This document summarizes key considerations and guidelines around issues of medical futility and end-of-life decision making. It discusses patients' rights to refuse treatment, problems that can arise from determining futility, and the obligations of physicians to initiate discussions with patients about treatment preferences. It also addresses guidelines for communicating with surrogate decision makers, including ensuring they understand the patient's diagnosis, prognosis and values to make decisions reflecting the patient's wishes. The document emphasizes open communication with patients and surrogates about medical realities and options to avoid prolonging dying unnecessarily against a patient's values and interests.
Archer USMLE step 3 Ethics lecture notes. These lecture notes are samples and are intended for use with Archer video lectures. For video lectures, please log in at http://www.ccsworkshop.com/Pay_Per_View.html
What is Informed Consent?
Informed consent is the process by which a patient voluntarily confirms his/her willing participation in an operation after having been informed about all the aspects of the operation that is its benefits, its prognosis, and complications
Informed consent must be in written form and documented with the patients signature and date of consent
Archer USMLE step 3 Ethics lecture notes. These lecture notes are samples and are intended for use with Archer video lectures. For video lectures, please log in at http://www.ccsworkshop.com/Pay_Per_View.html
What is Informed Consent?
Informed consent is the process by which a patient voluntarily confirms his/her willing participation in an operation after having been informed about all the aspects of the operation that is its benefits, its prognosis, and complications
Informed consent must be in written form and documented with the patients signature and date of consent
Series of lectures I gave for the PEER (Professionalism and Ethics Education for Residents) Project sponsored and organized by the Saudi Commission for Health Specialties (SCHS).
OUTLINE:
What is an informed consent to treatment?
What is the elf basis to consent?
What makes the consent an ethically valid one?
Types of Consent
When it is needed? When could it be waived?
How to take an informed consent?
What if the patient is not able to give consent?
Documentation of Consent
Special Issues about Consent
Bioethics- Case study on Autonomy and Decision making in medicineavi sehgal
Bioethics- A case study on Autonomy and Decision making in medicine. Forensic Medicine PowerPoint for medical (MBBS/MD) students trying to understand AETCOM.
Series of lectures I gave for the PEER (Professionalism and Ethics Education for Residents) Project sponsored and organized by the Saudi Commission for Health Specialties (SCHS).
OUTLINE:
What is an informed consent to treatment?
What is the elf basis to consent?
What makes the consent an ethically valid one?
Types of Consent
When it is needed? When could it be waived?
How to take an informed consent?
What if the patient is not able to give consent?
Documentation of Consent
Special Issues about Consent
Bioethics- Case study on Autonomy and Decision making in medicineavi sehgal
Bioethics- A case study on Autonomy and Decision making in medicine. Forensic Medicine PowerPoint for medical (MBBS/MD) students trying to understand AETCOM.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
2. E. M. Cioran
…once pain rouses us, there is no one but ourselves,
alone with our disease, with the thousand
thoughts it provokes in us and against us.
3. California Probate Code 4650
An adult patient has the fundamental right to have life-sustaining
treatment withheld or withdrawn.
The prolongation of the process of dying for a person for whom continued
health care does not improve the prognosis for recovery may:
Violate patient dignity, and
Cause unnecessary pain and suffering,
While providing nothing medically necessary or beneficial
4. Problems with determination of futility are
often caused by physicians
Institute of Medicine study on improving care at the end of life
1.There is overuse of care;
2. Inconsistent with patient preferences and
prognosis;
3. Underuse of care to treat symptoms;
4. Untimely referral to hospice;
5. Poor palliative care;
6. Poor communication regarding prognosis and
treatment preferences.
Annals of Internal Medicine (2001) 135:8.
5. Physicians are obligated to initiate
patient dialogue
Give patient the greatest opportunity to make
his or her own choices –
Communicate with the patient while you can -
before loss of capacity.
6. Physicians Don’t Generally Discuss
End of Life Decisions
In a prospective cohort study in five tertiary medical
centers found that:
<23% physicians discussed CPR performance
with seriously ill patients
(n1589)
Annals of Internal Medicine: (1997) 127:1; 1-12
7. Prolonged Ventilation
12% discussed preferences with their physicians
20% said that they wanted it
80% said that they did not want it. (n 1573)
Annals of Internal Medicine 1 July 1997 | Volume 127 Issue 1 | Pages 1-12
8. Effective vs. Excessive
Benefit of Treatment vs. Burden on Patient
Are we keeping the patient alive when there is no benefit to
life of the patient?
