Upload
marjory-morris
View
223
Download
0
Embed Size (px)
Citation preview
EEPPEECC
EEPPEECC
Medical Futility Medical FutilityModule 9Module 9Module 9Module 9
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
ObjectivesObjectives
List factors that might lead to futility List factors that might lead to futility situationssituations
Understand Understand
how to identify common factorshow to identify common factors
how to communicate and negotiate to how to communicate and negotiate to resolve conflict directlyresolve conflict directly
the steps involved in fair processes to the steps involved in fair processes to resolve intractable conflictresolve intractable conflict
List factors that might lead to futility List factors that might lead to futility situationssituations
Understand Understand
how to identify common factorshow to identify common factors
how to communicate and negotiate to how to communicate and negotiate to resolve conflict directlyresolve conflict directly
the steps involved in fair processes to the steps involved in fair processes to resolve intractable conflictresolve intractable conflict
Physicians and futilityPhysicians and futility
Patients / families may be invested in Patients / families may be invested in interventionsinterventions
Physicians / other professionals may Physicians / other professionals may be invested in interventionsbe invested in interventions
Any party may perceive futilityAny party may perceive futility
Patients / families may be invested in Patients / families may be invested in interventionsinterventions
Physicians / other professionals may Physicians / other professionals may be invested in interventionsbe invested in interventions
Any party may perceive futilityAny party may perceive futility
Definitions of medical futilityDefinitions of medical futility Won’t achieve the patient’s goalWon’t achieve the patient’s goal
Serves no legitimate goal of medical Serves no legitimate goal of medical practicepractice
Ineffective more than 99% of the timeIneffective more than 99% of the time
Does not conform to accepted Does not conform to accepted community standardscommunity standards
Won’t achieve the patient’s goalWon’t achieve the patient’s goal
Serves no legitimate goal of medical Serves no legitimate goal of medical practicepractice
Ineffective more than 99% of the timeIneffective more than 99% of the time
Does not conform to accepted Does not conform to accepted community standardscommunity standards
Is this really a futility case?Is this really a futility case? Unequivocal cases of medical futility Unequivocal cases of medical futility
are rareare rare
Miscommunication, value differences Miscommunication, value differences are more commonare more common
Case resolution more important than Case resolution more important than definitionsdefinitions
Unequivocal cases of medical futility Unequivocal cases of medical futility are rareare rare
Miscommunication, value differences Miscommunication, value differences are more commonare more common
Case resolution more important than Case resolution more important than definitionsdefinitions
Conflict over treatmentConflict over treatment
Unresolved conflicts lead to miseryUnresolved conflicts lead to misery
most can be resolvedmost can be resolved
Try to resolve differencesTry to resolve differences
Support the patient / familySupport the patient / family
Base decisions onBase decisions on
informed consent, advance care informed consent, advance care planning, goals of careplanning, goals of care
Unresolved conflicts lead to miseryUnresolved conflicts lead to misery
most can be resolvedmost can be resolved
Try to resolve differencesTry to resolve differences
Support the patient / familySupport the patient / family
Base decisions onBase decisions on
informed consent, advance care informed consent, advance care planning, goals of careplanning, goals of care
Differential diagnosis of futility situationsDifferential diagnosis of futility situations Inappropriate surrogateInappropriate surrogate
MisunderstandingMisunderstanding
Personal factorsPersonal factors
Values conflictValues conflict
Inappropriate surrogateInappropriate surrogate
MisunderstandingMisunderstanding
Personal factorsPersonal factors
Values conflictValues conflict
Surrogate selectionSurrogate selection
Patient’s stated preferencePatient’s stated preference
Legislated hierarchyLegislated hierarchy
Who is most likely to know what the Who is most likely to know what the patient would have wanted?patient would have wanted?
Who is able to reflect the patient’s best Who is able to reflect the patient’s best interest?interest?
Does the surrogate have the cognitive Does the surrogate have the cognitive ability to make decisions?ability to make decisions?
Patient’s stated preferencePatient’s stated preference
Legislated hierarchyLegislated hierarchy
Who is most likely to know what the Who is most likely to know what the patient would have wanted?patient would have wanted?
