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EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Osteopathic EPEC Osteopathic EPEC.

Published byErnest Marsh Modified over 9 years ago

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Presentation on theme: "EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Osteopathic EPEC Osteopathic EPEC."— Presentation transcript:

1 EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Osteopathic EPEC 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

2 EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Module 5 Physician-Assisted Suicide

3 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Objectives Define physician-assisted suicide (PAS) and euthanasia Describe their current status in the law Identify root causes of suffering that prompt requests

4 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... Objectives Understand a 6-step protocol for responding to requests Be able to meet most patients’ needs

5 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Physician-assisted suicide/euthanasia... Ancient medical issue Aiding or causing a suffering person’s death physician-assisted suicide 1. physician provides the means, patient acts euthanasia ­ physician performs the intervention

6 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... Physician-assisted suicide / euthanasia Many physicians receive a request Requests are a sign of patient crisis

7 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Why patients ask for PAS Asking for help Fear of psychosocial, mental suffering future suffering, loss of control, indignity, being a burden Depression Physical suffering

8 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC The legal and ethical debate... Principles obligation to relieve pain and suffering respect decisions to forgo life-sustaining treatment The ethical debate is ancient US Supreme Court recognized No right to PAS

9 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... The legal and ethical debate The legal status of PAS can differ from state to state Oregon is the only state where PAS is legal (as of 1999) Supreme Court Justices supported right to palliative care

10 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC 6-step protocol to respond to requests... 1. Clarify the request 2. Assess the underlying causes of the request 3. Affirm your commitment to care for the patient

11 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... 6-step protocol to respond to requests 4.Address the root causes of the request 5.Educate the patient and discuss legal alternatives 6.Consult with colleagues

12 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Step 1: Clarify the request Immediate, compassionate response Open-ended questions Suicidal thoughts, plans? Be aware of personal biases potential for counter-transference

13 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Step 2: Assess underlying causes... The 4 dimensions of suffering physical psychological social spiritual

14 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... Step 2: Assess underlying causes Particular focus on fears about the future depression, anxiety

15 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Assess for clinical depression... Underdiagnosed, undertreated Source of suffering Barrier to life closure, “good death” Diagnosis challenging no somatic symptoms helplessness, hopelessness, worthlessness

16 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... Assess for clinical depression Treatment choices depend on time available fast-acting psychostimulants SSRIs tricyclic anti-depressants

17 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Psychosocial suffering, practical concerns... Sense of shame Not feeling wanted Inability to cope Loss of function self-image control, independence

18 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... Psychosocial suffering, practical concerns Tension with relationships Increased isolation, misery Worries about practical matters who caregivers will be how domestic chores will be tended to who will care for dependents, pets

19 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Physical suffering Pain Breathlessness Anorexia/ cachexia Weakness/ fatigue Loss of function Nausea/vomiting Constipation Dehydration Edema Incontinence

20 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Spiritual suffering Existential concerns Meaning, value, purpose in life Abandoned, punished by God questions faith, religious beliefs anger

21 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Common fears Future Pain, other symptoms Loss of control, independence Abandonment, loneliness Indignity, loss of self-image Being a burden on others

22 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Step 3: Affirm your commitment Listen, acknowledge feelings, fears Explain your role Commit to help find solutions Explore current concerns

23 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Step 4: Address root causes Professional competence in: Withholding / withdrawal interventions aggressive comfort measures palliative care principles local palliative care programs Address suffering, fears

24 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Address psychological suffering Treat depression anxiety delirium Individual, group counseling Specialty referral as appropriate

25 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Address social suffering, practical concerns... Family situation Finances Legal affairs

26 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... Address social suffering, practical concerns What setting of care Who caregivers will be How to manage domestic chores Who will care for dependents, pets

27 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Address physical suffering… Aggressive symptom management Maximize residual functional capacity utilizing Osteopathic Manipulative Treatment Engage other health professionals Nursing, Physical therapy, Occupational therapy, Pharmacy, Dietary, Counseling

28 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC …Address spiritual suffering Explore prayer transcendental dimension meaning, purpose in life the power of touch gift giving, legacies Consult chaplain, psychiatrist, psychologist

29 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Address fear of loss of control... Explore areas of control, independence Right to determine one’s own medical care accept or refuse any medical intervention life-sustaining therapies

30 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... Address fear of loss of control Select personal advocate(s) proxy for decision-making Prepare advance directives Plan for death Make a commitment to help patient maintain as much control as possible

31 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Address fear of pain, other symptoms Explain control of pain, other symptoms sedation for intractable symptoms Commitment to manage symptoms

32 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Address fear of being a burden Establish specifics worry about caregiving 1. family willing 2. alternate settings worry about finances ­ resources, services available Refer to a social worker

33 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Address fear of indignity Discuss what indignity means to the individual dependence, burden, embarrassment Importance of control Explore resources to maintain dignity Reassure patient

34 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Address fear of abandonment Assurance that physician will continue to be involved in care Resources provided by hospice and palliative care

35 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Step 5: Educate, discuss legal alternatives Information giving Refusal of treatment Withdrawal of treatment Declining oral intake Sedation

36 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Decline oral intake... Any person can decline oral intake Force-feeding not acceptable Ensure food, water always accessible

37 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... Decline oral intake Accept / decline artificial hydration, nutrition Educate, support family members, caregivers re-focus their need to give care

38 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC End-of-life sedation... When symptoms are intractable at the end of life Continuous, intermittent Death attributed to illness, not sedation

39 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC... End-of-life sedation Benzodiazepines Anesthetics Barbiturates Continue analgesics

40 EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours EPECEPECEPECEPEC Step 6: Consult with colleagues Seek support from trusted colleagues Reasons for reluctance to consult

41 EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Physician-Assisted Suicide Summary

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