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The article focuses on decision-making laws for unrepresented patients, including choices affecting life-sustaining therapies (LST), is determined by U.S. states. It mentions searches of the Nexis Uni and Fastcase databases to identify statutes detailing out-of-court decision-making processes for incapacitated and unrepresented patients. It also mentions out-of-court process to identify healthcare decision makers for unrepresented patients.

Context: Patients with terminal illnesses often require surrogate decision makers. Prior research has demonstrated high surrogate stress, and that despite standards promoting substituted judgment, most patients do not want their surrogates to make pure substituted judgments for them. It is not known how best to help loved ones fulfill the surrogate role.Objectives: To test the effectiveness of an intervention to help surrogate decision makers.Methods: One hundred sixty-six patients (41% with amyotrophic lateral sclerosis and 59% with gastrointestinal cancers) and their surrogates at two university medical centers were randomized to an intensive nurse-directed discussion of the end-of-life decision control preferences of the patient (TAILORED) or a discussion of nutrition (CONTROL); 163 completed baseline interviews and underwent the intervention.Results: Twelve patients died during follow-up and 137 dyads completed the study. Post-intervention, using all available data, TAILORED patients and surrogates became more likely to endorse mutual surrogate decision making, that is, a balance of their own wishes and what the surrogate thinks best (adjusted odds compared with baseline for patients = 1.78, P = 0.04; adjusted odds for surrogates = 2.05, P = 0.03). CONTROL patients became 40% less likely to endorse mutual surrogate decision making (P = 0.08), and CONTROL surrogates did not change significantly from baseline (adjusted odds = 1.44, P = 0.28). Stress levels decreased for TAILORED surrogates (impact of events scale = 23.1 ± 14.6 baseline, 20.8 ± 15.3 f/u, P = 0.046), but not for CONTROL (P = 0.85), and post-intervention stress was lower for TAILORED than CONTROL (P = 0.04). Surrogates' confidence was uniformly high at baseline and did not change. Caregiver burden (Zarit) increased from 12.5 ± 6.5 to 14.7 ± 8.1 for TAILORED (P < 0.01), while not changing for CONTROL, yet satisfaction with involvement in decision making was higher at follow-up for TAILORED than for CONTROL (71% vs. 52%, P = 0.03).Conclusion: TAILORED patients and surrogates who completed the study adopted a more mutual decision-making style, balancing their own wishes with what the surrogate thinks would be best for them. Surrogates reported less stress and more satisfaction. Confidence was high at baseline and did not change. There was a modest increase in caregiver burden. These findings suggest that interventions like TAILORED might positively impact surrogate decision making. [ABSTRACT FROM AUTHOR]

Reading the following brief piece depends on having some knowledge of the famous essay to which it refers, Francis W Peabody's "The Care of the Patient," published 90 years ago in the Journal of the American Medical Association (JAMA 88:877--82). Peabody's essay was based on a talk he gave to Harvard medical students in 1925, and it was published shortly before his premature death in 1927. At the time, he was highly regarded as a consummate clinician and teacher, and in his essay, he laments problems he already saw affecting medical practice, such as the overvaluation of science relative to clinical medicine and a diminishing spirit of attentiveness to the most deeply human needs of patients. He deals in an especially astute and compassionate way with the care of patients suffering from what is now known as somatization disorder. Peabody's essay has been widely anthologized, is often an assigned reading for medical students, and has been revered by practitioners and students for almost 100 years. But times are changing ... [ABSTRACT FROM AUTHOR]

Abstract: Every ethos implies a mythos in the sense that every systematic approach to ethics is inevitably based on some fundamental religious or religion-like story that gives answers to questions such as: Where did I come from? Where am I going? How am I to live? These narratives generally lay hidden beneath the plane of the interpersonal interactions that characterize all clinical encounters, but caring for patients who are approaching death brings them closer to the surface. For many patients and practitioners, these narratives will be expressed in explicitly religious language; others may invoke a sense of “immanent transcendence” that affords a spiritual perspective without requiring theism or notions of eternity. In caring for patients at the end of life, practitioners should strive to be more conscious of the narratives that undergird their own spiritual and ethical positions as well as seek to understand those of the patients they serve. [Copyright &y& Elsevier]

