What is the standard of care?
How dangerous is propofol? Is the standard of care determined by the equipment, the competence of the provider, or some combination of the two?
Monday in court, defense witness Dr. Paul White testified multiple times he was unsure exactly what the term “standard of care” means.[1]
By the way, there is no good reason to believe that anything more than repositioning his airway would have been needed to keep Michael Jackson alive. The standard of care is to maintain adequate oxygenation and ventilation, even if the patient is occasionally apneic.
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Is a standard of care an actual treatment or is it a recognition that the person providing treatment was acting in the best interests of the patient?
If we ask some medical people we will get some unambiguous legal opinions.
If we ask some legal people we will get some unambiguous medical opinions.
The one definite characteristic about standard of care seems to be that the standard of care is ambiguous.
However, because the term standard of care is now used so freely in everyday medical discussion, we thought it could be useful to review its derivation, legal implication and how it relates to allied terms such as guidelines and consensus statements, all of which are continuously evolving as new evidence accumulates.[2]
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There is no medical definition for standard of care, although the term is firmly established in law and is defined as “the caution that a reasonable person in similar circumstances would exercise in providing care to a patient.”1 [2]
In EMS, the term reasonable person might result in even more ambiguity and argument than standard of care.
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The Daubert Case established certain criteria for evidence to be presented in court.[3]
This includes whether the theory or technique has been tested as scientifically valid, whether the idea has been subjected to scientific peer review or published in scientific journals, whether the theory or technique is generally accepted as valid by the relevant scientific community, and whether standards have been circulated to govern the operation of the technique and the known or potential rate of error involved in the technique. It focuses on methodology and principles, not only on the ultimate conclusions generated.3 [2]
All of the examples I have provided this week have been considered by medical people to be the standards of care.
The idea that they would not provide these treatments was absurd.
However, these treatments were not based on good evidence.
There are many other similar treatments.
For example, all of the ACLS (Advanced Cardiac Life Support) recommended ALS (Advanced Life Support) treatments for cardiac arrest are based on no evidence or on extremely weak evidence. They are not based on any evidence of improved survival from cardiac arrest. These are einephrine, vasopressin, norepinephrine, phenylephrine, amiodarone, lidocaine, magnesium, IV (IntraVenous) access, advanced airways (such as endotracheal intubation).
We are continually told that these are standards of care.
If we violate them, the baddies will take our first born children and our left testicles (left breasts for women). Gosh!
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The difficulty inherent in guidelines that are based in part on consensus is that the biases of the experts may shape the guideline and either exclude reasonable choices or incorporate personal favorites as preferred options.9 [2]
Guidelines may be biased?
Shocking, but true. That is why we have so many guidelines that we must get rid of.
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Without entering into any specific controversy, there may be examples in the literature of treatments which have been claimed to be standard of care without sufficient supporting evidence. Perhaps the term should not be used unless supported by confirmatory randomized controlled trials or meta-analysis that are unchallenged, because the presumed authority of the term may be used in a court of law to the detriment of a minority-view defendant who may think differently and who may be able to present an evidence-based argument to the contrary.[2]
Of course, that would mean that we need to have a better understanding of what we do and why we do it.
The less competent would have a hard time keeping their jobs – at least without remediation, but is that a bad thing?
Why do we have so many defenders of low standards?
Just follow the protocol and don’t ask questions!
There is no respect for our patients in that.
Another way of reading this paper is that the standard of care is competence and respect for our patients.
Is the guideline/protocol more important or the patient?
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Footnotes:
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[1] Murray defense expert: What is ‘standard of care?’
By Graham Winch
updated 12:46 PM EST, Fri January 06, 2012
HLNTV.com
Article
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[2] What does the medical profession mean by “standard of care?”.
Strauss DC, Thomas JM.
J Clin Oncol. 2009 Nov 10;27(32):e192-3. Epub 2009 Sep 21. No abstract available.
PMID: 19770363 [PubMed – indexed for MEDLINE]
Free Full Text from J Clin Oncol.
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[3] Daubert standard
Wikipedia
Article
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Standard of Care is a legal, not medical term. Standard of Care is determined by a jury at trial when someone sues because of a bad outcome. The jury determines if the practitioner met the standard as you outline above.
Doctors use the term thinking that they know what it means. As Inigo Montoya would say,
“You use that phrase a lot. I don’t think it means what you think it means.”
It’s amazing how many doctors think they know more law than lawyers do. Conversely, I’ve never met a lawyer who thinks he knows more medicine than a doctor. Well, unless he’s one of those dreaded lawyer-doctors.
The next time a doctor starts prattling on about “standard of care” ask them to define the term.
Too Old To Work,
That is the problem. When I ask why we are doing something, I am often told it is the standard of care, as if that is an appropriate answer.
Many of us are willing to accept the standard of care answer.
There is not enough reason to accept that answer.
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It doesn’t help that the Daubert criteria can be self-contradictory. We’ve all seen treatments that are “generally accepted as valid by the relevant scientific community,” but yet have not “been tested as scientifically valid,”; if nothing else, this blog has pointed out many of those types of treatment.
Daubert, and “standard of care” in general, is IMHO the medico-legal version of “I know it when I see it.”