C-L Case Conference: Assessment of Dispositional Capacity in Medically Complex Patients.

We present the case of a 76-year-old male with mild cognitive impairment and delirium who was referred to consultation-liaison psychiatry for an assessment of capacity to choose discharge. Cases involving "dispositional capacity" are complex and increasingly frequent, with momentous consequences for patients and their families, but are rarely discussed in the literature. In this article, experts in functional assessment, cognition, and ethics provide guidance for this commonly encountered clinical scenario based on their experience and available literature.

Requests for Directed Blood Donations.

This Ethics Rounds presents a request for directed blood donation. Two parents feel helpless in the setting of their daughter's new leukemia diagnosis and want to directly help their child by providing their own blood for a transfusion. They express hesitancy about trusting the safety of a stranger's blood.

A Cross Sectional Survey of Recruitment Practices, Supports, and Perceived Roles for Unaffiliated and Non-scientist Members of IRBs.

Background: Institutional Review Boards (IRBs) are federally mandated to include both nonscientific and unaffiliated representatives in their membership. Despite this, there is no guidance or policy on the selection of unaffiliated or non-scientist members and reports indicate a lack of clarity regarding members' roles. In the present study we sought to explore processes of recruitment, training, and the perceived roles for unaffiliated and non-scientist members of IRBs.

What does the word healing mean to you? Perceptions of patients with life-limiting illness.

Introduction: There is a growing consensus that patient-centered care is more effective in treating patients than a strictly biomedical model, where there are known challenges to involving the patient in assessments, treatment goals, and determining preferred outcomes.

Objectives: The current study seeks to integrate patient values and perspectives by exploring how people diagnosed with a life-limiting disease define healing in their own words.

Methods: As a part of a larger study that included cognitive interviewing, we asked the question "what does the word healing mean to you?" Data were collected during face-to-face interviews with patients from three metropolitan healthcare facilities.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration.

Background: Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings.

The VA Life-Sustaining Treatment Decisions Initiative: A qualitative analysis of veterans with advanced kidney disease.

Background: Documentation of patients' goals of care is integral to promoting goal-concordant care. In 2017, the Department of Veterans Affairs (VA) launched a system-wide initiative to standardize documentation of patients' preferences for life-sustaining treatments (LST) and related goals-of-care conversations (GoCC) that included using a note template in its national electronic medical record system. We describe implementation of the LST note based on documentation in the medical records of patients with advanced kidney disease, a group that has traditionally experienced highly intensive patterns of care.

Discharges against medical advice and 30-day healthcare costs: an analysis of commercially insured adults.

Prior literature detailing the consequences of a discharge against medical advice (DAMA) has not focused on costs. We examine costs following a DAMA. This retrospective cohort study utilized the IQVIA PharMetrics Plus database to identify adults hospitalized during 2007-2015.

Healthcare Resource Utilization Following a Discharge Against Medical Advice: An Analysis of Commercially Insured Adults.

Background: A discharge against medical advice (DAMA) is associated with adverse health outcomes. Its association with postdischarge healthcare resource utilization (HcRU) outside an inpatient setting is unknown. This information can help us understand how a DAMA may affect healthcare-seeking behavior following a hospital stay.

"Doc, I'm Going for a Walk": Liberalizing or Restricting the Movement of Hospitalized Patients-Ethical, Legal, and Clinical Considerations.

When patients are admitted to the hospital, they are generally expected to remain in or within close proximity to their assigned rooms in order to promote their safety and appropriate medical care. Although there are circumstances when patients may safely leave their hospital room or floor, guidance within the medical literature for the management of patient movement within the hospital are lacking. Excessive restrictions on patient movement may be seen as overly paternalistic, while lax requirements may interfere with high quality care, patient safety and efficient hospital practice.

The role of patient-provider interactions: Using an accounts framework to explain hospital discharges against medical advice.

The phenomenon of leaving the hospital against medical advice (AMA) despite being quite common and associated with significant deleterious health outcomes remains inadequately understood and addressed. Researchers have identified certain patient characteristics as predictors of AMA discharges, but the patients' reasons for these events have not been comprehensively explored. Moreover, because the medical authority model dominates this research area, providers' experiences of AMA discharges remain unstudied.