Is It Ever Wise to Disregard Absolute Practice Guidelines? Absolutely

Abstract

Bottinor and colleagues1 present the case of a 60-year-old woman in whom massive pulmonary embolism (PE) led to cardiac arrest with pulseless electrical activity. After her successful resuscitation, she was given systemic thrombolytic therapy and survived. Ordinarily, such management and outcome would not merit an editorial, because thrombolysis is the first-line treatment in patients with PE who present with cardiogenic shock or persistent arterial hypotension.2,3 However, the case in question wasn't ordinary. Eight weeks before her PE occurred, the patient had sustained a hemorrhagic cerebrovascular accident. That event took on added significance, because any history of hemorrhagic stroke or stroke of unknown origin is considered an absolute contraindication to thrombolytic therapy.2 Faced with a critically ill patient at high risk for in-hospital death, Bottinor and associates carefully decided to disregard the aforementioned guideline and initiated systemic thrombolysis. Their decision not only proved to be life-saving, it illustrated a basic principle of good patient care: no practice guideline—therapeutic or otherwise, relative or absolute—should ever displace sound clinical judgment. Several points about clinical practice guidelines deserve emphasis. First, guidelines can only summarize the best available evidence, which often is weak.4 In truth, guidelines are nothing more than roadmaps designed to lead us in the right direction5; roadmaps, however, don't necessarily tell us the best path to take. Second, guidelines vary considerably in how they are developed and written,5–9 in whether they are derived primarily from expert opinion or objective evidence,4,5 and in how often they undergo revision as new evidence accumulates.4,5 Third, guidelines occasionally are marred by conflicts of interest6,8,9 and by clear-cut, sometimes intentional, bias.6,10 Fourth, guidelines increasingly serve as ammunition for the issuance of regulatory and insurance mandates.11,12 Fifth, guidelines tend to promote herd mentality.13 All too frequently, in fact, physicians view guidelines as items of dogma and follow them mindlessly. Fortunately for their patient, Bottinor and associates didn't do that.