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second level
third level
fourth level
fifth level
Click to edit Master title style<=
/div>
Click to edit Master subtitle sty=
le
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Module 9:
Medical Futility
© EPEC Project, 2003
Permission to reproduce for educational purposes granted
Page ‹#›
------=_NextPart_01C7D83D.83289CB0
Content-Location: file:///C:/2EC7B2F9/Module9MedicalFutility_files/pres.xml
Content-Transfer-Encoding: quoted-printable
Content-Type: text/xml; charset="utf-8"
Permission to reproduce for educational purposes granted
Page ‹#›
![](3D"master07_background.gif")
![](3D"master07_image001.gif")
![](3D"master07_image002.gif")
E
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=
Medical
Futility
Module=
9
![](3D"master06_background.gif")
![](3D"master06_image003.gif")
Objectives
•L=
ist
factors that might lead to futility situations
•U=
nderstand
how to identify common factors
how to communicate and negotiate to resolve
conflict directly
the steps involved in fair processes to resolve
intractable conflict
Physicians and futility
<=
span
style=3D'mso-special-format:bullet;color:#FF3300;position:absolute;left:-3=
.97%'>•Patients
/ families may be invested in interventions
=
•Physicians / other
professionals may be invested in interventions
• Any party may perceive
futility
Definitions of
medical futility
medical futility
<=
span
style=3D'font-weight:normal'>•Ineffective more than =
99%
of the time
•Does not conform to
accepted community standardsIs this really a futility case?
<=
span
style=3D'mso-special-format:bullet;color:#FF3300;position:absolute;left:-4=
.0%'>•Unequivocal
cases of medical futility are rare
•Miscommunication, value
differences are more common
•Case resolution more
important than definitions
Conflict over treatment
•U=
nresolved
conflicts lead to misery
most can be resolved
•T=
ry
to resolve differences
•S=
upport
the patient / family
•B=
ase
decisions on
informed consent, advance care planning, goals =
of
care
Differential diagnosis of futility
situations
Surrogate selection
Misunderstanding of <=
span
style=3D'position:absolute;top:51.8%;left:1.09%;width:97.36%;height:49.39%=
'>diagnosis
/ prognosis
Misunderstanding: underlying
causes . . .
<=
span
style=3D'font-weight:normal'>•Different or conflicti=
ng
information
<=
span
style=3D'font-weight:normal'>•Previous overoptimistic
prognosis
. .
. Misunderstanding: under=
lying
causes
Misunderstanding:
how to respond . . .
how to respond . . .
•C=
hoose
a primary communicator
•G=
ive
information in
small pieces
multiple formats
•U=
se
understandable language
•F=
requent
repetition may be required
. .
. Misunderstanding: how to
respond
<=
span
style=3D'font-weight:normal'>•Assess understanding
frequently
<=
span
style=3D'font-weight:normal'>•Do not hedge to
“provide hope”
<=
span
style=3D'font-weight:normal'>•Encourage writing down
questions
Personal factors
Types of futility conflicts
•D=
isagreement
over
goals
benefit
Difference in values
A due process
approach to futility . . .
approach to futility . . .
. .
. A due process appro=
ach to
futility
<=
span
style=3D'font-weight:normal'>•Transfer of care to
another physician
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End of Module 9:
Medical Futility
Review Fast Facts
Complete Module 9 Post Assessment
‹header›
‹date/time›=
Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
‹footer›
‹#›
Clear and unequivocal situations =
of
medical futility are rare. More often than not the issue is conflict
resolution. The physician may be pursuing unrealistic or unwanted plans.&#=
13;There
may be difficulty for the proxy to perform his or her role. There may be m=
isunderstandings
over prognosis. There may be personal factors such as distrust or guilt, or
there may be differences in values. Understanding the nature of the confli=
ct may
allow ready resolution. For intractable difficulties, a fair process for
conflict resolution is recommended.
There may be times in each
physician’s career when a patient or surrogate decision maker asks f=
or
therapy that the physician does not think is beneficial, or vice versa. In=
some
hospitals, these situations, often called medical futility, are common rea=
sons
for ethics consultation.
Imagine a case involving a patient in a
vegetative state, whose life is being supported mechanically, and whose fa=
mily
insists that “everything be done.” How should physicians appro=
ach
this type of situation? How might the physician better understand the reas=
ons
for the family’s seemingly irrational request? Are there techniques =
that
are useful for ensuring that both parties feel they have been supported and
understood? In those rare
instances where a mutually acceptable resolu=
tion
is not possible, how should the physician balance his or her own concerns =
with
those of the patient and family, and those of the health care system?
