Clinical Practice Guidelines vs. Standard of Care in Litigation

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Guidelines and Clinical Conduct

Nurse-midwifery guidelines, policies, procedures, and protocols are not rules or standards, per se, but they exist to support reasonable conduct and quality of care. Although there is always room for originality in patient care management, practice documents are created to define and enhance expectations for clinical conduct, especially among providers of varying backgrounds and education.  Individual practice documents should be consistent with the specific expectations for practice set forth by professional organizations.

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     The use of CPGs to define or represent standards of care in the context of malpractice litigation is variable.  Courts are frequently confronted with arguments regarding CPGs and whether they represent the practice standard of care for providers who utilize them.  Some courts have allowed the use of clinical practice guidelines to represent standard of care. Before they will be admitted into evidence for this purpose, the court may require expert testimony supporting the scientific validity of the guidelines presented, and whether they actually do reflect the standards of practice at issue.

Practice Guidelines As Evidence In Court 

A significant issue is whether clinical practice guidelines, that are in conflict with the ACNM definitions of nurse-midwifery standard of care, should ever be considered as CNM standard of care in a court case.  Regardless, the use of CPGs to represent CNM practice standard of care will require the testimony of a qualified nurse-midwifery expert to either defend or refute the validity of the guidelines and the conduct of the midwife who relied on them.*

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Should Practice Guidelines Be Evidence Based?    

When drafting practice guidelines, nurse-midwives should consider whether they are supported by sound, well-accepted clinical and scholarly evidence (like ACNM standards of practice). When considering any prospective employment opportunity, the CNM should review the CPGs that are in place at the prospective practice (hospital, clinic, or private practice) and whether they are consistent with ACNM documents and guidelines. If there are any perceived conflicts between behaviors sanctioned in the CPGs and what the CNM knows to be standard ACNM established practice, these conflicts must be addressed and resolved prior to accepting employment. 

How Practice Guidelines May Be Utilized at Trial

In the event of a lawsuit claiming CNM negligence, Plaintiff’s counsel will compare the CPGs with the alleged clinical misconduct. Again, if the practice guidelines allow conduct that is inconsistent or in conflict with ACNM standards, a CNM/CM defendant may not prevail with an argument that she was just following the practice CPGs. 

If you find yourself as a CNM/CM defendant, expect to be examined in detail regarding your familiarity with your employer’s practice guidelines. In a court case, the CPGs utilized by a defendant in professional practice may support appropriate conduct or highlight evidence of negligence.

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* Recupiro, Patricia R. Clinical Practice Guidelines as Learned Treatises: Understanding Their Use as Evidence in the Courtroom. Journal of the American Academy of Psychiatry and the Law: Online September 2008, 36(3) 290-301.

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