1. EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Osteopathic EPEC 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

2. EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Goals of Care Module 7

3. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

4. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... 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

5. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

6. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... Introduction Hope, goals, expectations change with illness Physician’s role to clarify goals, treatment plan

7. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Potential goals of care 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

8. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

9. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Relieve suffering (hospice) Curative / life-prolonging therapy Presentation Death Figure 1: A dichotomous intent

10. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Multiple goals of care Multiple goals often apply simultaneously Goals are often contradictory Certain goals may take priority over others

11. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Patient-centered Care Goals of Patient - initial assessment May Vary over time - ongoing assessment Curative  Palliative Self  Family Physical  Spiritual Integrated  Focused

12. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

13. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Curative / life-prolonging therapy Presentation Death Relieve suffering (palliative care) Figure 2: The interrelationship of therapies with curative and palliative intent

14. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Palliative care: expanding the options... Interdisciplinary care Symptom control Supportive care

15. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... 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

16. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 7-step protocol to negotiate goals of care... 1.Create the right setting 2.Determine what the patient and family know 3.Explore what they are expecting or hoping for

17. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... 7-step protocol to negotiate goals of care 4.Respond empathically 5.Suggest realistic goals 6.Make a plan and follow-through including clarification/documentation of code status 7. Review and revise periodically, as appropriate

18. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

19. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Truth-telling and maintaining hope False hope may deflect from other important issues True clinical skill to help find hope for realistic goals

20. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

21. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Language to describe the 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

22. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Language to describe the 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

23. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... Language to describe the 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

24. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Cultural differences Who gets the information? How to talk about information? Who makes decisions? Ask the patient Consider a family meeting

25. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours Determine specific priorities Based on values, preferences, clinical circumstances Influenced by information from physician, team members

26. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

27. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

28. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

29. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... 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.

30. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours 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

31. Click to edit Master title style l Click to edit Master subtitle style EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours... When a patient lacks capacity Why turn to others Respects patient Builds trust Reduces guilt and decision-regret

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