The Advocate Update Report --
April 2004
by Dr.
Matthew McCoy, Chair – WCA Chiropractic Advocacy Council
Informed Consent & the CCP Guidelines
Hopefully you are aware that the
Council on Chiropractic Practice recently released its revision and
update of its Clinical Guideline Number One: Vertebral Subluxation
in Chiropractic Practice
http://www.ccp-guidelines.org/
Attributes of good guidelines
include their addressing the topics of Patient Preferences and
the Role of Value Judgments. These two issues are inextricably
tied to the concept of Informed Consent/Terms of Acceptance.
The following is the text from the
sections of the CCP Guides that deal with these two topics. For more
information, a complete copy of the guidelines, to make a donation to
CCP and for the references cited in this section please visit
http://www.ccp-guidelines.org/
Patient Preferences
While the CCP Guidelines were
developed for a wide variety of interested parties the major group
impacted by these guidelines are the consumers of health care
services. An overriding theme as regards the establishment of health
promotion activities is the concept of patient empowerment.142-143
Patients must have the right to choose the type of health care they
desire and not be restricted or forced to acquire their care from
practitioners they do not wish to see, to have procedures they do not
wish to have nor engage with systems of healing with which they
disagree.
Every
consumer of health care is ultimately responsible for his/her own
health choices and the patient’s expectations should be consistent
with the provider’s goals. If the patient perceives those goals as
anything different, proper and safe choices cannot be assured. Thus,
it is important to recognize that chiropractic is a limited, primary
profession which contributes to health in one way by addressing the
safe detection, location, and correction or stabilization of vertebral
subluxation(s). It is important that the chiropractor take the steps
necessary to foster proper patient perception and expectation of the
practitioner’s professional goals and responsibilities. Several topics
related to this concept of patient preferences are discussed below.
Referral Issues
Professional Referral: Professional referral
requires authority and competence to acquire accurate information
concerning matters within the scope and practice of the professional to
whom a referral is made. There are two types of professional referrals
made by chiropractors:
(A) Intraprofessional referral:
Chiropractors, by virtue of their professional objective, education, and
experience, have authority and competence to make direct referrals within
the scope and practice of chiropractic. Such a referral may be made when
the attending chiropractor is not able to address the specific
chiropractic needs of a particular patient. Under these circumstances,
the chiropractor may refer the patient directly to or consult with another
chiropractor better suited by skill, experience or training to address the
patient’s chiropractic needs.
(B) Interprofessional referral: In
the course of patient assessment and the delivery of chiropractic care, a
practitioner may encounter findings which are outside his/her professional
and/or legal scope, responsibility, or authority to address. The
chiropractor has a responsibility to report such findings to the patient,
and record their existence. Additionally, the patient should be advised
that it is outside the responsibility and scope of chiropractic to offer
advice, assessment or significance, diagnosis, prognosis, or treatment for
said findings and that, if the patient chooses, he/she may consult with
another provider, while continuing to have his/her chiropractic needs
addressed.
Diagnosis
While training and statute may allow
the chiropractor broad diagnostic scope, chiropractors may also elect to
limit their practice and diagnostic scope to the detection,
characterization and care of vertebral subluxations, and determining the
safety and appropriateness of chiropractic care.
There exists a wide variety of health
care practitioners, systems of health care and cultural overlays that
effect how the public utilizes health care services. While every
practitioner should be sensitive to this wide variety of cultural and
individual practices, it is not possible to dictate a particular class of
provider that a patient must see for evaluation of unusual findings. This
must be done on a case by case basis and must be a decision the patient is
empowered to make.
Nothing here absolves the chiropractor
from knowing the limits of his or her authority and skill, and from
determining the safety and appropriateness of chiropractic care. The
chiropractor has a duty to disclose to the patient any unusual findings
discovered in the course of examination, and may collaborate with other
health professionals when it is in the best interests of the patient to do
so.
Asymptomatic Care
Chiropractic care to detect and correct
vertebral subluxations may offer benefits for all people, including those
who do not demonstrate symptoms of a disease or health condition.141
Therefore, the presence or absence of
symptoms and/or a medical diagnosis should not be a factor in determining
the need for or appropriateness of chiropractic analysis and/or
adjustments, nor should the presence of symptoms be required by any
chiropractic board, insurance company or court of law to justify the
rendering of chiropractic care to any patient.
Further support for this can be found
in the Association of Chiropractic Colleges’ Position Paper No. 1,
endorsed by all chiropractic colleges in the U.S. and Canada and virtually
every chiropractic organization in the world. It states in part: "The
practice of chiropractic includes: establishing a diagnosis; facilitating
neurological and biomechanical integrity through appropriate chiropractic
case management, and; promoting health" (section 3.0, The Chiropractic
Paradigm).
The paper goes on to state:
"Chiropractic is concerned with the preservation and restoration of
health, and focuses particular attention on the subluxation; A subluxation
is a complex of functional and/or structural and/or pathological articular
changes that compromise neural integrity and may influence organ system
function and general health; A subluxation is evaluated, diagnosed, and
managed through the use of chiropractic procedures based on the best
available rational and empirical evidence." (Section 4.0, The
Subluxation). Nowhere does this defining document state or imply that
chiropractic is to be used only for patients exhibiting symptoms.
The use of health care procedures on
asymptomatic patients is commonplace in all medical and alternative care
fields, both as a preventive measure and in recognition of the fact many
health conditions do not exhibit outward signs, particularly in their
early stages.
The need for chiropractic care by
asymptomatic patients is one that has been widely supported by the
chiropractic profession. It is estimated, based on the findings of an
expert panel of seven chiropractic researchers, that 97% of the
chiropractic profession provides chiropractic services to asymptomatic
patients if subluxations are present.
A “Terms of Acceptance” is the recorded, written
informed consent agreement between a chiropractor and the patient. This
document provides the patient with disclosure of the responsibilities of
the chiropractor and limits of chiropractic, and the reasonable benefit to
be expected.
This enables the patient to make an informed choice,
based on their preferences, either to engage the services of the
chiropractor, aware of the intended purpose of the care involved, or not
to engage those services if the proposed goals are not acceptable or not
desired. This embodies the responsibility of assuring patient preference
and safety by not providing false or misleading promises, claims or
pretenses to the patient.144 -150
The Role of Value Judgments
Clearly the individuals involved in the development
of these guidelines share common values regarding the existence of the
vertebral subluxation and the importance of identifying its manifestation
in patients, followed by its reduction and/or correction. This becomes
obvious as one looks at the various backgrounds which the individuals
bring to the process. It can also be said that the Panel’s views on the
subluxation and the literature reviewed mirrors that of the average
practicing chiropractor. This is evidenced by a recent study which found
significant agreement amongst chiropractors regarding the concept of
subluxation and how it is diagnosed and managed.151
Another issue that is somewhat apparent is the
panel’s adherence to an evidence-based model for evaluation and
characterization of vertebral subluxation. This additionally reflects the
value placed on the objective identification of subluxation and assessment
of outcome following the introduction of care intended to correct it.
For more information, to purchase a
bound copy of the guidelines, to make a donation to CCP and for the
references cited in this section please visit
http://www.ccp-guidelines.org/
Dr. Matthew McCoy – Chair WCA Advocacy Council
advocate@worldchiropracticalliance.org
Dr.
Matthew McCoy, Chair – WCA Council on
Chiropractic Advocacy
