May 2004

Informed Consent and the CCP Guidelines

by Dr. Matthew McCoy, Chairman, WCA Chiropractic Advocacy Council

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"( 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.

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. 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.

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.

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.

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 www.ccp guidelines.org/