1. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms 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 American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Module 9 Medical Futility

3. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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 patient’s universe

4. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

5. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours The Nature and Limitations of Futility “Definitions” Won’t achieve the patient’s 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.”

6. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

7. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

8. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

9. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Surrogate selection Patient’s stated preference Legislated hierarchy Who is most likely to know what the patient would have wanted? Who is able to reflect the patient’s best interest? Does the surrogate have the cognitive ability to make decisions?

10. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Misunderstanding of diagnosis / prognosis Underlying causes How to assess How to respond

11. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Misunderstanding: underlying causes... Doesn’t know the diagnosis Too much jargon Different or conflicting information Previous overoptimistic prognosis Stressful environment

12. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... Misunderstanding: underlying causes Sleep deprivation Emotional distress Psychologically unprepared Inadequate cognitive ability

13. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

14. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... Misunderstanding: how to respond Assess understanding frequently Do not hedge to “provide hope” Encourage writing down questions Provide support Involve other health care professionals

15. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Personal factors Distrust Guilt Grief Intrafamily issues Secondary gain Physician / nurse

16. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Types of futility conflicts Disagreement over Goals Benefit Whatever the conflict, it is important to reaffirm the values and desires of the patient

17. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Difference in values Religious Miracles Value of life

18. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours A due process approach to futility... Earnest attempts in advance Joint decision making Negotiation of disagreements Involvement of an institutional committee

19. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... A due process approach to futility Transfer of care to another physician Transfer to another institution

20. EPECEPECEPECEPEC American Osteopathic Association D.O.s: Physicians Treating People, Not Just Symptoms Medical Futility Summary