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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. - PowerPoint PPT Presentation
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Osteopathic EPECOsteopathic EPEC Osteopathic EPECOsteopathic 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 AssociationAOA: Treating Our Family and Yours
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Module 11
Withholding, Withdrawing Treatment
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Objectives• Know the principles for
withholding or withdrawing therapy
• Apply these principles to the withholding or withdrawal of• Artificial feeding, hydration
• Ventilation
• Cardiopulmonary resuscitation
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Role of the physician . . .• The physician helps the patient
and family • Elucidate their own values
• Decide about life-sustaining treatments
• Dispel misconceptions
• Understand goals of care
• Facilitate decisions, reassess regularly
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Role of the physician• Discuss alternatives
• Including palliative and hospice care
• Document preferences, medical orders
• Involve, inform other team members
• Assure comfort, non-abandonment
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Common concerns . . .• Legally required to “do
everything?”
• Is withdrawal, withholding euthanasia?
• Are you killing the patient when you remove a ventilator or treat pain?
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Common concerns• Can the treatment of
symptoms constitute euthanasia?
• Is the use of substantial doses of opioids euthanasia?
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Life-sustaining treatments• Resuscitation
• Elective intubation
• Surgery
• Dialysis
• Blood transfusions, blood products
• Diagnostic tests
• Artificial nutrition, hydration
• Antibiotics
• Other treatments
• Future hospital, ICU admissions
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
8-step protocol to discuss treatment preferences . . .1. Be familiar with policies,
statutes
2. Appropriate setting for the discussion
3. Ask the patient, family what they understand
4. Discuss general goals of care
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . 8-step protocol to discuss treatment preferences
5. Establish context for the discussion
6. Discuss specific treatment preferences
7. Respond to emotions
8. Establish and implement the plan
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Aspects of informed consent• Problem treatment would address
• What is involved in the treatment / procedure
• What is likely to happen if the patient decides not to have the treatment
• Treatment benefits
• Treatment burdens
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Example 1: Artifical nutrition, hydration• Difficult to discuss
• Food, water are symbols of caring
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Review goals of care
• Establish overall goals of care
• Will artificial feeding, hydration help achieve these goals?
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Address misperceptions• Cause of poor appetite,
fatigue
• Relief of dry mouth
• Delirium
• Urine output
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Help family with need to give care
• Identify feelings, emotional needs
• Identify other ways to demonstrate caring• Teach the skills they need
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Normal dying• Loss of appetite
• Decreased oral fluid intake
• Artificial food / fluids may make situation worse• Breathlessness• Edema• Ascites• Nausea / vomiting
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Example 2: Ventilator withdrawal• Rare, challenging
• Ask for assistance
• Assess appropriateness of request
• Role in achieving overall goals of care
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Immediate extubation• Remove the endotracheal tube
after appropriate suctioning
• Give humidified air or oxygen to prevent the airway from drying
• Ethically sound practice
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Terminal weaning• Rate, PEEP, oxygen levels are
decreased first
• Over 30–60 minutes or longer
• A Briggs T piece may be used in place of the ventilator
• Patients may then be extubated
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Ensure patient comfort• Anticipate and prevent
discomfort, offer OMT when indicated
• Have anxiolytics, opioids immediately available
• Titrate rapidly to comfort
• Be present to assess, reevaluate
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Prevent symptoms
• Breathlessness• Opioids
• Anxiety• Benzodiazepines
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Preparing for ventilator withdrawal• Determine degree of desired
consciousness
• Bolus 2-20 mg morphine IV, then continuous infusion
• Bolus 1-2 mg midazolam IV, then continuous infusion
• Titrate to degree of consciousness, comfort
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Prepare the family . . .• Describe the procedure
• Reassure that comfort is a primary concern
• Medication is available
• Patient may need to sleep to be comfortable
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Prepare the family• Involuntary movements
• Provide love and support
• Describe uncertainty
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Prior to withdrawal
• Prior to procedure• Discussion and agreement to
discontinue with patient (if conscious)
with family, nurses, respiratory therapists
• Document on the patient’s chart
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Withdrawal Protocol -– Part 1• Procedure
• Shut off alarms• Remove restraints • NG tube is removed • Family is invited into the room• Pressors are turned off• Parents may hold child
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Withdrawal protocol -- Part 2• Establish adequate symptom
control prior to extubation
• Have medications IN HAND • Midazolam, lorazepam, or diazepam
• Set FiO2 to 21%
• Adjust medications
• Remove the ET tube
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Withdrawal Protocol -- Part 3 . . .
• Invite family to bedside
• Washcloth, oral suction catheter, facial tissues
• Reassess frequently
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Withdrawal Protocol – Part 3• After the patient dies
• Talk with family and staff
• Provide acute grief support
• Offer bereavement support to family members• Follow up to ensure they are
okay
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Example 3: Cardiopulmonary resuscitation• Establish general goals of care
• Use understandable language
• Avoid implying the impossible
• Ask about other life-prolonging therapies
• Affirm what you will be doing
• Clarify that resuscitation really means an attempt with no guarantee of success
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Write appropriate medical orders
• DNR
• DNI
• Do not transfer
• Others
• POLST
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Withholding, Withdrawing Treatment
Summary