Journal of general internal medicine
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Substituted judgment is often invoked as a guide for decision making when a patient lacks decision making capacity and has no advance directive. Using substituted judgment, doctors and family members try to make the decision that the patient would have made if he or she were able to make decisions. However, empirical evidence suggests that the moral basis for substituted judgment is unsound. ⋯ Given compelling evidence that the use of substituted judgment has insurmountable flaws, other approaches should be considered. One approach provides limits on decision making using a best interest standard based on community norms. A second approach uses narrative techniques and focuses on each patient's dignity and individuality rather than his or her autonomy.
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Multicenter Study
Empathy and life support decisions in intensive care units.
Although experts advocate that physicians should express empathy to support family members faced with difficult end-of-life decisions for incapacitated patients, it is unknown whether and how this occurs in practice. ⋯ Physicians vary considerably in the extent to which they express empathy to surrogates during deliberations about life support, with no empathic statements in one-third of conferences. There is an association between more empathic statements and higher family satisfaction with communication.
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Randomized Controlled Trial Multicenter Study
Does outpatient telephone coaching add to hospital quality improvement following hospitalization for acute coronary syndrome?
Telephone counseling in chronic disease self-management is increasing, but has not been tested in studies that control for quality of medical care. ⋯ Telephone coaching post-hospitalization for ACS was modestly effective in accomplishing short-term, but not long-term life-style behavior change. Previous positive results shown in primary care did not transfer to free-standing telephone counseling as an adjunct to care following hospitalization.
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Lower extremity peripheral arterial disease (PAD) is highly prevalent and strongly associated with cardiovascular morbidity and mortality. The ankle-brachial index used to screen for PAD is not routinely performed in primary care settings. ⋯ Self-reported PAD is an independent risk factor for future vascular events in this predominantly non-white cohort. The addition of two simple PAD questions to the routine medical history in general medicine settings could identify high-risk patients who would benefit from further vascular evaluation and risk factor modification.
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Multicenter Study
Literacy, social stigma, and HIV medication adherence.
Prior studies have linked limited literacy to poorer HIV medication adherence, although the precise causal pathways of this relationship have only been initially investigated. ⋯ While low literacy was a significant risk factor for improper adherence to HIV medication regimens in our study, perceived social stigma mediated this relationship. Low literacy HIV intervention strategies may also need to incorporate more comprehensive psychosocial approaches to overcome stigma barriers.