NICE and their astonishing view of the clinical relationship

If you are pregnant, NICE want you to given a carbon monoxide test. This test is to see if you smoke. But look at the flowchart on page 11- you are to have this test even if you say you don’t smoke, and even if you say you do.

I don’t think this is conducive to a  trusting relationship. Being bulldozed into tests isn’t ethical, apart from anything else – no matter if the midwife has good intentions or not, competent adults are allowed to do legal things, and to refuse tests – even if you as a healthcare provider don’t like them.

Apart from anything else, the test is not foolproof – passive smokers, or people living near busy roads can elevate the test to ‘smoking’ levels even in non smokers. If you do smoke – a confession that is clearly to be extracted from you no matter what – you will be referred to stop smoking counselling, even if you don’t want to go. (The issue of false positive tests is jollied along by NICE, who say ‘it is best to use a low cut-off point to avoid missing someone who may need help to quit’. They don’t say much about  the falsely accused woman.)

The evidence around treating addictions is firm about one thing: the person themselves has to be motivated to stop. I am especially concerned about this guidance as there is a clear relationship between lower social class and smoking. There is an argument that poverty is more damaging to the developing child than exposure to smoke in utero. And what about the unintended adverse effects this intiative will have? Will the smoking woman avoid disclosing other concerns or worries about her pregnancy in the context of a clinical relationship which, first of all, essentially asked her if she was lying?

For what it’s worth, I am a non smoker and would have  refused any such carbon monoxide test in pregnancy. I would love someone to tell me that I’m wrong, but there are 30 people listed as being on the advisory committee to NICE’s recommendations, 2 of whom are GPs and one of whom is a psychologist. I can find no midwives at all, and the majority of members are from public health backgrounds where I would not expect them to have direct experience of consulting individually with patients.

It’s this disregard for the consultation that I find most disturbing. The very essence of what goes on is based on trust, and this recommendation is a retrograde step.

9 Responses to “NICE and their astonishing view of the clinical relationship”

  1. Kate June 25, 2010 at 1:35 am #

    There are some worrying trends in they way lifestyle choices are being medicalised and transformed into health problems. Lack of consent for treatment and coercion don’t seem ethical to me.

    This might interest you, Margaret – Coerced addiction treatment: Client perspectives and the implications of their neglect
    http://www.harmreductionjournal.com/content/pdf/1477-7517-7-13.pdf

  2. Bob Phillips June 25, 2010 at 5:01 pm #

    It does sound quite surprising. Have you had a chance to do any spadework on the consultation, the stakeholders, comments offered and responses? Has this concern been raised previously in the production process?

  3. Margaret McCartney
    margaretmccartney June 28, 2010 at 8:09 pm #

    I’ve asked NICE to comment. Will update when I hear…

    I have been told by several women in various parts of the country that they were breath tested in the antenatal clinic without being told what it was for or why.

    This is a real problem with any ‘guidelines’ – they get distilled down into unquestioned commandments.

    Thanks Kate for the reference – I am also concerned about unintended negative impacts of this test – will it make smoking pregnant women more likely not to attend antenatal appointments or to withhold other information? These are adult women, not delinquents.

  4. Margaret McCartney
    margaretmccartney July 2, 2010 at 4:22 pm #

    NICE have sent me the responses to the consultation here

    http://www.nice.org.uk/nicemedia/live/11754/46451/46451.pdf

    which does not include the Royal College Midwives response, but their reaction to th e guidance is below.
    Midwives question use of carbon monoxide monitoring

    for pregnant women who smoke

    Commenting on the NICE Guidelines on quitting smoking in pregnancy and following childbirth published today (23 June 2010), Sue Macdonald, Education and Research Manager at the Royal College of Midwives, said: “We welcome these guidelines, because there is no doubt about the negative effects of smoking on the health of women and their babies. Midwives and other health workers should be doing all they can to encourage women to stop smoking. However, this must be in the context of being non – judgemental, non-biased, and being aware that smoking rates amongst the more vulnerable women are often high.

    “Strategies for smoking cessation should apply to all women regardless of being pregnant. There is no doubt that most women are aware of the effects of smoking. The challenge is to reduce the numbers doing it.

    “There appears to an emphasis on pregnant women, which is appropriate given the evidence. However the key issue here for NICE is their emphasis on the CO2 monitor. It is crucial that health practitioners, including midwives, focus on being supportive rather than making women feeling guilty, or as though they may not be truthful. Use of the carbon monoxide monitor has the potential to make women feel guilty and not engaged. We need to look at a range of individualised interventions for women that meet their needs and aspirations.

    “There is also the cost implication of all midwives carrying monitors, and issues such as safety and infection control, and whether this is the best use of funds to address smoking cessation.”

    I think the RCM and I are in agreement. It’s rather amazing that NICE didn’t take account of midwives views – it is their practice that the guidance is all about.

  5. Bob Phillips July 6, 2010 at 11:58 am #

    Well, that’s shocking – the Royal College Midwives didn’t get a response in to the draft guidance, and it’s also pretty surprising that the RCOG didn’t pick it up either. Surely the RCM should have been a stakeholder, and circulated with the information, and responded to such an important guideline?

    I guess the other interesting thing is that there are at least two GPs in the country who support the routine use of CO testing. Instead of viewing it as disbelief in the woman’s smoking claims, could this be viewed in a similar light to the HIV testing of all volunteer blood donors?

  6. Margaret McCartney
    margaretmccartney July 6, 2010 at 9:45 pm #

    The RCM are going to raise the non appearance of their comments with NICE. They were stakeholders – but as it is I agree, it is uncertain whether NICE accounted for their concerns – they certainly haven’t shown that they have.

    I think the HIV comparison is a bit different – you aren’t being disbelieved about your status or not – you may not know it. If you are asked to do a CO test as a declared non smoker, it’s tantamount to your clinician not believing you.

  7. Bob Phillips July 7, 2010 at 8:52 am #

    Yup – fair point about the HIV test.

    I think there are similar sorts of problems raise by the NPSAs recent pregnancy/pre-surgery rapid response (http://bit.ly/b9Uxot ). In view of unanticipated pregnancy and surgery leading to miscarriage, organisations are being asked to consider blanket testing of all potentially-pregnant women (ie post-menarche, pre-menopause) undergoing surgery.

    In this setting, if you declare there is no chance you can be pregnant, yet are tested, it’s the same issue as the CO monitor. And similar risks and benefits being balanced, ethically, although the scales may differ.

    (The background documents adds a bit more to the short report – it suggests The American Society of Anesthesiologists suggests “The Task Force recognises that a history and physical examination may be insufficient for identification of early pregnancy. Pregnancy testing may be considered for all female patients of childbearing age.” and NICE 2003 pre-op testing has “Testing may also be considered for a woman with a history of last menstrual period or who says that it is not possible for her to be pregnant.”)

  8. Kerry July 8, 2010 at 7:00 am #

    My reaction? For fucks sake! I determine whether people smoke by ASKING them. I refer them to stop smoking services if they want me to, not if they don’t. Brief interventions are apparently the best anyway.

    Looking at the algorithm doing the CO test is number 1, three steps before ASKING HER

    Something is truly rotten in the state of Great Britain, when did things get so dumb?

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