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