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

EEPPEECC

American Osteopathic AssociationD.O.s: Physicians Treating People, Not Just Symptoms

Medical FutilitySummary