The reality of clinical discretion
NICE guidelines are not law. They are evidence-based recommendations for the care of the typical patient. In practice, the typical patient is a rarity. We manage individuals with complex comorbidities, polypharmacy, and unique social circumstances. Rigid adherence to a guideline, when clinical judgement suggests otherwise, is not safe medicine. It is a dereliction of our duty to tailor care.
I have seen junior doctors hesitate to deviate, fearing governance repercussions. The safer option, however, is often the one you arrive at after a thorough assessment, even if it diverges from the standard pathway. The key is in the justification and the documentation.
When deviation becomes the standard of care
Consider anticoagulation in atrial fibrillation. NICE CG180 provides a clear CHA₂DS₂-VASc threshold. But what about the 85-year-old with a score of 4 who has had two unwitnessed falls in the last month and lives alone? The guideline recommends anticoagulation. Clinical judgement, however, must weigh the significant and potentially fatal risk of a major haemorrhage from a fall against the stroke risk.
In this scenario, deviating from NICE by opting for no anticoagulation or aspirin is frequently the safer, more defensible decision. The guideline cannot account for every individual's risk of harm. Your assessment does.
Polypharmacy and frailty
Another common area is polypharmacy in the frail elderly. NICE may recommend an SGLT2 inhibitor for a patient with type 2 diabetes and CKD. But if that patient has a history of recurrent UTIs, frailty, and borderline continence, initiating a drug that promotes glycosuria is a predictable disaster. Deviating to a safer alternative, or even accepting a slightly higher HbA1c, is the safer management plan. The goal is patient wellbeing, not guideline checkbox-ticking.
Documenting the decision: The why, the what, and the consent
Poor documentation makes a defensible decision look negligent. Good documentation is your evidence of a reasoned clinical process. It should be a concise but complete narrative.
Structuring the note
A clear pattern works well. I use a mental checklist for the entry:
- Why NICE is applicable but unsuitable: State the guideline and the specific recommendation. Then detail the patient-specific factors that make it high-risk or inappropriate.
- The alternative plan: Clearly state what you *are* going to do instead.
- Risk-benefit discussion: Document the conversation with the patient (or family) about the risks of both following and deviating from the guideline.
- Informed consent: Record that the patient understands and agrees to the proposed plan.
A concrete example: Post-MI beta-blocker
Imagine a 70-year-old admitted with an NSTEMI. NICE CG172 recommends starting a beta-blocker. The patient has a history of severe COPD with an FEV1 of 40% predicted and is on home oxygen.
Poor documentation: "Not starting bisoprolol due to COPD." This is weak and suggests a oversight.
Robust documentation: "Discussed NICE CG172 recommendation for beta-blocker post-MI. In this case, patient has severe COPD (FEV1 40%) and is oxygen-dependent. A beta-blocker, even cardio-selective, carries a significant risk of precipitating bronchospasm and respiratory failure. Alternative plan: optimise secondary prevention with high-dose statin, dual antiplatelet therapy, and ACE inhibitor. Risks of deviation (slightly increased mortality risk vs. standard care) and risks of adherence (acute respiratory deterioration) discussed at length with patient. Patient understands and agrees with the decision to avoid beta-blocker."
The second entry provides a clear, logical trail for anyone reviewing the notes, including a coroner. It demonstrates active decision-making, not passive omission.
The role of shared decision-making and consent
Deviation is not a unilateral decision. It is a collaborative process with the patient. Your role is to present the evidence, including the guideline recommendation, and explain why their personal context suggests an alternative may be safer.
For instance, a patient with a small, localised basal cell carcinoma might be recommended surgical excision by NICE. If they are 95, bedbound, and the lesion is asymptomatic, the risks of anaesthesia and transfer to theatre may outweigh the benefits. The safer option could be conservative management or topical treatment. The conversation must outline the very slow progression of the disease, the risks of surgery, and the rationale for a different approach.
Documenting this discussion is as important as documenting the clinical reasoning. "Patient understands that excision is standard but agrees that given their frailty, the risks of procedure are unacceptable. Agrees to conservative management with review." This transforms a deviation into a patient-centred care plan.
Governance and defensibility: The audit trail
The fear of deviation often stems from a misunderstanding of clinical governance. Governance is not about punishing deviation; it is about ensuring decisions are reasoned, documented, and made in the patient's best interest. A well-documented deviation is often more defensible than a poorly documented adherence to a guideline that caused harm.
This is where systematic approaches to documentation are critical. They ensure that every necessary element of the decision—the rationale, the alternative, and the consent—is captured consistently. This creates a robust audit-safe standards framework for your practice, turning clinical notes into a clear audit trail rather than a cryptic diary.
Conclusion: Judgement over juniors
Guidelines are tools, not tramlines. They provide a essential baseline, but our expertise is applied in knowing when to step off the path. The safest option is the one informed by a comprehensive assessment of the individual in front of you. The defensibility of that decision rests entirely on the quality of your documentation and the evidence of shared decision-making.
Embrace the discretion your grade affords you. Document it meticulously. This is the practice of safe, senior clinical decision-making. For a broader view on the frameworks that support this, a useful resource is the audit standards index.