EEPPEECC

Medical FutilityModule 9Module 9

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

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

situationssituations Understand Understand

how to identify common factorshow to identify common factorshow to communicate and negotiate to how to communicate and negotiate to

resolve conflict directlyresolve conflict directlythe steps involved in fair processes to the steps involved in fair processes to

resolve intractable conflictresolve intractable conflict

Physicians and futility Patients / families may be invested in Patients / families may be invested in

interventionsinterventions Physicians / other professionals may Physicians / other professionals may

be invested in interventionsbe invested in interventions Any party may perceive futilityAny party may perceive futility

Definitions of medical futility Won’t achieve the patient’s goalWon’t achieve the patient’s goal Serves no legitimate goal of medical Serves no legitimate goal of medical

practicepractice Ineffective more than 99% of the timeIneffective more than 99% of the time Does not conform to accepted Does not conform to accepted

community standardscommunity standards

Is this really a futility case? Unequivocal cases of medical futility Unequivocal cases of medical futility

are rareare rare Miscommunication, value differences Miscommunication, value differences

are more commonare more common Case resolution more important than Case resolution more important than

definitionsdefinitions

Conflict over treatment Unresolved conflicts lead to miseryUnresolved conflicts lead to misery

most can be resolvedmost can be resolved Try to resolve differencesTry to resolve differences Support the patient / familySupport the patient / family Base decisions onBase decisions on

informed consent, advance care informed consent, advance care planning, goals of careplanning, goals of care

Differential diagnosis of futility situations Inappropriate surrogateInappropriate surrogate MisunderstandingMisunderstanding Personal factorsPersonal factors Values conflictValues conflict

Surrogate selection Patient’s stated preferencePatient’s stated preference Legislated hierarchyLegislated hierarchy Who is most likely to know what the Who is most likely to know what the

patient would have wanted?patient would have wanted? Who is able to reflect the patient’s best Who is able to reflect the patient’s best

interest?interest? Does the surrogate have the cognitive Does the surrogate have the cognitive

ability to make decisions?ability to make decisions?

Misunderstanding of diagnosis / prognosis Underlying causesUnderlying causes How to assessHow to assess How to respondHow to respond

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

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

Misunderstanding: how to respond . . . Choose a primary communicator Choose a primary communicator Give information inGive information in

small piecessmall piecesmultiple formatsmultiple formats

Use understandable language Use understandable language Frequent repetition may be requiredFrequent repetition may be required

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

professionalsprofessionals

Personal factors DistrustDistrust GuiltGuilt GriefGrief Intrafamily issuesIntrafamily issues Secondary gainSecondary gain Physician / nursePhysician / nurse

Types of futility conflicts Disagreement overDisagreement over

goalsgoalsbenefitbenefit

Difference in values ReligiousReligious MiraclesMiracles Value of lifeValue of life

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

committeecommittee

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

EEPPEECC Medical Futility Medical Futility

SummarySummary