American Osteopathic Association

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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
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Module 9

• Medical Futility

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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 patients universe

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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

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The Nature and Limitations of Futility
Definitions

• Wont achieve the patients 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.

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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

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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

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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

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Surrogate selection

• Patients stated preference
• Legislated hierarchy
• Who is most likely to know what the patient would
  have wanted?
• Who is able to reflect the patients best
  interest?
• Does the surrogate have the cognitive ability to
  make decisions?

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Misunderstanding of diagnosis / prognosis

• Underlying causes
• How to assess
• How to respond

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Misunderstanding underlying causes . . .

• Doesnt know the diagnosis
• Too much jargon
• Different or conflicting information
• Previous overoptimistic prognosis
• Stressful environment

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. . . Misunderstanding underlying causes

• Sleep deprivation
• Emotional distress
• Psychologically unprepared
• Inadequate cognitive ability

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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

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. . . Misunderstanding how to respond

• Assess understanding frequently
• Do not hedge to provide hope
• Encourage writing down questions
• Provide support
• Involve other health care professionals

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Personal factors

• Distrust
• Guilt
• Grief
• Intrafamily issues
• Secondary gain
• Physician / nurse

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Types of futility conflicts

• Disagreement over
• Goals
• Benefit
• Whatever the conflict, it is important to
  reaffirm the values and desires of the patient

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Difference in values

• Religious
• Miracles
• Value of life

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A due process approach to futility . . .

• Earnest attempts in advance
• Joint decision making
• Negotiation of disagreements
• Involvement of an institutional committee

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. . . A due process approach to futility

• Transfer of care to another physician
• Transfer to another institution

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Medical Futility

• Summary