Background: Surrogate accuracy in predicting patient treatment preferences (i.e., what patients want) has been studied extensively, but it is not known whether surrogates can predict how patients want loved ones to make end-of-life decisions on their behalf.Objective: To evaluate the ability of family members to correctly identify the preferences of seriously-ill patients regarding family involvement in decision making.Design: Cross-sectional survey.Participants: Twenty-five pancreatic cancer and 27 amyotrophic lateral sclerosis (ALS) patients and their family members (52 dyads total).Main Measures: Patients and family members completed the Decision Control Preferences (DCP) scale regarding patient preferences for family involvement in health care decisions using conscious and unconscious scenarios.Key Results: Patient and family member agreement was 56% (29/52 dyads) for the conscious scenario (kappa 0.29) and 46% (24/52 dyads) for the unconscious scenario (kappa 0.15). Twenty-four family members identified the patient's preference as independent in the unconscious scenario, but six of these patients actually preferred shared decision making and six preferred reliant decision making. In the conscious scenario, preference for independent decision making was associated with higher odds of patient-family agreement (AOR 5.28, 1.07-26.06). In the unconscious scenario, cancer patients had a higher odds of agreement than ALS patients (AOR 3.86; 95% CI 1.02-14.54).Conclusion: Family members were often unable to correctly identify patient preferences for family involvement in end-of-life decision making, especially when patients desired that decisions be made using the best-interest standard. Clinicians and family members should consider explicitly eliciting patient preferences for family involvement in decision making. Additional research is still needed to identify interventions to improve family member understanding of patient preferences regarding the decision-making process itself. [ABSTRACT FROM AUTHOR]

Background: Pay-for-performance is proliferating, yet its impact on key stakeholders remains uncertain.Objective: The Society of General Internal Medicine systematically evaluated ethical issues raised by performance-based physician compensation.Results: We conclude that current arrangements are based on fundamentally acceptable ethical principles, but are guided by an incomplete understanding of health-care quality. Furthermore, their implementation without evidence of safety and efficacy is ethically precarious because of potential risks to stakeholders, especially vulnerable patients.Conclusion: We propose four major strategies to transition from risky pay-for-performance systems to ethical performance-based physician compensation and high quality care. These include implementing safeguards within current pay-for-performance systems, reaching consensus regarding the obligations of key stakeholders in improving health-care quality, developing valid and comprehensive measures of health-care quality, and utilizing a cautious evaluative approach in creating the next generation of compensation systems that reward genuine quality. [ABSTRACT FROM AUTHOR]

The article offers guidance on when to incorporate spirituality and religion in clinical care. According to the author, religions provide patients with specific moral guidance on several medical issues and suggest rituals that are important to patients. He stresses the positive and negative aspects of religious coping which can impact patient care. He also discusses the definition of spirituality and religion, spiritual issues that serious illness presents for patients and the moral obligations of physicians in addressing patients' spiritual concerns.

The article discusses the difference between authentic faith in miracles and the psychological denial in the middle of serious illness. According to the author, atheists who consider all religious beliefs are just a mere delusion would not bother to accept the meaningfulness of the distinction. However, this distinction will be easy in any clinical case. Thus, he suggests several questions that would distinguish between authentic faith in miracles and the psychiatric state of denial.

Comments on the Roman Catholic Church teaching about the use of life-sustaining treatments. Presumption in favor of providing nutrition and hydration to all patients; Criteria by which the treatment could be considered extraordinary or morally optional; Fundamental change in Catholic teaching about life-sustaining treatments.

OBJECTIVES: To assess whether older physicians have discussed their preferences for medical care at the end of life with their physicians, whether they have established an advance directive, and what life-sustaining treatment they wish in the event of incapacity to make these decisions for themselves. DESIGN: Mailed survey to a cohort of physicians. SETTING: Physicians who were medical students at the Johns Hopkins University in graduating classes from 1946 to 1964. PARTICIPANTS: Physicians who completed the advance directive questionnaire (mean age 68). MEASUREMENTS: Questionnaires were sent out to known surviving physicians of the Precursors Study, an on-going study that began in 1946, asking physicians about their preferences for life-sustaining treatments. RESULTS: Of 999 physicians who were sent the survey, 765 (77%) responded. Forty-six percent of the physicians felt that their own doctors were unaware of their treatment preferences or were not sure, and of these respondents, 59% had no intention of discussing their wishes with their doctors within the next year. In contrast, 89% thought their families were probably or definitely aware of their preferences. Sixty-four percent reported that they had established an advance directive. Compared with physicians without advance directives, physicians who established an advance directive were more likely to believe that their doctors (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.49-4.69) or family members (OR = 9.58, 95% CI = 5.33-17.23) were aware of their preferences for end-of-life care and were more likely to refuse treatments than those without advance directives. CONCLUSION: This survey of physicians calls attention to the gap between preferences for medical care at the end of life and expressing wishes to others through discussion and advance directives, even among physicians. [ABSTRACT FROM AUTHOR]

