It's a spiral staircase, not just two steps: An iterative approach to assessing patient capacity for medical decision-making.

The assessment of medical decision-making capacity as part of the process of clinical informed consent has been considered a bioethical housekeeping matter for decades. Yet in practice, the reality bears little resemblance to what is described in the medical literature and professed in medical education. Most literature on informed consent refers to medical decision-making capacity as a precondition to the consent process. That is, a clinician must first determine if a patient has capacity, and only then may the clinician engage with the patient for the rest of informed consent. The problem with this two-step approach is that it makes no sense in actual practice. We see the assessment of medical decision-making capacity within the process of informed consent as a spiral staircase, not just two steps, requiring clinicians to keep circling up and around, making progress, until they get to where they need to be: 1. Clinicians start with a general presumption of capacity for most adults, sometimes having a provisional appraisal of capacity based on prior patient contact. 2. Then, they begin performing informed consent for the current situation and intervention options. 3. Next, they must reassess capacity during this process. 4. After that, they continue with informed consent. 5. If capacity is not yet clear, they repeat 1-4.

Storylines of family medicine IV: perspectives on practice-lenses of appreciation.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'IV: perspectives on practice-lenses of appreciation', authors address the following themes: 'Relational connections in the doctor-patient partnership', 'Feminism and family medicine', 'Positive family medicine', 'Mindful practice', 'The new, old ethics of family medicine', 'Public health, prevention and populations', 'Information mastery in family medicine' and 'Clinical courage.' May readers nurture their curiosity through these essays.

Facing Progress with Pragmatism: Telemedicine and Family Medicine.

The singular expertise of family physicians is the ability to manage complexity with pragmatism, both clinically and ethically. Telemedicine raises multiple questions about the nature of the patient-physician relationship as manifested in clinical encounters. Some of these questions are concerning, underscoring the need to assess whether medical care is better with this new technology-or if it is just different or maybe even worse. It seems clear, however, that, regardless of its limitations, telemedicine is here to stay. The pragmatic complex ethical question, then, is how all of us together-both medical professionals and society at large-will manage it.

The Consent Continuum: A New Model of Consent, Assent, and Nondissent for Primary Care.

The practice around informed consent in clinical medicine is both inconsistent and inadequate. Indeed, in busy, contemporary health care settings, getting informed consent looks little like the formal process developed over the past sixty years and presented in medical textbooks, journal articles, and academic lectures. In this article, members of the Society of Teachers of Family Medicine (STFM) Collaborative on Ethics and Humanities review the conventional process of informed consent and its limitations, explore complementary and alternative approaches to doctor-patient interactions, and propose a new model of consent that integrates these approaches with each other and with clinical practice. The model assigns medical interventions to a consent continuum defined by the discrete categories of traditional informed consent, assent, and nondissent. Narrative descriptions and clinical exemplars are offered for each category. The authors invite colleagues from other disciplines and from the academic ethics community to provide feedback and commentary.

Ways of Being in Generalist Practice: Using Five "T" Habits of Mind to Guide Ethical Behavior.

The practice of generalist medicine differs from the practice of other clinical disciplines. We postulate that the application of ethics in generalist practice similarly differs from its application in other healthcare settings. In contrast to the problem-focused practice of ethics in other medical specialties, the practice of ethics in generalist medicine blends habits of mind with behaviors applied routinely over time-an ethical way of being. Using a graphic summary and tabular matrix, we present five "T" habits of mind (time, talk, tact, touch, and trust), associate them with applicable practice characteristics, and link them to observable clinician behaviors to demonstrate how the application of ethics in generalist practice is a day-to-day endeavor and not simply a means to resolve episodic conflicts. We textually review key aspects of the matrix and present two case studies that illustrate how such habits of mind and practice behaviors inform the ethical way of being we espouse. We invite generalist practitioners to incorporate the five "T" habits and associated behaviors into their daily care of patients, and we encourage clinical ethicists and other clinical faculty members to consider using them as a model for ethics education with medical students and resident physicians.

A Reflective Case Study in Family Medicine Advance Care Planning Conversations.

Advance care planning conversations traditionally have been promoted using the Standard of Substituted Judgment and the Standard of Best Interests. In practice, both are often inadequate. Patients frequently avoid these conversations completely, making substituted judgment decisions nearly impossible. Surrogates are also often unable to make clinical decisions representing the best interests of family members as patients. Many physicians are unskilled at discussing these difficult and complex decisions with surrogates as well. Using an integrative family medicine ethics approach, we present a case study that demonstrates how skillful family physicians might introduce and conduct these conversations at routine office appointments, reconciling ethical theory with both patient-centered and physician-centered considerations in a practical and time-sensitive fashion. We believe 3 physician behaviors will help prepare patients to engage their surrogates and help empower surrogates to serve their role well, if and when that time comes: 1) thinking broadly about clinical issues and ethical considerations; 2) engaging in a mindful and contemporaneous deliberation with the patient-and surrogate when appropriate and possible-about these issues and considerations; and 3) cultivating a reflective responsiveness to these interactions, both when things go well and when they do not.

Family Medicine Ethics: An Integrative Approach.

The practice of modern medical ethics is largely acute, episodic, fragmented, problem-focused, and institution-centered. Family medicine, in contrast, is built upon a relationship-based model of care that is accessible, comprehensive, continuous, contextual, community-focused and patient-centered. "Doing ethics" in the day-to-day practice of family medicine is therefore different from doing ethics in many other fields of medicine, emphasizing different strengths and exemplifying different values. For family physicians, medical ethics is more than just problem solving. It requires reconciling ethical concepts with modern medicine and asking the principal medical ethics question-What, all things considered, should happen in this situation?-at every clinical encounter over the course of the patient-doctor relationship. We assert that family medicine ethics is an integral part of family physicians' day-to-day practice. We frame this approach with a four-step process modified from other ethical decision-making models: (1) Identify situational issues; (2) Identify involved stakeholders; (3) Gather objective and subjective data; and (4) Analyze issues and data to direct action and guide behavior. Next, we review several ethical theories commonly used for step four, highlighting the process of wide reflective equilibrium as a key integrative concept in family medicine. Finally, we suggest how to incorporate family medicine ethics in medical education and invite others to explore its use in teaching and practice.

Assessing capacity in psychiatric patients with acute medical illness who refuse care.

Three cases are presented that demonstrate the difficulty of assessing medical decision-making capacity in patients with psychiatric illness who are refusing care. Health professionals often assess capacity differently in practice. Provided their patients have some understanding of their illness and have some plans for meeting basic needs, psychiatrists are often inclined to give patients the freedom to refuse care even if they do not exhibit a full understanding of the medical facts of their case and why they are refusing it. Adult medicine physicians, in contrast, are inclined to require patients to state a more complete understanding of the benefits and burdens of evaluation and treatment before allowing them to refuse care when their refusals might result in adverse medical outcomes. The 3 cases exemplify the tension between these approaches and highlight the role of hospital ethics consultation in addressing this conflict.