Ultimately, what is the physician’s responsibility in providing futi=
le
care?
These cases tend to be frustrating and distressing. The health c=
are
team may feel that the family is being unreasonable, wasting scarce econom=
ic
resources, and causing the patient to undergo increased pain and suffering
prior to his/her ultimate demise. Physicians may at times respond by
distancing themselves from the family, accusing family members of ulterior
motives, or arguing that nonprofessionals should not be allowed to make
“medical decisions.” Meanwhile, the patient and/or family, alr=
eady
stressed by the realities of life-threatening illness, may feel isolated,
misunderstood, or abandoned. Family members may react by suggesting that t=
he
health care team does not “care” about their loved one, or eve=
n by
imputing financial, racial, or other prejudices to the team.
This modu=
le
offers practical suggestions for preventing, minimizing, and resolving conflicts between patients and
physicians before relationships deteriorate to the point of irreparable
damage. The module will not attempt to solve the debate about what constit=
utes
medical futility. However, it will provide a rational framework to use whe=
n there
is conflict about medical decisions.
This module will focus principall=
y on the
issues that arise when families want care that the physician and other
professionals feel is futile. Less commonly acknowledged, but of equal
importance, are those situations where the physician or other professional
persists in recommending therapy that the patient or family does not think=
is
beneficial, or where evidence dose not support any benefit to the patient.=
This
inclination to intervene may be
out of a sense of needing to maintain
hope, a personal belief that it is the professional’s job to maintain
life at all costs, or a need to avoid feeling failure or shame for not hel=
ping
the patient. Physicians and caregivers, as well as patients and families, =
may
need to feel that “everything possible” was done so that, after
the death, they will feel no regret or guilt
A fundamental question to=
ask
is “Who are we doing this for?” The physician should be
particularly careful to center care around the patient’s values. Aft=
er
all, the patient’s life and body are in question. Differences should=
be
resolved in a manner that avoids showing disrespect for the
professionals’ expertise and knowledge yet fully respects the
centrality
of the patient.
Many definitions of medical futil=
ity have
been proposed, based on a range of possible approaches. One definition
proposes that futility exists when the treatment won’t achieve the
patient’s intended goal. Others have defined a futile treatment as o=
ne
that does not serve a legitimate goal of medical practice. Some have advoc=
ated
for a precise definition, suggesting that a treatment is futile when it is
ineffective more than 99% of the time. Still
others have indicated that
treatment outside accepted community standards could be construed as
futile.
In the majority of situations in which death is imminent,
consensus is reached and lifesustaining interventions are not provided.
Investigators in one large study found that less than 1% of patients whose
prognosis for survival was less than 1% on their third hospital day who did
not have a do-not-resuscitate (DNR) order in the medical record.
Most
situations that arise are not straightforward issues of futility. Rather, =
they
represent conflict about the relative value of treatments. Examples of med=
ical
interventions in which questions of relative value may be raised include:&=
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------=_NextPart_01C7D83D.83289CB0
Content-Location: file:///C:/2EC7B2F9/Module9MedicalFutility_files/fullscreen.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
Module 9
------=_NextPart_01C7D83D.83289CB0--
· life-sustaining interventions for patients in a persistent
vegetative state
· resuscitation efforts for the life-threateningly ill
· use of chemotherapy in patients with far advanced cancer
=
;
· use of antibiotics or artificial hydration for patients who =
are
in advanced stages of the
illness
Unequivocal cases of truly futile
interventions are rare. A clear example would be an attempt to resuscitate=
a
patient who is decapitated. In this situation, CPR would be futile accordi=
ng
to all conceivable definitions.
More commonly, the concept of medical
futility is invoked when there is a conflict over treatment and it is not
clear how to reach resolution. In order to avoid conflict, some have argued
that physicians should neither offer nor provide therapy that is unlikely =
to
work, or will only result in a poor quality of life. To do otherwise, they=
believe,
would be to violate professional integrity, offer false hope to patients a=
nd families,
and inflict harm on
patients without the possibility of benefit. Others
would disagree, wondering why, in cases of disagreement, the physicianR=
17;s
values should override patient and family values, especially when those va=
lues
are religiously based. Many would point out the difficulty in differentiat=
ing
“futile” therapy from “low-yield” therapy.
Consequently, an increasing number of groups recommend defining futility o=
n a
case-by-case basis. Approaches are based on the need to find a fair proces=
s of
resolution rather than a final definition of what is futile
Unresolved conflicts about treatm=
ent
goals and specific therapies lead to increased misery for the patient, fam=
ily,
and health care professional. Yet, most conflicts about care can be resolv=
ed
through a process of effective communication and discussion. It is part of=
the
physician’s role to try to understand and resolve any differences in=
perception
about treatment. This responsibility can be challenging because it calls o=
n important
skills involving communication, compassion, and empathy. In negotiating is=
sues
of perceived futility, it remains the physician’s obligation to supp=
ort
the patient and family and try to relieve their suffering. The physician c=
an
use the principles for decision making based on informed consent, as well =
as
prior advance care planning and the identified goals of care, to help achi=
eve
resolution
Most disagreements about futile care are actually the result of
misunderstandings or lack of attention to the family’s or care
team’s emotional reaction to the patient’s dying. Thus, the
critical issue is to understand why there is disagreement. Typicall=
y, the
conflict can be resolved in a manner that is respectful of the point of vi=
ew
of both the physician and the patient/family. Moreover, by concentrating on
understanding points of view, one often
can initiate interventions that help with bereavement.
Approaching issues of futility fr=
om the
point of view of resolving conflict will likely lead to resolution in the
majority of cases. Among cases in which futility is claimed, most can be
attributed to a problem in surrogate authority, a misunderstanding, or per=
sonal
factors. Occasionally, there is a genuine value conflict, over either goal=
s or
the worth of a treatment.
If the patient lacks capacity, the
physician must rely on a surrogate. The surrogate should be the person whom
the patient prefers. Look for documentation of advance directives—
either statutory or advisory.
In the absence of an advance directive,
some states have legislation laying out a hierarchy for surrogate
deci=
sion
makers. In cases of conflict, one may need to have a guardian named. It is=
useful
to know the statutes under which you work. Blood relationship does not nec=
essarily
ensure the best surrogate. The following questions may help in finding who=
is
the right surrogate: Has the patient stated a preference for the person he=
or
she would want as a surrogate if the patient should become incompetent? Wh=
o is
most likely to know what the
patient would have wanted? Who is most li=
kely
to try to make a decision that reflects the patient’s best interest?
Does the surrogate have the cognitive ability to make decisions?
A rare
but sometimes necessary question is, “Is the surrogate acting
appropriately in the patient’s interests?” If the physician
believes that the surrogate is not doing so, it may be necessary to secure=
a
different proxy. This usually involves going to court to appoint a guardia=
n ad
litum.
Misunderstandings have a number o=
f common
causes. The physician should know how to assess and respond to
misunderstandings.
Conflict may arise primarily because of
misunderstanding on the part of the patient, the patient’s parents, =
or
surrogate about diagnosis or prognosis. There are many sources of
misunderstanding. For example, no one may have actually informed the paren=
ts
or surrogate of the diagnosis or prognosis. Alternatively, the language us=
ed
to inform the surrogate may not have been understandable. Including too mu=
ch
jargon and using a vocabulary that only has meaning to other health care
professionals is common. Other health care professionals may have given the
surrogate different or conflicting information. Health care professionals =
may
have “hedged” regarding the patient’s prognosis in the
interests of not wanting to sound too pessimistic. In addition, the stress=
ful
environment,
sleep deprivation, and emotional distress surrounding the
situation may lead to a decrease in understanding. Finally, the patient,
family, or surrogate may not be psychologically prepared to hear the bad n=
ews
(“denial”) or may lack the cognitive ability to understand the
information. This is especially true when the dying patient is a
child.
A frequent source of misunderstan=
ding is
the interpretation of the phrase “do everything.”
In medic=
al
jargon, it is frequently used to connote maximal medical attempts to save =
or
prolong life, whether or not it is expected to be of benefit. Mistaken not=
ions
of legal requirements sometimes propel such use. In contrast, families may=
use
the same phrase to communicate that they don’t want their loved one =
to
be abandoned or to die.
Misunderstanding: how to assess
In order to assess misunderstanding, the physician must carefully listen to
the patient’s and family’s or surrogate’s view of things.
Use good communication skills. Get
the setting right in order to have the discussion with the surrogate. Ask
open-ended questions like:
· What do you understand about what is going on?
· Tell me what you know so far about the situation for your
child.
· What’s your understanding of your mother’s
condition?
