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ATTRIBUTES OF GOOD PRACTICE GUIDELINES 69 CLINICAL FLEXIBILITY Flexibility requires that a set of guidelines identify, where warranted, exceptions to their recommendations. The objective of this attribute is to allow necessary leeway for clinical judgment, patient preferences, and clinically relevant conditions of the delivery system (including necessary equipment and skilled personnel).7 Operationalizing this attribute may be difficult. In the committee's view, a fairly rigorous approach should be adopted, one that requires a set of guidelines to (1) list the major foreseeable exceptions and the rationale for such exceptions, (2) categorize generally the less foreseeable or highly idiosyncratic circumstances that may warrant exceptions, (3) describe the basic information to be provided to patients and the kinds of patient preferences that may be appropriately considered, and (4) indicate what data are needed to document exceptions based on clinical circumstances, patient preferences, or delivery system characteristics. The role of patient preferences, whether considered in the context of daily clinical practice or in the context of developing guidelines, is a particularly complex issue. For example, there is much disagreement about the proper behavior for practitioners faced with preferences they believe are unreasonable or unacceptable (Brock and Wartman, 1990). Likewise, the balance between patient preferences and societal resources is the subject of intense debate. A thorough treatment of this issue was not part of the committee's charge. However, in addition to recommending that patient interests be taken into account at several points in the process of developing guidelines, the committee makes two observations. First, patient preference for a service generally need not be acceded to when the service cannot be expected to provide any benefit or when it can be expected to produce a clear excess of harm over benefit. Second, when a mentally competent patient unreasonably wishes (in a practitioner's view) to forego treatment, the practitioner can try to persuade the patient to accept care but cannot, with rare exceptions, insist on treatment. CLARITY Clarity means that guidelines are written in unambiguous language. Their presentation is logically organized and easy to follow, and the use of abbreviations, symbols, and similar aids is consistent and well explained. Key terms and those subject to misinterpretation are defined. Vague clinical 7 Clinical applicability and clinical flexibility could be grouped together as one attribute. Keeping them separate emphasizes the distinctions among the populations or settings that are covered by guidelines and those that are not so covered.