Osteopathic EPEC

1. 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 American Osteopathic Association AOA: Treating our Family and Yours

2. Module 11 Withholding, Withdrawing Treatment American Osteopathic Association AOA: Treating our Family and Yours

3. Objectives • Know the principles for withholding or withdrawing therapy • Apply these principles to the withholding or withdrawal of • Artificial feeding, hydration • Ventilation • Cardiopulmonary resuscitation American Osteopathic Association AOA: Treating our Family and Yours

4. 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 American Osteopathic Association AOA: Treating our Family and Yours

5. . . . Role of the physician • Discuss alternatives • Including palliative and hospice care • Document preferences, medical orders • Involve, inform other team members • Assure comfort, non-abandonment American Osteopathic Association AOA: Treating our Family and Yours

6. Common concerns . . . • Legally required to “do everything?” • Is withdrawal, withholding euthanasia? • Are you killing the patient when you remove a ventilator or treat pain? American Osteopathic Association AOA: Treating our Family and Yours

7. . . . Common concerns • Can the treatment of symptoms constitute euthanasia? • Is the use of substantial doses of opioids euthanasia? American Osteopathic Association AOA: Treating our Family and Yours

8. Resuscitation Elective intubation Surgery Dialysis Blood transfusions, blood products Diagnostic tests Artificial nutrition, hydration Antibiotics Other treatments Future hospital, ICU admissions Life-sustaining treatments American Osteopathic Association AOA: Treating our Family and Yours

9. 8-step protocol to discuss treatment preferences . . . • Be familiar with policies, statutes • Appropriate setting for the discussion • Ask the patient, family what they understand • Discuss general goals of care American Osteopathic Association AOA: Treating our Family and Yours

10. . . . 8-step protocol to discuss treatment preferences • Establish context for the discussion • Discuss specific treatment preferences • Respond to emotions • Establish and implement the plan American Osteopathic Association AOA: Treating our Family and Yours

11. 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 American Osteopathic Association AOA: Treating our Family and Yours

12. Example 1: Artifical nutrition, hydration • Difficult to discuss • Food, water are symbols of caring American Osteopathic Association AOA: Treating our Family and Yours

13. Review goals of care • Establish overall goals of care • Will artificial feeding, hydration help achieve these goals? American Osteopathic Association AOA: Treating our Family and Yours

14. Address misperceptions • Cause of poor appetite, fatigue • Relief of dry mouth • Delirium • Urine output American Osteopathic Association AOA: Treating our Family and Yours

15. Help family with need to give care • Identify feelings, emotional needs • Identify other ways to demonstrate caring • Teach the skills they need American Osteopathic Association AOA: Treating our Family and Yours

16. Normal dying • Loss of appetite • Decreased oral fluid intake • Artificial food / fluids may make situation worse • Breathlessness • Edema • Ascites • Nausea / vomiting American Osteopathic Association AOA: Treating our Family and Yours

17. Example 2: Ventilator withdrawal • Rare, challenging • Ask for assistance • Assess appropriateness of request • Role in achieving overall goals of care American Osteopathic Association AOA: Treating our Family and Yours

18. Immediate extubation • Remove the endotracheal tube after appropriate suctioning • Give humidified air or oxygen to prevent the airway from drying • Ethically sound practice American Osteopathic Association AOA: Treating our Family and Yours

19. 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 American Osteopathic Association AOA: Treating our Family and Yours

20. 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 American Osteopathic Association AOA: Treating our Family and Yours

21. Prevent symptoms • Breathlessness • Opioids • Anxiety • Benzodiazepines American Osteopathic Association AOA: Treating our Family and Yours

22. 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 American Osteopathic Association AOA: Treating our Family and Yours

23. Prepare the family . . . • Describe the procedure • Reassure that comfort is a primary concern • Medication is available • Patient may need to sleep to be comfortable American Osteopathic Association AOA: Treating our Family and Yours

24. . . . Prepare the family • Involuntary movements • Provide love and support • Describe uncertainty American Osteopathic Association AOA: Treating our Family and Yours

25. 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 American Osteopathic Association AOA: Treating our Family and Yours

26. 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 American Osteopathic Association AOA: Treating our Family and Yours

27. 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 American Osteopathic Association AOA: Treating our Family and Yours

28. Withdrawal Protocol -- Part 3 . . . • Invite family to bedside • Washcloth, oral suction catheter, facial tissues • Reassess frequently American Osteopathic Association AOA: Treating our Family and Yours

29. . . . 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 American Osteopathic Association AOA: Treating our Family and Yours

30. 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 American Osteopathic Association AOA: Treating our Family and Yours

31. Write appropriate medical orders • DNR • DNI • Do not transfer • Others • POLST American Osteopathic Association AOA: Treating our Family and Yours

32. Withholding, Withdrawing Treatment Summary American Osteopathic Association AOA: Treating our Family and Yours