· What do you have in mind when you think about ‘doing
everything’?
· What do you expect to happen if we ‘do
everything’?
Be sure to have a clear idea of what the surrogate (or patient, if compete=
nt)
thinks of the situation before you begin to give information.
Try to minimize the chaos caused =
by
multiple caregivers and too much information. Choose one health care
professional to serve as primary communicator. Give information in small
pieces and check for understanding frequently. Information can be given in
multiple formats, both written and verbal. Be sure to use language that is=
appropriate
to the educational level. You will need to provide adequate time for the d=
iscussions,
knowing
that frequent repetition may be required. Avoid the tendency to
“hedge,” rationalizing that it may preserve hope. Unclear and
vague communication only promotes misunderstanding. Encourage the decision
maker to write down questions. Provide support. Above all, attend to the
surrogate’s (or parents’) emotional state. Remember that denia=
l is
a normal psychological defense mechanism. It may be very helpful to involve
other health care
professionals. In the case of a dying child, it is
imperative to involve child life or child psychology staff for the
patient’s siblings.
Distrust
Patients and families may make comments that suggest they do not trust the=
information
they are being given. Because they may be trying to be polite and respectf=
ul,
the clues may be subtle rather than overt. Comments about how other physic=
ians
were wrong, the previous hospital wasn’t very good, the patient̵=
7;s
previous physician was only interested in money, the nurses never answered=
the
call lights or administered the wrong treatments,
racial or ethnic
prejudice was suspected, etc, should trigger the question: “Do they =
distrust
us?”
It is often helpful to address this gently, but directly.
Questions like the fol=
lowing
might be helpful:
· What you’ve been through makes me wonder if it is hard=
for
you to trust medical
people now.
· From what you’ve said, I can imagine it might be diffi=
cult
for you to trust us.
Once established, it is then useful to explore the dimensions of the distr=
ust.
Ask patients and families to describe their issues fully. The process of
active listening and eliciting concerns may go a long way to establishing
trust. Give the clear message that the physician and team are interested a=
nd
willing to hear about negative feelings, in order to facilitate repair of =
any
problem and the building of trust.
After establishing that distrust is=
an
issue, and after learning about its dimensions, the physician may pursue o=
ther
avenues to strengthen trust. Emphasize what is being done for the patient.
Offer to facilitate a second opinion or find other individuals whom the pa=
tient
and family are more likely to trust. Make it clear that everyone wants the
best care for the patient, and you want to work together with them to achi=
eve
that. Affirm that you
want to share accurate and complete information based on mutual trust=
and
respect.
Grief
Grief is a natural human response to loss. Conflict with the physician and=
the
health care team over issues of futility may be an extension of anticipato=
ry
grief that is overwhelming. Comments like, “I can’t live witho=
ut
him,” or “What will I do when she dies?” are markers of
overwhelming grief.
The physician and other members of the health care
team can help the patient with grief. Social work, chaplaincy, nursing, and
other disciplines can help the physician offer support. In making decision=
s,
help the family distinguish between what the patient would want and what t=
he
family wants in response to their grief.
Guilt
A powerful motivator for human behavior is guilt. Guilt over relationship
issues with the dying patient is often subtly present in decision-making
discussions between physicians and patients/families. The archetypal,
not-so-subtle situation is the arrival of the longestranged or distanced
relative at the bedside saying, “You must do everything; you canR=
17;t
let her die.”
Eliciting this dimension requires skillful
interviewing and the willingness to assess the situation using a broad
perspective. It may help to include in this assessment the contributions a=
nd
information gathered by other members of the team, such as nurses, social
workers, and chaplains. Because guilt is sometimes associated with a sense=
of shame,
families may not readily reveal this dimension to the physician whom they =
do not
know well, may respect, and may fear. Consequently, the guilt may provoke =
conflicts
about futility determination. Active listening may help modify the situati=
on. Involvement
of multiple team members over time is usually essential. Asking the family=
to
come to internal resolution and work through 1 spokesperson can sometimes =
contain
the effects of guilt within the family, protecting decisions for the patie=
nt. Negotiated
time-limited trials may be helpful.
Conflicted relationships are rarely resolved and resultant guilt is
rarely eliminated. However, it remains the task of the physician and health
care team to develop an understanding of their dimension. That understandi=
ng
alone may illuminate behavior that previously seemed inexplicable.
Intrafamily issues
Health care decisions about a patient may be influenced by family dynamics.
