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