Osteopathic EPEC

1. 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 AOA: Treating Our Family and Yours American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms

2. Module 9 Medical Futility American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms

3. 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 American Osteopathic Association AOA: Treating Our Family and Yours

4. 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 American Osteopathic Association AOA: Treating Our Family and Yours

5. 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.” American Osteopathic Association AOA: Treating Our Family and Yours

6. 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 American Osteopathic Association AOA: Treating Our Family and Yours

7. 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 American Osteopathic Association AOA: Treating Our Family and Yours

8. 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 American Osteopathic Association AOA: Treating Our Family and Yours

9. 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? American Osteopathic Association AOA: Treating Our Family and Yours

10. Misunderstanding of diagnosis / prognosis • Underlying causes • How to assess • How to respond American Osteopathic Association AOA: Treating Our Family and Yours

11. Misunderstanding: underlying causes . . . • Doesn’t know the diagnosis • Too much jargon • Different or conflicting information • Previous overoptimistic prognosis • Stressful environment American Osteopathic Association AOA: Treating Our Family and Yours

12. . . . Misunderstanding: underlying causes • Sleep deprivation • Emotional distress • Psychologically unprepared • Inadequate cognitive ability American Osteopathic Association AOA: Treating Our Family and Yours

13. 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 American Osteopathic Association AOA: Treating Our Family and Yours

14. . . . Misunderstanding: how to respond • Assess understanding frequently • Do not hedge to “provide hope” • Encourage writing down questions • Provide support • Involve other health care professionals American Osteopathic Association AOA: Treating Our Family and Yours

15. Personal factors • Distrust • Guilt • Grief • Intrafamily issues • Secondary gain • Physician / nurse American Osteopathic Association AOA: Treating Our Family and Yours

16. Types of futility conflicts • Disagreement over • Goals • Benefit • Whatever the conflict, it is important to reaffirm the values and desires of the patient American Osteopathic Association AOA: Treating Our Family and Yours

17. Difference in values • Religious • Miracles • Value of life American Osteopathic Association AOA: Treating Our Family and Yours

18. A due process approach to futility . . . • Earnest attempts in advance • Joint decision making • Negotiation of disagreements • Involvement of an institutional committee American Osteopathic Association AOA: Treating Our Family and Yours

19. . . . A due process approach to futility • Transfer of care to another physician • Transfer to another institution American Osteopathic Association AOA: Treating Our Family and Yours

20. Medical Futility Summary American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms