Legal Issues in Caring for Patients With Kidney Disease by Selectively Integrating Complementary Therapies

      Clinical integration of complementary and alternative medical (CAM) therapies, such as acupuncture and traditional oriental medicine, chiropractic, herbal medicine, massage therapy, and “mind-body” therapies, into conventional health care raises important legal and risk management issues. Understanding which CAM therapies patients use is legally prudent, as conventional treatment advice may interact with patients’ own efforts toward self-care. In addition, nephrologists may limit potential liability for medical malpractice by classifying any given therapy as follows: (1) the medical evidence supports both safety and efficacy—recommend; (2) the medical evidence supports safety, but evidence regarding efficacy is inconclusive—accept but monitor; (3) the medical evidence supports efficacy, but evidence regarding safety is inconclusive—accept but monitor; and (4) the medical evidence indicates either serious risk or inefficacy—avoid and discourage. Applying this framework whether a therapy is labeled “conventional” or “CAM” is consistent with the key recommendation of the recent report by the Institute of Medicine at the National Academy of Sciences on Complementary and Alternative Medicine, namely, to apply the same principles and standards of evidence of treatment effectiveness to all treatments. Liability risk management also includes going beyond legal and ethical informed consent requirements by engaging the patient in shared decision making concerning all material treatment options, including CAM therapies, if supported by evidence. Physicians further should familiarize themselves with documentation standards suggested by the Federation of State Medical Board Guidelines and whether these are applicable in their state or home institution. These steps aim to enable nephrologists to respond to patient interest in CAM therapies in a way that is clinically responsible, ethically appropriate, and legally defensible.

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