Discusses the material considerations in giving health care justice to people through hospice care in the U.S. Characteristics of human beings; Assumptions of health care justice theories; Comparison on the alternatives to hospice and flu vaccines.

Rising health care expenditures have led to numerous cost-control proposals. An examination of the ethical questions surrounding the role that physicians play in the control of health care costs suggests that unilateral rationing decisions by individual physicians at the bedside are morally unacceptable. Such decisions are arbitrary, ineffective in redistributing health care resources, and formally unjust. Restrictive gatekeeping (the creation of financial incentives for physicians to limit care given to individual patients) also seems unacceptable because of its morally significant effects. First, it disguises the role of those actually responsible for cost-control decisions; second, it routinely creates a "moral stress test" by forcing physicians to act in ways that are contrary to their own interests in order to serve the needs of patients; third, it undermines the trust between doctor and patient; and fourth, it rations by class of persons rather than class of technology. In contrast, a morally sound system would attempt to control costs by honestly informing patients and assigning responsibility justly, would encourage physicians to act in the interests of patients, would foster trust, and would recognize the great importance of equal treatment for all patients. Such a system would depend on input from an informed public and would apply equally to all members of society. [ABSTRACT FROM AUTHOR]

The relation between the timing of do-not-resuscitate (DNR) orders and the cost of medical care is not well understood. This prospective observational study compares hospital costs and length of stay of 265 terminally ill patients with admission DNR orders, delayed DNR orders (occurring after 24 hours), or no DNR orders (full code). Patients whose orders remained full code throughout a hospital stay had similar lengths of stay, total hospital costs, and daily costs as patients with admission DNR orders. Patients with delayed DNR orders, by contrast, had a greater mortality, longer length of stay, and higher total costs than full code or admission DNR patients, but similar daily costs. The causes of delay in DNR orders and the associated higher costs are a matter for future research. [ABSTRACT FROM AUTHOR]

The author discusses substituted interests model, an integrated model of surrogate decision making in medicine, the moral focus of medicine and the good of the patients care. Topics discussed include the U.S. state laws for surrogate decision making; patients' dilemma on how they make decisions as well as how they should be treated; and the need to changes in policy, practice and law for the good of the patients.

A personal narrative is presented which explores the authors' experience of being examined at a modern examination room, highlighting the behavior of the doctor which is unhurried and paying his full attention to them as his patients.

Objectives: Spirituality is related to the care and the quality of life of cancer patients. Thus, it is very important to assess their needs. The objective of this study was the translation and cultural adjustment of the Spiritual Needs Assessment for Patients (SNAP) questionnaire to the Brazilian Portuguese language. Methodology: The translation and cultural adjustment of the SNAP questionnaire involved six stages: backtranslation, revision of backtranslation, translation to the original language and adjustments, pre-test on ten patients, and test and retest with 30 patients after three weeks. Adult patients, with a solid tumour and literate with a minimum of four years schooling were included. For analysis and consistency we used the calculation of the Cronbach alpha coefficient and the Pearson linear correlation. Results: The final questionnaire had some language and content adjustments compared to the original version in English. The correlation analysis of each item with the total score of the questionnaire showed coefficients above 0.99. The calculation of the Cronbach alpha coefficient was 0.9. The calculation of the Pearson linear correlation with the test and retest of the questionnaire was equal to 0.95. Conclusion: The SNAP questionnaire translated into Brazilian Portuguese is adequately reliable and consistent. This instrument allows adequate access to spiritual needs and can help patient care. [ABSTRACT FROM AUTHOR]