Are we giving the patient time to recover to a level of
quality of life that the patient will accept,
Or are we merely prolonging or exacerbating the process
of death?
9. What does the patient/surrogate need to
understand when considering futility
Diagnosis, prognosis
Burdens of Illness
Effectiveness of Treatment
Potential of rehabilitation, and
Diminished quality of life.
Right to refuse treatment, and
Right to request palliative care/comfort care
10. Faith and Dignity
Fiduciary: from Latin - fides, meaning faith
A fiduciary is expected to act with the highest
level of good faith, loyalty and trust.
11. The surrogate is not your patient.
When a patient looses capacity to make decisions, he or she does
not loose the right to effectuate his or her choice.
There is no fiduciary relationship or duty to the surrogate.
The fiduciary relationship with your patient continues,
The Surrogate must be solely used as a conduit for the
wishes and choices of the patient.
Therefore the surrogate must receive the same type and
amount of information the patient would receive if able to
make decisions.
12. Dealing with Surrogate Decision Makers
Surrogates are agents. They must effectuate the
wishes of the patient - not their own wishes.
To do so they must understand the illness, its effect
on the patient, and the prognosis.
If they won’t listen and /or will not act, they cannot
be a surrogate.
13. California Probate Code §4714
A surrogate shall make a health care decision in accordance with the patient's
individual health care instructions, if any, and other wishes to the
extent known to the surrogate.
Otherwise, the surrogate shall make the decision in accordance with the surrogate's
determination of the patient's best interest.
In determining the patient's best interest, the surrogate shall consider the patient's
personal values to the extent known to the surrogate.
14. Surrogates and the Therapeutic Privilege
Physicians may decide that telling a patient the truth
about their illness is not in the patient’s best interest.
This does not, however, apply to a surrogate decision
maker.
If a surrogate cannot fully and intelligently participate,
then he or she cannot be the surrogate. Then a second
surrogate must be identified, if possible. If not turn to a
best interest standard.
15. Significant Delay must not be permitted to
impact on pt’s best interests
A surrogate cannot be permitted to cause a delay in
decision making which will harm the patient.
If a surrogate cannot or will not be fully informed and
understand the diagnosis and prognosis, he or she
may not continue as surrogate – because they are
not speaking for the patient.
If a surrogate cannot or will not decide – find a new
surrogate
16. California Probate Code 4714
A surrogate, shall make a health care decision in
accordance with the patient's individual health care
instructions, if any, and other wishes to the extent
known to the surrogate. Otherwise, the surrogate
shall make the decision in accordance with the
surrogate's determination of the patient's best interest.
In determining the patient's best interest, the surrogate
shall consider the patient's personal values to the
extent known to the surrogate.
17. Statutory Right of the Physician regarding the
Determination of Futility
A health care provider or health care institution may
decline to comply with an individual health care
instruction or health care decision that requires
medically ineffective health care or health care
contrary to generally accepted health care standards
applicable to the health care provider or institution.
California Probate Code § 4735
18. California Probate Code
§4766
A petition may be filed under this part for…
(c) Determining whether the acts or proposed acts of an agent or surrogate are
consistent with the patient's desires as expressed in an advance health care directive
or otherwise made known to the court or, where the patient's desires are unknown
or unclear, whether the acts or proposed acts of the agent or surrogate are in the
patient's best interest.
(d) Declaring that the authority of an agent or surrogate is terminated, upon a
determination by the court that …
(1) The agent or surrogate has failed to perform, or is unfit to
perform, the duty under an advance health … [or] , is acting (by action or
inaction) in a manner that is clearly contrary to the patient's best interest.
19. Disqualification of a Surrogate
A patient having capacity may disqualify, at anytime,
another person, including a member of the patient’s
family, from acting as the patient’s surrogate by a
signed writing, or by personally informing the
supervising healthcare provider of the disqualification.
(California Probate Code Section 4715).
Such disqualification should be promptly recorded in
the patient’s healthcare record, noting the date and time
of such declaration.
20. Technology can Mask Futility
Physicians may tend to overuse technologically
aggressive, life-prolonging treatments and,
underuse communication skills that can assist
patients in making choices.
