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.

Implantable cardioverter defibrillators are life-saving devices for many patients with cardiac disease. Recipients of these devices, nevertheless, often suffer from progressive comorbid and cardiac conditions. Therefore, physicians should anticipate situations in which the defibrillator is no longer desired by the patient or no longer medically appropriate. Near the end of life, many of these patients may decline cardiopulmonary resuscitation. The comanagement of do-not-resuscitate orders and implanted defibrillators can be confusing to patients and physicians alike since the former proscribe the use of electrical cardioversion while the latter provide this precise treatment. Although the use of implanted defibrillators has important ethical implications, few studies have examined these issues, and guidelines have not yet been developed to assist physicians in caring for patients who have received defibrillators. This paper discusses bioethical considerations in disabling implantable cardioverter defibrillators.

A multitarget visual cancellation test was administered to patients with Alzheimer's disease (AD) and age-matched healthy controls (HC). Attentional loads--physical similarity (number of features shared by target and distractors; 3 levels) and density (number of items per page; 3 levels)--were varied systematically. As physical similarity increased, both groups slowed their search, but whereas the HC group maintained accuracy, the AD group increased commission errors and tended to miss more targets. Increased density yielded slower search and more target omissions in the AD group. Commission errors are additional indicators of higher order attentional deficits, especially in early disease. The findings suggest that patients with AD may rely increasingly on physical features of stimuli during a search, leading to inefficient bottom-up processing strategies.