Transcript Osteopathic EPEC Module 7 - American Osteopathic Association

E
E
P
P
E
E
C
C
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
American
Osteopathic
Association
AOA:Treating
Treating
Our
Family
and
Yours
AOA:
Our
Family
and
Yours
E
E
P
P
E
E
C
C
Module 7
Goals of Care
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Objectives . . .
•
Understand the different goals and how
they interrelate and change
Click to edit Master title
style
• Understand how to use the 7-step
protocol to negotiate goals of care
•
•
Be
able to
prognosis and its
Click
to communicate
edit Master subtitle
uncertainty
style
Understand how to tell the truth and
identify reasonable hope
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
. . . Objectives
• Be able
use language
Click
to to
edit
Mastereffectively
title
• Be able to set limits on
style
unreasonable goals
• Be able to adjust care and
 Click to edit Master subtitle
communication according to culture
style
• Understand how to identify goals
when patients lack capacity
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Introduction . . .
Click
to edit
titleof
• Everyone
has aMaster
personal sense
style
• Who we are
• What we like to do
•
Control
we like
to have
Click
to edit
Master
subtitle
•style
Goals for our lives
• Things we hope for
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
. . . Introduction
Click
togoals,
editexpectations
Master title
• Hope,
change
with illness
style
• Physician’s role to clarify goals,
treatment plan
 Click to edit Master subtitle
style
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Potential goals of care
Click
edit Master
• Cure to
of disease
• Relief title
of suffering
• Avoidance of
• Quality of life
style
premature death
•
•
Staying in control
Maintenance or
• Asubtitle
good death
in Master
improvement
Click to edit
function
style
• Support for
• Prolongation of
families and
life
loved ones
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Historically, a dichotomous
division of goals of care
Click to edit Master title
• Focus on curing illness
style
• Little attention to relief of
careMaster
of dying
suffering,
Click to edit
subtitle
style / palliative care arose in
• Hospice
response to a need
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
Figure 1: A dichotomous intent
P
P
E
E
C
C
Curative / life-prolonging therapy
Click to edit Master title
style

Presentation
Click to edit Master subtitle
style
Death
Relieve suffering (hospice)
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Multiple goals of care
Click to edit Master title
• Multiple goals often apply
style
simultaneously
• Goals are often contradictory
 Click to edit Master subtitle
• Certain goals may take priority over
style
others
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Patient-centered Care
•
Goals of Patient - initial assessment
Click to edit Master title
• May Vary over time - ongoing
style
assessment
• Curative  Palliative
Self to
 Family
Click
edit Master subtitle
•style
Physical  Spiritual
•
• Integrated  Focused
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Goals may change
•
Osteopathic Principles make very clear
the distinction of treating disease that
occurs in patients and caring for the
patient in whom disease occurs
•
Some goals take precedence over others
Click to edit Master title
style
•
Click
Master
shifttoinedit
focus
of caresubtitle
• style
Is gradual
The
•
Is an expected part of the continuum of
medical care
American Osteopathic Association
AOA: Treating Our Family and Yours
EFigure 2: The interrelationship of therapies with
E
P
Pcurative and palliative intent
E
E
C
C
Curative / life-prolonging therapy
Click to edit Master title
style

Presentation
Click to edit Master subtitle
style
Death
Relieve suffering (palliative care)
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Palliative care: expanding
the options . . .
Click to edit Master title
• Interdisciplinary care
style
• Symptom control
• Supportive
care
Click to edit
Master subtitle
style
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
. . . Palliative care:
expanding the options
Click
to edit Master
• Any life-threatening
diagnosis title
• Anytime during illness
style
•
Whenever patient / family prepared to
accept it
•
Click to edit Master subtitle
May
be combined with curative therapies
style
•
May be focus of care

American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
7-step protocol to
negotiate goals of care . . .
Click
tothe
edit
1. Create
rightMaster
setting title
style
2. Determine what the patient and
family know
Click towhat
edit they
Master
3. Explore
aresubtitle
expecting or
style for
hoping
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
. . . 7-step protocol to
negotiate goals of care
Click
to empathically
edit Master title
4. Respond
5. Suggest realistic goals
style
6. Make a plan and follow-through including
clarification/documentation of code
status
Click to edit Master subtitle
style and revise periodically, as
7. Review
appropriate
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Communicating prognosis
Click
to edittheMaster
title
• Over-estimate
likelihood of
a good
prognosis
style
•
Helps patient / family cope, plan
•
•
Increase access to hospice, other services
Click to edit Master subtitle
Offer a range or average for life
style
expectancy

