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.

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

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.

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.

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.

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.

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.

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.

A new standard for incapacitated patient decision making: the clinical standard of surrogate empowerment.

Founded upon the primacy of the principle of respect for autonomy, three methods of surrogate decision making traditionally have been promoted to help the family and friends of incapacitated patients. Unfortunately, the standards of advance directives, substituted judgment, and best interests are often inadequate in practice. Studies report that few patients have formal, written advance directives; that patients often change their minds about treatment over time; that many patients are simply not ready or willing to plan ahead--in part, because some patients and families simply don't believe in autonomy; that those patients who do plan ahead often do not communicate their plans; and that while some patients want their directives followed strictly, many prefer that their surrogates use judgment in making decisions.

Advance care directives: realities and challenges in Central California.

Purpose: To discover where patients with advance directives (ADs) obtain them and to learn what patients' understanding is of how ADs function.

Methods: Adult patients with ADs admitted to the four acute-care hospitals in Monterey County, California, were asked to participate in a survey during the study period 1 July to 8 September 2009.

Results: Of 5,811 total admissions, 455 patients (7 percent) had an AD.

Common skin conditions during pregnancy.

Common skin conditions during pregnancy generally can be separated into three categories: hormone-related, preexisting, and pregnancy-specific. Normal hormone changes during pregnancy may cause benign skin conditions including striae gravidarum (stretch marks); hyperpigmentation (e.g.