EPECEPECEPECEPEC EPECEPECEPECEPEC Medical Futility Medical Futility Module 9 The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation

Objectives l List factors that might lead to futility situations l 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 l List factors that might lead to futility situations l 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

Physicians and futility l Patients / families may be invested in interventions l Physicians / other professionals may be invested in interventions l Any party may perceive futility l Patients / families may be invested in interventions l Physicians / other professionals may be invested in interventions l Any party may perceive futility

Definitions of medical futility l Won’t achieve the patient’s goal l Serves no legitimate goal of medical practice l Ineffective more than 99% of the time l Does not conform to accepted community standards l Won’t achieve the patient’s goal l Serves no legitimate goal of medical practice l Ineffective more than 99% of the time l Does not conform to accepted community standards

Is this really a futility case? l Unequivocal cases of medical futility are rare l Miscommunication, value differences are more common l Case resolution more important than definitions l Unequivocal cases of medical futility are rare l Miscommunication, value differences are more common l Case resolution more important than definitions

Conflict over treatment l Unresolved conflicts lead to misery most can be resolved l Try to resolve differences l Support the patient / family l Base decisions on informed consent, advance care planning, goals of care l Unresolved conflicts lead to misery most can be resolved l Try to resolve differences l Support the patient / family l Base decisions on informed consent, advance care planning, goals of care

Differential diagnosis of futility situations l Inappropriate surrogate l Misunderstanding l Personal factors l Values conflict l Inappropriate surrogate l Misunderstanding l Personal factors l Values conflict

Surrogate selection l Patient’s stated preference l Legislated hierarchy l Who is most likely to know what the patient would have wanted? l Who is able to reflect the patient’s best interest? l Does the surrogate have the cognitive ability to make decisions? l Patient’s stated preference l Legislated hierarchy l Who is most likely to know what the patient would have wanted? l Who is able to reflect the patient’s best interest? l Does the surrogate have the cognitive ability to make decisions?

Misunderstanding of diagnosis / prognosis l Underlying causes l How to assess l How to respond l Underlying causes l How to assess l How to respond

Misunderstanding: underlying causes... l Doesn’t know the diagnosis l Too much jargon l Different or conflicting information l Previous overoptimistic prognosis l Stressful environment l Doesn’t know the diagnosis l Too much jargon l Different or conflicting information l Previous overoptimistic prognosis l Stressful environment

... Misunderstanding: underlying causes l Sleep deprivation l Emotional distress l Psychologically unprepared l Inadequate cognitive ability l Sleep deprivation l Emotional distress l Psychologically unprepared l Inadequate cognitive ability

Misunderstanding: how to respond... l Choose a primary communicator l Give information in small pieces multiple formats l Use understandable language l Frequent repetition may be required l Choose a primary communicator l Give information in small pieces multiple formats l Use understandable language l Frequent repetition may be required

... Misunderstanding: how to respond l Assess understanding frequently l Do not hedge to “provide hope” l Encourage writing down questions l Provide support l Involve other health care professionals l Assess understanding frequently l Do not hedge to “provide hope” l Encourage writing down questions l Provide support l Involve other health care professionals

Personal factors l Distrust l Guilt l Grief l Intrafamily issues l Secondary gain l Physician / nurse l Distrust l Guilt l Grief l Intrafamily issues l Secondary gain l Physician / nurse

Types of futility conflicts l Disagreement over goalsbenefit goalsbenefit

Difference in values l Religious l Miracles l Value of life l Religious l Miracles l Value of life

A due process approach to futility... l Earnest attempts in advance l Joint decision making l Negotiation of disagreements l Involvement of an institutional committee l Earnest attempts in advance l Joint decision making l Negotiation of disagreements l Involvement of an institutional committee

... A due process approach to futility l Transfer of care to another physician l Transfer to another institution l Transfer of care to another physician l Transfer to another institution

EPECEPECEPECEPEC EPECEPECEPECEPEC Medical Futility Summary Summary