Osteopathic EPEC Module 7 - 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
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American
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AOA:Treating
Treating
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Module 7
Goals of Care
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Objectives . . .
•
Understand the different goals and how
they interrelate and change
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style
• Understand how to use the 7-step
protocol to negotiate goals of care
•
•
Be
able to
prognosis and its
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to communicate
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uncertainty
style
Understand how to tell the truth and
identify reasonable hope
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. . . Objectives
• Be able
use language
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to to
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Mastereffectively
title
• Be able to set limits on
style
unreasonable goals
• Be able to adjust care and
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communication according to culture
style
• Understand how to identify goals
when patients lack capacity
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Introduction . . .
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to edit
titleof
• Everyone
has aMaster
personal sense
style
• Who we are
• What we like to do
•
Control
we like
to have
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to edit
Master
subtitle
•style
Goals for our lives
• Things we hope for
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. . . Introduction
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togoals,
editexpectations
Master title
• Hope,
change
with illness
style
• Physician’s role to clarify goals,
treatment plan
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style
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Potential goals of care
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edit Master
• Cure to
of disease
• Relief title
of suffering
• Avoidance of
• Quality of life
style
premature death
•
•
Staying in control
Maintenance or
• Asubtitle
good death
in Master
improvement
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function
style
• Support for
• Prolongation of
families and
life
loved ones
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Historically, a dichotomous
division of goals of care
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• Focus on curing illness
style
• Little attention to relief of
careMaster
of dying
suffering,
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subtitle
style / palliative care arose in
• Hospice
response to a need
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Figure 1: A dichotomous intent
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Curative / life-prolonging therapy
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style

Presentation
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style
Death
Relieve suffering (hospice)
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Multiple goals of care
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• Multiple goals often apply
style
simultaneously
• Goals are often contradictory
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• Certain goals may take priority over
style
others
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Patient-centered Care
•
Goals of Patient - initial assessment
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• May Vary over time - ongoing
style
assessment
• Curative  Palliative
Self to
 Family
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edit Master subtitle
•style
Physical  Spiritual
•
• Integrated  Focused
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Goals may change
•
Osteopathic Principles make very clear
the distinction of treating disease that
occurs in patients and caring for the
patient in whom disease occurs
•
Some goals take precedence over others
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style
•
Click
Master
shifttoinedit
focus
of caresubtitle
• style
Is gradual
The
•
Is an expected part of the continuum of
medical care
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EFigure 2: The interrelationship of therapies with
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Pcurative and palliative intent
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Curative / life-prolonging therapy
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style

Presentation
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style
Death
Relieve suffering (palliative care)
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Palliative care: expanding
the options . . .
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• Interdisciplinary care
style
• Symptom control
• Supportive
care
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Master subtitle
style
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. . . Palliative care:
expanding the options
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to edit Master
• Any life-threatening
diagnosis title
• Anytime during illness
style
•
Whenever patient / family prepared to
accept it
•
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May
be combined with curative therapies
style
•
May be focus of care

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7-step protocol to
negotiate goals of care . . .
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tothe
edit
1. Create
rightMaster
setting title
style
2. Determine what the patient and
family know
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edit they
Master
3. Explore
aresubtitle
expecting or
style for
hoping
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. . . 7-step protocol to
negotiate goals of care
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to empathically
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4. Respond
5. Suggest realistic goals
style
6. Make a plan and follow-through including
clarification/documentation of code
status
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style and revise periodically, as
7. Review
appropriate
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Communicating prognosis
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to edittheMaster
title
• Over-estimate
likelihood of
a good
prognosis
style
•
Helps patient / family cope, plan
•
•
Increase access to hospice, other services
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Offer a range or average for life
style
expectancy

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Truth-telling and
maintaining hope
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edit
title
• Falseto
hope
mayMaster
deflect from
other
important issues
style
• True clinical skill to help find hope
for realistic goals
 Click to edit Master subtitle
style
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Language with unintended
consequences
• Do you
to do everything
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towant
editus Master
title
possible?
style
• Will you agree to discontinue care?
•
It’s time we talk about pulling back
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• I think
style we should stop aggressive
therapy
•
I’m going to make it so he won’t
suffer
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Language to describe
the goals of care . . .
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totoedit
Master
title
• I want
give the
best care
possible
until
the
day
you
die
style
• We will concentrate on improving
the quality of your child’s life
 Click to edit Master subtitle
• We
want to help you live
style
meaningfully in the time that you
have
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Language to describe
the goals of care . . .
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toeverything
edit Master
titleyou
• I’ll do
I can to help
maintain
your
independence
style
• I want to ensure that your father
receives the kind of treatment he
wants
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style
• Your child’s comfort and dignity will
be my top priority
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. . . Language to describe
the goals of care
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edit
Master
title
• I willto
focus
my efforts
on treating
your symptoms
style
• Let’s discuss what we can do to
fulfill your wish to stay at home
 Click to edit Master subtitle
stylediscuss what we can do to
• Let’s
have your child die at home
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Cultural differences
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Master title
• Who to
getsedit
the information?
style
• How to talk about information?
• Who makes decisions?
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• Ask
the
patient
style
• Consider a family meeting
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Determine specific
priorities
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toonedit
Master
title
• Based
values,
preferences,
clinical circumstances
style
• Influenced by information from
physician, team members
 Click to edit Master subtitle
style
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Reviewing goals,
treatment priorities
• Goalsto
guide
care Master title
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edit
• Assess priorities to develop initial plan of
style
care
•
Review with any change in
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tostatus
edit Master subtitle
Health
• style
Advancing illness
•
•
•
Setting of care
Treatment preferences
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When the physician cannot
support a patient’s choices
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to edit
title
• Typically
occursMaster
when goals
are
unreasonable, illegal
style
• Set limits without implying
abandonment
 Click to edit Master subtitle
stylethe conflict explicit
• Make
• Try to find an alternate solution
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Reassess decision-making
capacity . . .
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totheedit
title
• Implies
abilityMaster
to understand
and
make own decision
style
•
Patient must
•
Understand information
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to edit Master subtitle
Use the information rationally
• style
Appreciate the consequences

•
•
Come to a reasonable decision for him or
her
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. . . Reassess decisionmaking capacity
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to edit
Master title
• Any physician
can determine
• Capacity varies by decision
style
•
Other cognitive abilities do not need to be
intact. Patient does not need to demonstrate
global
cognitive capabilities, as a
 Click to edit Master subtitle
prerequisite to expressing their wishes for
style decisions (patient may not be
end-of-life
able to recall to route to the grocery store,
but may clearly express a decision about
resuscitation.
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When a patient lacks
capacity . . .
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todecision-maker
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• Proxy
style
• Sources of information
• Written advance directives
•
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to edit
Master
subtitle
Patient’s
verbal
statements
•style
Patient’s general values and beliefs
• How patient lived his / her life
• Best interest determinations
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. . . When a patient lacks
capacity
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• Why turn to others
style
• Respects patient
• Builds trust
•
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to edit
subtitle
Reduces
guiltMaster
and decision-regret
style
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Goals of Care
Summary
American Osteopathic Association
AOA: Treating Our Family and Yours

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