Miettinen T, Tilvis RS. Medical futility as a cause of suffering of dying patients: the family members’
perspective. J Palliat Care. 1999;15:26-29
21. Do not mask futility with medicine
Things look better today, his
white count has come down
somewhat…
We think we can wean him
tomorrow - if not, we can
trach him…
He is still fighting this
infection, we don’t know yet
if he will be able to
overcome it…
If we cannot wean him we
should talk about whether
he would want to have a
tracheostomy and go to a
long term nursing facility, or
refuse further treatment.
22. Don’t frighten the patient or surrogate with
the word “futility.”
If we wait until the therapeutic impasse to tell the patient or
surrogate we create panic rather than understanding –
We risk loosing our ability to reason and discuss;
This leads to protest, denial and anger with the medical
treatment which you have been providing;
It hurts the patient
It sets the stage for consideration of claims of malpractice.
23. Discussing futility is made more difficult by:
Overly Optimistic or pessimistic prognoses
Lack of or poor communication about treatment
Failure to know the patient’s values, expectations,
and cultural and religious orientation.
G. Holloway, R. et al. JAMA 2005;294:725-733.
24. Elicit patient’s valued life activities to
help evaluate QOL
Time with family and friends, autonomy,
recreation, other
Probe positions on "life worth living" and
states considered "worse than death"
Include spiritual and ethical dimensions of
these values
25. Time-Limited trials
Gives surrogate opportunity and time to
participate and gain a better understand of
the benefits and burdens of treatment;
To allow families to work through grief and
intelligently participate in evaluating treatment
options and the patient’s values and wishes.
26. All Patients or surrogates must:
Be told their diagnosis and prognosis;
Be told what therapy is effective;
Told that they have the option to Refuse
Treatment;
27. Risks of Demanding Futile
Treatment Must be Disclosed
Just as informed consent is required for the
refusal of treatment, it is also required for the
demand of futile treatment: the patient
/surrogate must be told of:
Unnecessary Suffering
Unnecessary Prolongation of Imminent Death
Needless anguish, fear and insecurity for loved
ones
28. Acceptable Criteria
I don’t want to live in a SNF on machines –
So, I am refusing treatment. I understand that
I will die without this treatment.
I want everything done and let the Lord
decide when it’s my time.
29. Unacceptable Criteria
Patients:
My family wants my life insurance benefits.
I want to refuse treatment and die, but my children
want me to fight on, even though you have told me
that further treatment is futile.
Surrogates:
I know she is suffering needlessly but I don’t want to
feel I am killing her…
Her sister does not want me to …
30. Jose Ortega y Gasset
Law is born from despair of human nature.
31. The Law
Generally, Courts do not want to see you
unless there is a dispute.
Courts adjudicate disputes – they do not like
to make medical decisions.
32. California Probate Code 4765
4765. …a petition may be filed by
(a) The patient
(b) The patient's spouse, unless legally separated.
(c) A relative of the patient
(d) The patient's agent or surrogate
(e) The conservator of the person of the patient
(f) The court investigator, …
(g) The public guardian
(h) The Primary treating physician or hospital caring for the patient
(i) Any other interested person or friend of the patient.
33. Judicial Powers:
California Probate Code §3208 …
… the court may make an order authorizing withholding or
withdrawing artificial nutrition and hydration and all other
forms of healthcare where the recommended healthcare is
in accordance with the patient’s best interest, taking into
consideration the patient’s personal values to the extent
known to the petitioner.
34. The Law for Withholding Life Sustaining Treatment
Terminal Non Terminal
PVS
Yes Yes
Yes CCE of
Pt’s Intent
Minimally
Conscious
35. Transparency
Issues of futility address the most serious and fundamental
rights;
In cases where a patient has no surrogate, it is advisable to
have the Ethics Committee at your hospital review the case
and support your decision. Note in your progress record your
meeting with, and recommendations of the Ethics Committee.
Discussions with patients and families regarding, DNR orders;
transfer to hospice; withdrawal or withholding of treatment,
must be noted with specificity, and if possible, before a
witness.
36. Seeking Review and Recommendations of Ethics
Committees
Protects the patient;
Protects and supports the Primary Treating
Physician’s decision;
Assists the Court, if it’s assistance is sought
37. The ethics of terminal care
Dignity varies with different stages of life.
For the terminally ill, dignity is best reflected in
our level of respect for a person’s right to choose
and in the provision of truly humane and personal
care.