These conflicts may not be initially apparent to the physician, particular=
ly
if the physician does not see the entire family as a group. Evidence of
disagreement within the family, in the context of conflicts over futility,=
may
indicate intrafamily issues. family meeting, where all parties get togethe=
r to
hear information and make decisions, can be an excellent way in which to b=
oth
acknowledge intrafamily issues and come to a decision with which all can
live.
Secondary gain
Occasionally, discussions regarding futility may be influenced by other
implications of a patient’s death. For example, income to the family=
or
surrogate decision maker may be lost when the patient dies. The
patient’s death may also influence where the family member may live,=
or
whether he/she will have access to savings or social status. Conversely, t=
he
decision maker may stand to benefit with the patient’s death.
Ph=
ysicians
may be unaware of this dimension. Assessment by social workers may be very
helpful in figuring out the social framework in which decisions are being
made. Most often, resolution can be reached though sensitive discussions.
However, ethics or legal consultation may be needed, particularly if it is
apparent that the decision maker is not acting in the best interests of the
patient.
Physician/nurse
Physicians and nurses bring their own personal feelings about dying and ab=
out
the benefits and burdens of specific interventions to the case. Some push =
for
interventions because of their belief that death is worse than any other
state. Others push because they feel it is a failure in their care if they
were to do otherwise. Still others have strong personal desires to avoid
aggressive intervention and project this on the patient and family.
People may differ over values in =
health
care. What is futile to one may be worthwhile to another. Genuine value
conflicts, ie, not based on misunderstandings, are typically of 2 types:&#=
13;1.
Parties differ over goals. For example, one party wishes to preserve
life “at all costs” while the other party concludes that
preserving life is not a worthwhile goal.
2. Parties differ over
benefit. For example, one party wishes to pursue a therapy that is hig=
hly
unlikely to achieve the agreed upon goal (ie, a “miracle”) whi=
le
the other party does not believe the chances of success are high enough to
continue treatment. Whichever the type of conflict, it may be important to
explore the root of the value difference.
Some requests for therapies that =
others
characterize as ineffective or futile are genuinely a reflection of differ=
ing
values between the physician or system and the patient/family.
Religious beliefs
Many people have a firm religious foundation for their lives and the decis=
ions
they make. This may extend to decisions about medical treatments and
life-sustaining therapies. Families may make religious references in relat=
ing
their point of view. It is useful to explore the religious dimension that
patients or families use in decision
making. Physicians may need to
overcome the social convention of avoiding religious topics in order to ha=
ve
this discussion. Relying on chaplains, perhaps the family’s own, to =
help
discuss and elucidate the patient’s or family’s religious
framework can be helpful.
An indication that the patient and family may
rely on religious fatalism in facing serious illness is the phrase,
“It’s in the Lord’s hands,” in response to questio=
ns
about preference and decision making. In such circumstances you may need m=
ore information
on preferences. It is sometimes helpful to say something like, “What=
you
say is important, and it helps me to understand how you feel about things.=
Can
you help me to further understand
what decisions would respect your be=
lief
about being in the Lord’s hands? For instance, if you were to be in
...[describe situation] would you feel I had decided right if I were to
...[describe situation]?”
Physicians need to know their own
disposition and must work to avoid imposing their views on the patient and
family. Decisions that go against a physician’s values should be avo=
ided
whenever possible by arranging for transfer ahead of time.
Miracles
Patients and families may express a belief in miracles. This may have a fo=
rmal
religious connotation or it may be less formalized. It is an expression of
hope that a supernatural or paranormal force will intervene to change the
course of events. Comments like, “Only God determines when someone
dies,” may be a clue. Attending to concomitant emotion and grief is
important. It may be helpful to discuss the situation in terms of what is =
in
the physician’s power to influence and what is not. Miracles are, by
definition, rare and unpredictable. It may be helpful to express the same =
hope
for a miracle that the family has, but introduce the concept of planning f=
or what
should be done if there isn’t a miracle, so helping them hope for the
best but plan for the worst. It may also be appropriate to ask the patient=
or
family if they have also considered that, “God might be calling him/=
her
and we are preventing that from occurring.” Such conversations need =
to
be scrupulously attentive to accuracy and appropriateness. The inclusion o=
f a
chaplain or religious counselor may be essential.