Who is able to reflect the patient’s best Who is able to reflect the patient’s best interest?interest?
Does the surrogate have the cognitive Does the surrogate have the cognitive ability to make decisions?ability to make decisions?
Misunderstanding of diagnosis / prognosisMisunderstanding of diagnosis / prognosis Underlying causesUnderlying causes
How to assessHow to assess
How to respondHow to respond
Underlying causesUnderlying causes
How to assessHow to assess
How to respondHow to respond
Misunderstanding: underlying causes . . .Misunderstanding: underlying causes . . . Doesn’t know the diagnosisDoesn’t know the diagnosis
Too much jargonToo much jargon
Different or conflicting information Different or conflicting information
Previous overoptimistic prognosisPrevious overoptimistic prognosis
Stressful environmentStressful environment
Doesn’t know the diagnosisDoesn’t know the diagnosis
Too much jargonToo much jargon
Different or conflicting information Different or conflicting information
Previous overoptimistic prognosisPrevious overoptimistic prognosis
Stressful environmentStressful environment
. . . Misunderstanding: underlying causes. . . Misunderstanding: underlying causes Sleep deprivationSleep deprivation
Emotional distress Emotional distress
Psychologically unprepared Psychologically unprepared
Inadequate cognitive abilityInadequate cognitive ability
Sleep deprivationSleep deprivation
Emotional distress Emotional distress
Psychologically unprepared Psychologically unprepared
Inadequate cognitive abilityInadequate cognitive ability
Misunderstanding: how to respond . . .Misunderstanding: how to respond . . . Choose a primary communicator Choose a primary communicator
Give information inGive information in
small piecessmall pieces
multiple formatsmultiple formats
Use understandable language Use understandable language
Frequent repetition may be requiredFrequent repetition may be required
Choose a primary communicator Choose a primary communicator
Give information inGive information in
small piecessmall pieces
multiple formatsmultiple formats
Use understandable language Use understandable language
Frequent repetition may be requiredFrequent repetition may be required
. . . Misunderstanding: how to respond. . . Misunderstanding: how to respond Assess understanding frequentlyAssess understanding frequently
Do not hedge to “provide hope”Do not hedge to “provide hope”
Encourage writing down questionsEncourage writing down questions
Provide supportProvide support
Involve other health care Involve other health care professionalsprofessionals
Assess understanding frequentlyAssess understanding frequently
Do not hedge to “provide hope”Do not hedge to “provide hope”
Encourage writing down questionsEncourage writing down questions
Provide supportProvide support
Involve other health care Involve other health care professionalsprofessionals
Personal factorsPersonal factors
DistrustDistrust
GuiltGuilt
GriefGrief
Intrafamily issuesIntrafamily issues
Secondary gainSecondary gain
Physician / nursePhysician / nurse
DistrustDistrust
GuiltGuilt
GriefGrief
Intrafamily issuesIntrafamily issues
Secondary gainSecondary gain
Physician / nursePhysician / nurse
Types of futility conflicts Types of futility conflicts
Disagreement overDisagreement over
goalsgoals
benefitbenefit
Disagreement overDisagreement over
goalsgoals
benefitbenefit
Difference in valuesDifference in values
ReligiousReligious
MiraclesMiracles
Value of lifeValue of life
ReligiousReligious
MiraclesMiracles
Value of lifeValue of life
A due process approach to futility . . .A due process approach to futility . . . Earnest attempts in advanceEarnest attempts in advance
Joint decision makingJoint decision making
Negotiation of disagreementsNegotiation of disagreements
Involvement of an institutional Involvement of an institutional committeecommittee
Earnest attempts in advanceEarnest attempts in advance
Joint decision makingJoint decision making
Negotiation of disagreementsNegotiation of disagreements
Involvement of an institutional Involvement of an institutional committeecommittee
. . . A due process approach to futility. . . A due process approach to futility Transfer of care to another physicianTransfer of care to another physician
Transfer to another institutionTransfer to another institution
Transfer of care to another physicianTransfer of care to another physician
Transfer to another institutionTransfer to another institution
EEPPEECC
EEPPEECC Medical Futility Medical Futility
SummarySummaryMedical Futility Medical Futility
SummarySummary