Journal of general internal medicine
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Comparative Study
Assessment of patient capacity to consent to treatment.
To compare results of a specific capacity assessment administered by the treating clinician, and a Standardized Mini-Mental Status Examination (SMMSE), with the results of expert assessments of patient capacity to consent to treatment. ⋯ Specific capacity assessments by the treating clinician and SMMSE scores agree closely with results of expert assessments of capacity. Clinicians can use these practical, flexible, and evaluated measures as the initial step in the assessment of patient capacity to consent to treatment.
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Comparative Study
Racial variation in the use of do-not-resuscitate orders.
To compare the use of do-not-resuscitate (DNR) orders in African-American and white patients using a large, multisite, community-based sample. ⋯ The use of DNR orders was substantially lower in African Americans than in whites, even after adjusting for severity of illness and other covariates. Identification of factors underlying such differences will improve our understanding of the degree to which expectations for care differ in African American and white patients.
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To assess whether physicians would be more likely to override a do-not-resuscitate (DNR) order when a hypothetical cardiac arrest is iatrogenic. ⋯ Physicians may believe that DNR orders do not apply to iatrogenic cardiac arrests and that patients do not consider the possibility of an iatrogenic arrest when they negotiate a DNR order. Physicians may also believe that there is a greater obligation to treat when an illness is iatrogenic, and particularly when an illness results from the physician's error. This response to iatrogenic cardiac arrests, and its possible generalization to other iatrogenic complications, deserves further consideration and discussion.
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To describe how and why attending physicians respond to learner behaviors that indicate negative attitudes toward patients. ⋯ Because of uncertainty about appropriateness and effectiveness, attending physicians were reluctant to respond to perceived disrespect, uncaring, or hostility toward patients by members of their medical team. They tended to avoid, rationalize, or medicalize these behaviors, and to respond in ways that avoided moral language, did not address underlying attitudes, and left room for face-saving reinterpretations. Although these oblique techniques are sympathetically motivated, learners in stressful clinical environments may misinterpret, undervalue, or entirely fail to notice such subtle feedback.