Faculty Bibliography

The care of adult patients without decision-making abilities is a routine part of medical practice. Decisions for these patients are typically made by surrogates according to a process governed by a hierarchy of 3 distinct decision-making standards: patients' known wishes, substituted judgments, and best interests. Although this framework offers some guidance, it does not readily incorporate many important considerations of patients and families and does not account for the ways in which many patients and surrogates prefer to make decisions. In this article, the authors review the research on surrogate decision making, compare it with normative standards, and offer ways in which the 2 can be reconciled for the patient's benefit.

In recent years, interest in improving health care to diverse patient populations has stimulated the development of academic and clinical resources to improve physicians' cultural competence. These efforts have focused on increasing physicians' sensitivity to the roles patients' ethnicity and culture play in health care. However, the influence of physicians' own demographic characteristics on their practice of medicine is an important, yet relatively overlooked, consideration among efforts to improve cross-cultural care. There is a strong presumption in the medical literature that clinicians are neutral operators governed by objective science and are unaffected by personal variables. Yet, there is a body of research that finds physicians' practice patterns are influenced by their own demographic characteristics, and patient care is affected by the demographic concordance or discordance of the physician-patient dyad. The author discusses this existing literature to illustrate the presence and importance of the impact of physicians' demographic characteristics on the care they provide and discusses strategies to mitigate this influence. Greater attention to understanding the way in which physician demographic characteristics influence clinical care using multidisciplinary and multimodal approaches provides an opportunity to improve the quality of medical education and improve the quality and efficacy of medical care.

Discharges against medical advice (AMA) account for approximately 1% of discharges for general medical patients. Patients discharged AMA have longer eventual hospital stays and worse health outcomes. These patients are also less likely to have an established relationship with a physician, tend to have poorer social supports, and are more likely to abuse alcohol and other substances. These discharges are also distressing for physicians and other health professionals. How should physicians manage their conflicted obligations to respect patients' choices and to prevent harms from befalling their patients? What are physicians' obligations to their patients who leave accepting only partial or inadequate treatment plans or no treatment at all? When should physicians question the decision-making capacity of patients who make dangerous judgments to leave the hospital? This article examines the ethical and professional implications of discharge AMA.