Osteopathic EPEC Module 9 - American Osteopathic Association

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Osteopathic EPEC
Education for Osteopathic Physicians on End-of-Life Care
Based on The EPEC Project, created by the American Medical Association
and supported by the Robert Wood Johnson Foundation. Adapted by the
American Osteopathic Association for educational use.
American
Osteopathic
Association
American
Osteopathic
Association
D.O.s: AOA:
Physicians
Treating
People,
NotYours
Just Symptoms
Treating
Our Family
and
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Module 9
Medical Futility
American Osteopathic Association
D.O.s: Physicians Treating People, Not Just Symptoms
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Objectives
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List factors that might lead to futility situations
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Understand
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How to identify common factors
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How to communicate and negotiate to resolve
conflict directly
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The steps involved in fair processes to resolve
intractable conflict
Understand the importance of implementing the
best possible processes for the patient and others
in that patient’s universe
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AOA: Treating Our Family and Yours
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Physicians and futility
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Patients / families may be invested in
interventions
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Physicians / other professionals may be invested
in interventions
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Any party may perceive futility
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Physicians must acknowledge their own feelings
about each unique patient encounter
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Differences should be resolved in a manner that
respects the patient as well as professional
expertise of provider
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The Nature and Limitations of
Futility “Definitions”
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Won’t achieve the patient’s goal
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Serves no legitimate goal of medical practice
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Ineffective more than 99% of the time
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Does not conform to accepted community
standards
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Some argue that physicians should rely on
the principle, “first do no harm.”
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Is this really a futility
case?
• Unequivocal cases of medical
futility are rare
• Miscommunication, value
differences are more common
• Case resolution more important
than definitions
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Conflict over treatment
• Unresolved conflicts lead to misery
• Most can be resolved
• Try to resolve differences
• Support the patient / family
• Base decisions on
• Informed consent, advance care
planning, goals of care
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AOA: Treating Our Family and Yours
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Differential diagnosis of
futility situations
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Inappropriate surrogate
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Misunderstanding
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Personal factors
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Values conflict
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Important to have a shared
understanding on the healthcare team –
ethical and legal resources should be
utilized
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AOA: Treating Our Family and Yours
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Surrogate selection
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Patient’s stated preference
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Legislated hierarchy
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Who is most likely to know what the
patient would have wanted?
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Who is able to reflect the patient’s
best interest?
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Does the surrogate have the cognitive
ability to make decisions?
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AOA: Treating Our Family and Yours
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Misunderstanding of
diagnosis / prognosis
• Underlying causes
• How to assess
• How to respond
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AOA: Treating Our Family and Yours
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Misunderstanding:
underlying causes . . .
• Doesn’t know the diagnosis
• Too much jargon
• Different or conflicting information
• Previous overoptimistic prognosis
• Stressful environment
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AOA: Treating Our Family and Yours
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. . . Misunderstanding:
underlying causes
• Sleep deprivation
• Emotional distress
• Psychologically unprepared
• Inadequate cognitive ability
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AOA: Treating Our Family and Yours
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Misunderstanding:
how to respond . . .
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Choose a primary communicator, but
provide access to all team members
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Give information in
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Small pieces
Multiple formats
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Use understandable language
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Frequent repetition may be required
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AOA: Treating Our Family and Yours
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. . . Misunderstanding:
how to respond
• Assess understanding frequently
• Do not hedge to “provide hope”
• Encourage writing down questions
• Provide support
• Involve other health care
professionals
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Personal factors
• Distrust
• Guilt
• Grief
• Intrafamily issues
• Secondary gain
• Physician / nurse
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Types of futility conflicts
• Disagreement over
• Goals
• Benefit
• Whatever the conflict, it is
important to reaffirm the values
and desires of the patient
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AOA: Treating Our Family and Yours
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Difference in values
• Religious
• Miracles
• Value of life
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AOA: Treating Our Family and Yours
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A due process
approach to futility . . .
• Earnest attempts in advance
• Joint decision making
• Negotiation of disagreements
• Involvement of an institutional
committee
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. . . A due process
approach to futility
• Transfer of care to another
physician
• Transfer to another institution
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AOA: Treating Our Family and Yours
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Medical Futility
Summary
American Osteopathic Association
D.O.s: Physicians Treating People, Not Just Symptoms

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