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Module 9

The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation. Medical Futility. Module 9. Objectives. List factors that might lead to futility situations Understand how to identify common factors

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Module 9

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  1. The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation Medical Futility Module 9

  2. 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

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

  4. Definitions of medical futility • 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

  5. 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

  6. 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

  7. Differential diagnosis of futility situations • Inappropriate surrogate • Misunderstanding • Personal factors • Values conflict

  8. 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?

  9. Misunderstanding of diagnosis / prognosis • Underlying causes • How to assess • How to respond

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

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

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

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

  14. Personal factors • Distrust • Guilt • Grief • Intrafamily issues • Secondary gain • Physician / nurse

  15. Types of futility conflicts • Disagreement over • goals • benefit

  16. Difference in values • Religious • Miracles • Value of life

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

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

  19. Medical Futility Summary

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