Value of life
When this type of conflict occurs, it may be expressed by comments such as
“life is worth preserving at all costs,” or “physicians
shouldn’t play God.” This issue may or may not be religiously
based. Some physicians have used this justification for continuing therapi=
es
that conflict with patient and family wishes. To help resolve this conflic=
t,
it may be helpful to focus on the patient’s point of view and the
patient’s expression of prior wishes in advance directives, either
formally or informally.
The foregoing discussion was mean=
t to
help the physician understand the nature of situations that may lead to
conflict over medical treatment between the physician and patient/family. =
It
is also a framework for preventing and resolving conflict. This process of=
ten
leads to obvious and acceptable solutions. But this is not always so.
=
If
conflict persists we suggest a process whereby that conflict might be
resolved. Many institutions and communities have policies related to the
provision of futile care that employ a step-by-step process of communicati=
on
and problem solving to help resolve differences between the physician and =
the
patient/family. This type of due process approach may include the following
steps:
1. Attempt to negotiate an understanding between patient,
surrogate, and physician about what constitutes futile care in advance of
actual conflict. This step can preempt conflict.
2. To the maximum ext=
ent
possible, joint decision making should occur between the patient or surrog=
ate
and physician. Negotiate solutions to disagreements, if they arise, in ord=
er
to reach a resolution satisfactory to all parties. Use the assistance of c=
onsultants
as appropriate. Much of the preceding text is meant to provide a basis for=
this
negotiation.
3. If disagreements persist, suggest the participation of
other consultants, colleagues, and/or a group, such as an institutional et=
hics
committee. These additional resources may provide a reasoned impartial
assessment and evaluation of the conflict. The value of ethics committees =
has
been well described in the medical literature. The Joint Commission for
Accreditation of Healthcare Institutions requires hospitals to have an eth=
ics
committee to aid its physicians, patients, and families to resolve difficu=
lt
issues. The aim is to provide the maximum possible place for patient auton=
omy
in the conduct of ethical medical practice.
4. If the institutional re=
view
supports the patient’s position and the physician remains unpersuade=
d,
transfer of care to another physician within the institution may be arrang=
ed.
5.
If the review supports the physician’s position and the
patient/surrogate remains unpersuaded, transfer to another institution can=
be
carried out if both the transferring and receiving institutions agree. If
transfer to a physician in another institution is not possible, the
intervention need not be offered. However, there needs to be a diligent se=
arch
for this option.
6. This process does not solve the problem when no
receiving institution can be found. The issue of cost of medical care, bot=
h to
patients and families as well as to the institution and the health care
system, is implicit in many of these steps.
Situations involving true medical
futility are rare. More often than not, the question of futility comes up =
when
there is distress with consequent miscommunication and conflict. Sources of
conflict may be identified as follows. The proxy may not be performing the
role well. There may be misunderstandings over prognosis. There may be
personal factors such as distrust or guilt. Or there may be differences in
values. For intractable difficulties a fair process for conflict resolutio=
n is
recommended. This process should include, if at all possible, prior discus=
sion
as to what constitutes futility, joint decision making with the patient/pr=
oxy
and other parties, involvement of a consultant and/or ethics committee, and
transfer of care to another physician or institution if necessary.
Rarely,
if no physician or institution can be found to provide the
intervention, it may be necessary to withdraw or withhold what the
patient/proxy or family has requested.
------=_NextPart_01C7D83D.83289CB0
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Content-Location: file:///C:/2EC7B2F9/Module9MedicalFutility_files/script.js
Content-Transfer-Encoding: quoted-printable
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parent.SldUpdated(GetSldId())
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InitHLinkArray()
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MakeSldVis();
ChkAutoAdv()
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setTimeout( "document.body.start()", sld.filters.revealtrans.duration * =
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function MakeSldVis()=20
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function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"=
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cltHeight=3Ddocument.body.clientHeight-padding
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if( cltHeight < g_origH*factor )
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newSize =3D g_origSz * factor
if( newSize < 1 ) newSize=3D1
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s.fontSize=3DnewSize+"px"
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s.posHeight=3Dg_origH*factor
s.posLeft=3D(cltWidth-s.posWidth+padding)/2
s.posTop=3D(cltHeight-s.posHeight+padding)/2
if( g_scaleHyperlinks )
ScaleHyperlinks( factor )
}
function _InitAnimations()
{
animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined';
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g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc=
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if( g_animUseRuntime ) {
collSeq =3D document.all.tags("seq");
if( collSeq !=3D null ) {
for(ii=3D0;ii
' + ENDSHOW_MESG + '
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No=
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