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Futility Issues: Facilitating Goals of Care at the End of Life

Futility Issues: Facilitating Goals of Care at the End of Life. Deborah Ferretti, APRN, ACNP-BC, ACHPN Kate McEvoy, Esq Karen J. Stanley, RN, MSN, AOCN, FAAN. Futility: Considering Two Independent Thresholds. Utility. Probability. Futility.

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Futility Issues: Facilitating Goals of Care at the End of Life

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  1. Futility Issues: Facilitating Goals of Care at the End of Life Deborah Ferretti, APRN, ACNP-BC, ACHPN Kate McEvoy, Esq Karen J. Stanley, RN, MSN, AOCN, FAAN

  2. Futility: Considering Two Independent Thresholds Utility Probability

  3. Futility • Medical Futility -Qualitative: based on utility. Is there an effect without benefit? Based on quality of outcome or quality of life (“it would be useless to continues this therapy because the patient’s quality of life would be terrible”) -Quantitative: based on probability (“this therapy has only an exceedingly low chance of working, therefore it should not be used”) -Physiologic: based on ability to obtain physiologic response (“this therapy can not normalize the person’s labs/vital signs or will not improve the patient’s medical condition”) -SUBJECTIVITY: Patients and families may be interested in prognosis based on probability and utility but they integrate the person they have known and care about into the equation that that effects their understanding of the issues and decision-making processes • Legal Futility The courts rightfully do not wish to be involved in the determination of medical prognoses…this is left to the medical community

  4. Conflicting Rights • Goals of Care discussions can become a power struggle for decisional authority • Patient/Family Autonomy -Right to self-determination -Right to treatment • Healthcare Provider autonomy -Moral integrity -Right to refuse to provide treatment that is deemed inappropriate and violates personal values

  5. Distributive Justice: Allocation of Healthcare Resources • Extent to which society or a larger group owes its individual members in proportion to: 1) the individual’s needs, contribution and responsibility 2) the resources available to the society or organization 3) the society’s or organization’s responsibility to the common good. • In the context of health care, distributive justice requires that everyone receive equitable access to the basic health care necessary for living a fully human life insofar as there is a basic human right to health care

  6. Case Study: Mr. EGeneral information • HPI: 91 year old male, admitted to the hospital for fevers, hypotension, and pancytopenia • Myelodysplasia - refractory to chemotherapy (Amicar) • No infectious source identified despite persistent intermittent fevers • No improvement in blood counts: requires daily transfusions of red cells and platelets but continues to experience bleeding from the nose and in the mouth • Emotional status: describes each day as “miserable” • Poor functional status: non-ambulatory, requires assistance with daily activities • Code status: full code and continue all current care • Advance Healthcare Directive: states no CPR, artificial respirations, or measures to prolong life if terminal

  7. Mr. EPsychosocial / Spiritual • Psychosocial • Wife has dementia and lives in an ECF. She is currently in the hospital with aspiration pneumonia. Mr. E feels a need to be alive to care for her, as he promised. Her code status is DNR/DNI. • He worries about finances for healthcare • His pleasure in life is to watch sports on TV • His nephew is designated as his spokesperson • Has one step-daughter • Spiritual • Strong faith, belongs to the Armenian Church • Receives weekly visits from the priest.

  8. Mr. EGoals of Care Discussion • Family Meeting: Patient and Nephew • Reviewed problem of myelodysplasia, lack of response to treatment or further options, inability to support outpatient transfusion needs • High risk for a sudden catastrophic event from bleeding which would not respond to CPR • Becoming increasingly difficult to crossmatch patient to blood products • Outcomes of meeting: • As Mr. E is feeling OK and is alert and able to watch TV, they want to continue current care, including resuscitation if needed • Continue treatment since it is “working” and to stop it would be suicide • Does not believe his living will applies, because he is alert and able to interact with others, therefore not terminal

  9. Questions Raised • Is continuing blood product support in this patient futile? • What goals are being met by continuing all medical interventions? • Is patient terminal with continuation of care? • Is patient terminal with discontinuation of care? • How does this care impact society related to use of a limited resource? • How would you as a clinician feel about this care? • Should the medical community be able to decide to stop this level of care if the definition of futility has been met?

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