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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Legal Issues

    Futility: Lack of Consensus
    • Another controversial issue in end-of-life care is the process for determining when medical interventions are no longer effective
      • Especially when medical personnel and the patient or surrogate disagree about the decision

      • A number of cases suggest that this issue is still undergoing development in judicial analysis
    • To guide the process, some general principles can be drawn from medical practice and case law:
        1. Physicians should be careful when thinking that a treatment may be "futile"

        • In decision-making when a treatment under consideration may seem to be futile, the physician should ask, "futile for what goal?"

        • That goal should be defined by the patient or surrogate (or parents if the patient is a child) in conjunction with the physician

        2. Physicians’ recommendations for limiting treatment should be based as much as possible on

        • Objective determination of ineffectiveness, for the accepted goal

        • Rather than subjective opinions about the worth of the intervention or of the patient’s continued life

        • Where there is concern or question, a second clinical opinion about the potential effectiveness of treatment may be both beneficial and necessary

        3. Where the patient or family disagrees with the physician’s judgment

        • Ethics consultation
        • Committee review may be advisable

        4. If there is continued disagreement

        • Facilitate transfer of the patient when feasible to another health care practitioner or health care facility

        5. If transfer to another physician or institution is not possible, the intervention need not be offered
    • In cases where futility comes up
      • Commonly a major component of unsuccessful communication and strained relationships

      • Try to keep communication good, listen well, convey information effectively, and keep an empathic approach

      • In several studies a correlation exists between quality relationships and reduced malpractice rates, not only in futility cases but in general
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