats
Guidelines are often based on limited evidence. Many recommendations rely on consensus opinions or observational studies rather than randomized trials, particularly when ethical constraints prevent rigorous research. 1
Guidelines may contain conflicting recommendations across different organizations, highlighting clinical uncertainty rather than established best practice. 1
Guidelines typically exclude patients with multiple comorbidities from their evidence base, as clinical trials often exclude these complex patients, making recommendations less applicable to real-world practice. 2
The strength of recommendations matters. Weak or conditional recommendations explicitly acknowledge uncertainty and indicate that different choices will be appropriate for different patients based on their values and circumstances. 4