A consensus-based approach to providing palliative care to patients who lack decision-making capacity. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine.

Institute on Aging, University of Pennsylvania, Philadelphia 19104, USA.
Annals of internal medicine (Impact Factor: 16.1). 06/1999; 130(10):835-40.
Source: PubMed

ABSTRACT Making palliative care decisions for a patient who lacks decision-making capacity presents several challenges. Other people, such as family and caregivers, must choose for the patient. The goals and values of these decision makers may conflict with those of each other and with those of the patient, who now lacks the capacity to participate in the decision. This paper presents a case study of a patient with severe Alzheimer disease who has two common clinical problems: neurogenic dysphagia and aspiration pneumonia. The case study describes a consensus-based decision-making strategy that keeps what is known about the patient's wishes and values in the foreground but also expects guidance from the physician and elicits input from family members and other people who care for and have knowledge about the patient. The steps of this process, including key clinical prompts and potential transition statements, are outlined and described. The overall goal of the case commentary is to demonstrate that physicians can guide a highly emotional and personal process in a structured manner that has meaning for the patient, family, physician, and other caregivers.

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    ABSTRACT: Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circum-stances is a necessary exercise. The sixth edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging con-cerns. In addition, by reiterating ethical principles that have pro-vided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substi-tute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession. Ann Intern Med. 2012;156:73-104. For author affiliation, see end of text. The secret of the care of the patient is in caring for the patient. —Francis Weld Peabody (1) S ome aspects of medicine, like the patient–physician re-lationship, are fundamental and timeless. Medicine, however, does not stand still—it evolves. Physicians must be prepared to deal with changes and reaffirm what is fun-damental. This sixth edition of the Ethics Manual exam-ines emerging issues in medical ethics and professionalism and revisits older issues that are still very pertinent. Changes to the Manual since the 2005 (fifth) edition in-clude new or expanded sections on treatment without in-terpersonal contact; confidentiality and electronic health records; therapeutic nondisclosure; genetic testing; health system catastrophes; caring for oneself, persons with whom the physician has a prior nonprofessional relationship, and very important persons (VIPs); boundaries and privacy; so-cial media and online professionalism; surrogate decision making and end-of-life care; pay-for-performance and pro-fessionalism; physician–industry relations; interrogation; cross-cultural efficacy, cultural humility, and physician vol-unteerism; attending physicians and physicians-in-training; consultation, shared care, and the patient-centered medical home; protection of human subjects; use of human biolog-ical materials and research; placebo controls; scientific pub-lication; and sponsored research. A case method for ethics decision making is included (Appendix). Changes to the Manual from the fifth edition are noted in Box 1. The Manual is intended to facilitate the process of making ethical decisions in clinical practice, teaching, and medical research and to describe and explain underlying ethics principles, as well as the physician's role in society and with colleagues. Because ethics and professionalism must be understood within a historical and cultural con-text, the second edition of the Manual included a brief overview of the cultural, philosophical, and religious un-derpinnings of medical ethics in Western cultures. In this edition, we refer the reader to that overview (2, 3) and to other sources (4, 5) that more fully explore this rich heritage. The Manual raises issues and presents general guide-lines. In applying these guidelines, physicians should con-sider the circumstances of the individual patient and use their best judgment. Physicians have moral and legal obli-gations, and the two may not be concordant. Physician participation in torture is legal in some countries but is never morally defensible. Physicians must keep in mind the distinctions and potential conflicts between legal and eth-ical obligations and seek counsel when concerned about the potential legal consequences of decisions. We refer to the law in this Manual for illustrative purposes only; this should not be taken as a statement of the law or the legal consequences of actions, which can vary by state and coun-try. Physicians must develop and maintain an adequate knowledge of key components of the laws and regulations that affect their patients and practices. Medical and professional ethics often establish pos-itive duties (that is, what one should do) to a greater extent than the law. Current understanding of medical ethics is based on the principles from which positive duties
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    ABSTRACT: Objectives. To explore attitudes to making end-of-life decisions (ELDs) in a group of elderly Chinese with dementia and their carers. Methods. Four hypothetical case vignettes depicting different potentially life-threatening medical conditions in patients with dementia were presented. Subjects were interviewed about their treatment preferences and emotions after decision-making. Results. Most subjects with dementia preferred to follow the 'natural' way. They accepted that it was their fate and felt at ease making ELDs. They had no regrets though a strong feeling of helplessness was observed. The carers had different views on different scenarios. They would consider possibility of saving life as well as the quality of life. Carers had mixed feelings after making ELDs. A sense of guilt and helplessness, as well as uncertainty about the choice, was a common finding. Conclusions. Although the ability to express personal choices about ELD is impaired in people with advanced dementia, choices and feelings should be respected. The emotional burden imposed by the proxy decision carers who are forced to make should be acknowledged. Advance planning with collaborative decisions by people with dementia, their families, and health care professionals is recommended and may help to reduce the adverse emotions felt by relatives after making ELDs.
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