Download Osteopathic EPEC Module 11

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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.
American
Osteopathic
Association
American
Osteopathic
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AOA:
Treating
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Family
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AOA:
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Module 11
Withholding,
Withdrawing Treatment
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Objectives
• Know the principles for withholding
or withdrawing therapy
• Apply these principles to the
withholding or withdrawal of
• Artificial feeding, hydration
• Ventilation
• Cardiopulmonary resuscitation
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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
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. . . Role of the physician
• Discuss alternatives
• Including palliative and hospice care
• Document preferences, medical
orders
• Involve, inform other team
members
• Assure comfort, non-abandonment
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Common concerns . . .
• Legally required to “do
everything?”
• Is withdrawal, withholding
euthanasia?
• Are you killing the patient when you
remove a ventilator or treat pain?
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. . . Common concerns
• Can the treatment of symptoms
constitute euthanasia?
• Is the use of substantial doses of
opioids euthanasia?
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Life-sustaining treatments
•
Resuscitation
•
Diagnostic tests
•
Elective intubation
•
•
Surgery
Artificial nutrition,
hydration
•
Dialysis
•
Antibiotics
•
Blood transfusions,
blood products
•
Other treatments
•
Future hospital, ICU
admissions
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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
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. . . 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
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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
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Example 1: Artifical
nutrition, hydration
• Difficult to discuss
• Food, water are symbols of caring
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Review goals of care
• Establish overall goals of care
• Will artificial feeding, hydration
help achieve these goals?
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Address misperceptions
• Cause of poor appetite, fatigue
• Relief of dry mouth
• Delirium
• Urine output
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Help family with need to give care
• Identify feelings, emotional needs
• Identify other ways to demonstrate
caring
• Teach the skills they need
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Normal dying
•
Loss of appetite
•
Decreased oral fluid intake
•
Artificial food / fluids may make situation
worse
•
•
•
•
Breathlessness
Edema
Ascites
Nausea / vomiting
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Example 2: Ventilator
withdrawal
• Rare, challenging
• Ask for assistance
• Assess appropriateness of request
• Role in achieving overall goals of
care
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Immediate extubation
• Remove the endotracheal tube after
appropriate suctioning
• Give humidified air or oxygen to
prevent the airway from drying
• Ethically sound practice
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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
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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
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Prevent symptoms
• Breathlessness
• Opioids
• Anxiety
• Benzodiazepines
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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
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Prepare the family . . .
• Describe the procedure
• Reassure that comfort is a primary
concern
• Medication is available
• Patient may need to sleep to be
comfortable
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. . . Prepare the family
• Involuntary movements
• Provide love and support
• Describe uncertainty
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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
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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
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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
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Withdrawal Protocol -- Part 3 . . .
• Invite family to bedside
• Washcloth, oral suction catheter,
facial tissues
• Reassess frequently
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. . . 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
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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
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Write appropriate medical orders
• DNR
• DNI
• Do not transfer
• Others
• POLST
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Withholding, Withdrawing
Treatment
Summary
American Osteopathic Association
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