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 7 Goals of Care American Osteopathic Association AOA: Treating Our Family and Yours

3. Objectives . . . • Understand the different goals and how they interrelate and change • Understand how to use the 7-step protocol to negotiate goals of care • Be able to communicate prognosis and its uncertainty • Understand how to tell the truth and identify reasonable hope American Osteopathic Association AOA: Treating Our Family and Yours

4. . . . Objectives • Be able to use language effectively • Be able to set limits on unreasonable goals • Be able to adjust care and communication according to culture • Understand how to identify goals when patients lack capacity American Osteopathic Association AOA: Treating Our Family and Yours

5. Introduction . . . • Everyone has a personal sense of • Who we are • What we like to do • Control we like to have • Goals for our lives • Things we hope for American Osteopathic Association AOA: Treating Our Family and Yours

6. . . . Introduction • Hope, goals, expectations change with illness • Physician’s role to clarify goals, treatment plan American Osteopathic Association AOA: Treating Our Family and Yours

7. Cure of disease Avoidance of premature death Maintenance or improvement in function Prolongation of life Relief of suffering Quality of life Staying in control A good death Support for families and loved ones Potential goals of care American Osteopathic Association AOA: Treating Our Family and Yours

8. Historically, a dichotomous division of goals of care • Focus on curing illness • Little attention to relief of suffering, care of dying • Hospice / palliative care arose in response to a need American Osteopathic Association AOA: Treating Our Family and Yours

9. Figure 1: A dichotomous intent Curative / life-prolonging therapy Presentation Death Relieve suffering (hospice) American Osteopathic Association AOA: Treating Our Family and Yours

10. Multiple goals of care • Multiple goals often apply simultaneously • Goals are often contradictory • Certain goals may take priority over others American Osteopathic Association AOA: Treating Our Family and Yours

11. Patient-centered Care • Goals of Patient - initial assessment • May Vary over time - ongoing assessment • Curative  Palliative • Self  Family • Physical  Spiritual • Integrated  Focused American Osteopathic Association AOA: Treating Our Family and Yours

12. 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 • The shift in focus of care • Is gradual • Is an expected part of the continuum of medical care American Osteopathic Association AOA: Treating Our Family and Yours

13. Figure 2: The interrelationship of therapies with curative and palliative intent Curative / life-prolonging therapy Presentation Death Relieve suffering (palliative care) American Osteopathic Association AOA: Treating Our Family and Yours

14. Palliative care: expanding the options . . . • Interdisciplinary care • Symptom control • Supportive care American Osteopathic Association AOA: Treating Our Family and Yours

15. . . . Palliative care: expanding the options • Any life-threatening diagnosis • Anytime during illness • Whenever patient / family prepared to accept it • May be combined with curative therapies • May be focus of care American Osteopathic Association AOA: Treating Our Family and Yours

16. 7-step protocol to negotiate goals of care . . . • Create the right setting • Determine what the patient and family know • Explore what they are expecting or hoping for American Osteopathic Association AOA: Treating Our Family and Yours

17. . . . 7-step protocol to negotiate goals of care • Respond empathically • Suggest realistic goals 6. Make a plan and follow-through including clarification/documentation of code status 7. Review and revise periodically, as appropriate American Osteopathic Association AOA: Treating Our Family and Yours

18. Communicating prognosis • Over-estimate the likelihood of a good prognosis • Helps patient / family cope, plan • Increase access to hospice, other services • Offer a range or average for life expectancy American Osteopathic Association AOA: Treating Our Family and Yours

19. Truth-telling and maintaining hope • False hope may deflect from other important issues • True clinical skill to help find hope for realistic goals American Osteopathic Association AOA: Treating Our Family and Yours

20. Language with unintended consequences • Do you want us to do everything possible? • Will you agree to discontinue care? • It’s time we talk about pulling back • I think 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

21. Language to describethe goals of care . . . • I want to give the best care possible until the day you die • We will concentrate on improving the quality of your child’s life • We want to help you live meaningfully in the time that you have American Osteopathic Association AOA: Treating Our Family and Yours

22. Language to describethe goals of care . . . • I’ll do everything I can to help you maintain your independence • I want to ensure that your father receives the kind of treatment he wants • Your child’s comfort and dignity will be my top priority American Osteopathic Association AOA: Treating Our Family and Yours

23. . . . Language to describethe goals of care • I will focus my efforts on treating your symptoms • Let’s discuss what we can do to fulfill your wish to stay at home • Let’s discuss what we can do to have your child die at home American Osteopathic Association AOA: Treating Our Family and Yours

24. Cultural differences • Who gets the information? • How to talk about information? • Who makes decisions? • Ask the patient • Consider a family meeting American Osteopathic Association AOA: Treating Our Family and Yours

25. Determine specific priorities • Based on values, preferences, clinical circumstances • Influenced by information from physician, team members American Osteopathic Association AOA: Treating Our Family and Yours

26. Reviewing goals,treatment priorities • Goals guide care • Assess priorities to develop initial plan of care • Review with any change in • Health status • Advancing illness • Setting of care • Treatment preferences American Osteopathic Association AOA: Treating Our Family and Yours

27. When the physician cannot support a patient’s choices • Typically occurs when goals are unreasonable, illegal • Set limits without implying abandonment • Make the conflict explicit • Try to find an alternate solution American Osteopathic Association AOA: Treating Our Family and Yours

28. Reassess decision-making capacity . . . • Implies the ability to understand and make own decision • Patient must • Understand information • Use the information rationally • Appreciate the consequences • Come to a reasonable decision for him or her American Osteopathic Association AOA: Treating Our Family and Yours

29. . . . Reassess decision-making capacity • Any physician can determine • Capacity varies by decision • Other cognitive abilities do not need to be intact. Patient does not need to demonstrate global cognitive capabilities, as a prerequisite to expressing their wishes for end-of-life decisions (patient may not be 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

30. When a patient lacks capacity . . . • Proxy decision-maker • Sources of information • Written advance directives • Patient’s verbal statements • Patient’s general values and beliefs • How patient lived his / her life • Best interest determinations American Osteopathic Association AOA: Treating Our Family and Yours

31. . . . When a patient lacks capacity • Why turn to others • Respects patient • Builds trust • Reduces guilt and decision-regret American Osteopathic Association AOA: Treating Our Family and Yours

32. Goals of Care Summary American Osteopathic Association AOA: Treating Our Family and Yours