American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Truth-telling and
maintaining hope
Click
edit
title
• Falseto
hope
mayMaster
deflect from
other
important issues
style
• True clinical skill to help find hope
for realistic goals
 Click to edit Master subtitle
style
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Language with unintended
consequences
• Do you
to do everything
Click
towant
editus Master
title
possible?
style
• Will you agree to discontinue care?
•
It’s time we talk about pulling back
 Click to edit Master subtitle
• I think
style we should stop aggressive
therapy
•
I’m going to make it so he won’t
suffer
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Language to describe
the goals of care . . .
Click
totoedit
Master
title
• I want
give the
best care
possible
until
the
day
you
die
style
• We will concentrate on improving
the quality of your child’s life
 Click to edit Master subtitle
• We
want to help you live
style
meaningfully in the time that you
have
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Language to describe
the goals of care . . .
Click
toeverything
edit Master
titleyou
• I’ll do
I can to help
maintain
your
independence
style
• I want to ensure that your father
receives the kind of treatment he
wants
Click to edit Master subtitle
style
• Your child’s comfort and dignity will
be my top priority
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
. . . Language to describe
the goals of care
Click
edit
Master
title
• I willto
focus
my efforts
on treating
your symptoms
style
• Let’s discuss what we can do to
fulfill your wish to stay at home
 Click to edit Master subtitle
stylediscuss what we can do to
• Let’s
have your child die at home
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Cultural differences
Click
Master title
• Who to
getsedit
the information?
style
• How to talk about information?
• Who makes decisions?
 Click to edit Master subtitle
• Ask
the
patient
style
• Consider a family meeting
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Determine specific
priorities
Click
toonedit
Master
title
• Based
values,
preferences,
clinical circumstances
style
• Influenced by information from
physician, team members
 Click to edit Master subtitle
style
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Reviewing goals,
treatment priorities
• Goalsto
guide
care Master title
Click
edit
• Assess priorities to develop initial plan of
style
care
•
Review with any change in
Click
tostatus
edit Master subtitle
Health
• style
Advancing illness
•
•
•
Setting of care
Treatment preferences
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
When the physician cannot
support a patient’s choices
Click
to edit
title
• Typically
occursMaster
when goals
are
unreasonable, illegal
style
• Set limits without implying
abandonment
 Click to edit Master subtitle
stylethe conflict explicit
• Make
• Try to find an alternate solution
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Reassess decision-making
capacity . . .
Click
totheedit
title
• Implies
abilityMaster
to understand
and
make own decision
style
•
Patient must
•
Understand information
Click
to edit Master subtitle
Use the information rationally
• style
Appreciate the consequences

•
•
Come to a reasonable decision for him or
her
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
. . . Reassess decisionmaking capacity
Click
to edit
Master title
• Any physician
can determine
• Capacity varies by decision
style
•
Other cognitive abilities do not need to be
intact. Patient does not need to demonstrate
global
cognitive capabilities, as a
 Click to edit Master subtitle
prerequisite to expressing their wishes for
style decisions (patient may not be
end-of-life
able to recall to route to the grocery store,
but may clearly express a decision about
resuscitation.
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
When a patient lacks
capacity . . .
Click
todecision-maker
edit Master title
• Proxy
style
• Sources of information
• Written advance directives
•
Click
to edit
Master
subtitle
Patient’s
verbal
statements
•style
Patient’s general values and beliefs
• How patient lived his / her life
• Best interest determinations
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
. . . When a patient lacks
capacity
Click to edit Master title
• Why turn to others
style
• Respects patient
• Builds trust
•
Click
to edit
subtitle
Reduces
guiltMaster
and decision-regret
style
American Osteopathic Association
AOA: Treating Our Family and Yours
E
E
P
P
E
E
C
C
Goals of Care
Summary
American Osteopathic Association
AOA: Treating Our Family and Yours