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American Osteopathic AssociationAOA: Treating Our Family and Yours

Osteopathic EPECOsteopathic EPEC Osteopathic EPECOsteopathic 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.


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Goals of CareModule 7

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Objectives . . .• Understand the different goals and

how they interrelate and change

• Understand how to use the 7-step protocol to negotiate goals of care

• Be able to communicate prognosis and its uncertainty

• Understand how to tell the truth and identify reasonable hope




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. . . Objectives• Be able to use language effectively

• Be able to set limits on unreasonable goals

• Be able to adjust care and communication according to culture

• Understand how to identify goals when patients lack capacity




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Introduction . . .

• Everyone has a personal sense of• Who we are

• What we like to do

• Control we like to have

• Goals for our lives

• Things we hope for




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. . . Introduction

• Hope, goals, expectations change with illness

• Physician’s role to clarify goals, treatment plan




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Potential goals of care• Cure of disease

• Avoidance of premature death

• Maintenance or improvement in function

• Prolongation of life

• Relief of suffering

• Quality of life

• Staying in control

• A good death

• Support for families and loved ones




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Historically, a dichotomous division of goals of care• Focus on curing illness

• Little attention to relief of suffering, care of dying

• Hospice / palliative care arose in response to a need




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Relieve suffering (hospice)Relieve suffering (hospice)

Curative / life-prolonging therapyCurative / life-prolonging therapy

PresentationPresentation DeathDeath

Figure 1: A dichotomous intentFigure 1: A dichotomous intent




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Multiple goals of care

• Multiple goals often apply simultaneously

• Goals are often contradictory

• Certain goals may take priority over others




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Patient-centered Care• Goals of Patient - initial

assessment

• May Vary over time - ongoing assessment

• Curative Palliative

• Self Family

• 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

• The shift in focus of care• Is gradual• Is an expected part of the continuum of

medical care




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Curative / life-prolonging therapyCurative / life-prolonging therapy

PresentationPresentation DeathDeath

Relieve suffering (palliative care)Relieve suffering (palliative care)

Figure 2: The interrelationship of therapies with Figure 2: The interrelationship of therapies with curative and palliative intentcurative and palliative intent




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Palliative care: expanding the options . . .• Interdisciplinary care

• Symptom control

• Supportive care




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. . . Palliative care: expanding the options• Any life-threatening diagnosis

• Anytime during illness

• Whenever patient / family prepared to accept it

• May be combined with curative therapies

• May be focus of care




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7-step protocol to negotiate goals of care . . .1. Create the right setting

2. Determine what the patient and family know

3. Explore what they are expecting or hoping for




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. . . 7-step protocol to negotiate goals of care4. Respond empathically

5. Suggest realistic goals

6. Make a plan and follow-through including clarification/documentation of code status

7. Review and revise periodically, as appropriate




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Communicating prognosis• Over-estimate the likelihood of a

good prognosis

• Helps patient / family cope, plan• Increase access to hospice, other

services

• Offer a range or average for life expectancy




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Truth-telling and maintaining hope• False hope may deflect from

other important issues

• True clinical skill to help find hope for realistic goals




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Language with unintended consequences• Do you want us to do everything

possible?

• Will you agree to discontinue care?

• It’s time we talk about pulling back

• I think we should stop aggressive therapy

• I’m going to make it so he won’t suffer




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Language to describethe goals of care . . .• I want to give the best care

possible until the day you die

• We will concentrate on improving the quality of your child’s life

• We want to help you live meaningfully in the time that you have




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Language to describethe goals of care . . .• I’ll do everything I can to help

you maintain your independence

• I want to ensure that your father receives the kind of treatment he wants

• Your child’s comfort and dignity will be my top priority




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. . . Language to describethe goals of care• I will focus my efforts on

treating your symptoms

• Let’s discuss what we can do to fulfill your wish to stay at home

• Let’s discuss what we can do to have your child die at home




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Cultural differences

• Who gets the information?

• How to talk about information?

• Who makes decisions?

• Ask the patient

• Consider a family meeting




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Determine specific priorities• Based on values, preferences,

clinical circumstances

• Influenced by information from physician, team members




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Reviewing goals,treatment priorities• Goals guide care

• Assess priorities to develop initial plan of care

• Review with any change in• Health status• Advancing illness• Setting of care• Treatment preferences




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When the physician cannot support a patient’s choices• Typically occurs when goals are

unreasonable, illegal

• Set limits without implying abandonment

• Make the conflict explicit

• Try to find an alternate solution




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Reassess decision-making capacity . . .• Implies the ability to understand

and make own decision

• Patient must • Understand information

• Use the information rationally

• Appreciate the consequences

• Come to a reasonable decision for him or her




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. . . Reassess decision-making capacity• Any physician can determine

• Capacity varies by decision

• Other cognitive abilities do not need to be intact. Patient does not need to demonstrate global cognitive capabilities, as a prerequisite to expressing their wishes for end-of-life decisions (patient may not be 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 . . .• Proxy decision-maker

• Sources of information• Written advance directives

• Patient’s verbal statements

• Patient’s general values and beliefs

• How patient lived his / her life

• Best interest determinations




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. . . When a patient lacks capacity

• Why turn to others• Respects patient

• Builds trust

• Reduces guilt and decision-regret

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Goals of CareSummary

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