Guardianship determinations by judges, attorneys, and guardians

Guardianship is intended to protect incapacitated individuals through the appointment of a surrogate decision maker. Little is known about how judges, attorneys, and professional guardians assess the need for guardianship, to what extent they apply statutory guidelines when making these determinations, and how their decisions compare. Three groups of participants (probate judges, elder law attorneys, and professional guardians) read vignettes portraying older adults that varied in the extent to which the evidence supported the appointment of a guardian. They were asked about the appropriateness of various resolutions. Participants were reluctant to endorse full guardianship even when warranted by the evidence and preferred informal, family-based interventions that do not involve legal action. Professional groups did not always agree on the appropriate resolutions, suggesting that one's professional orientation may play a role in perceptions of older adults.     

Attorney-client trust among convicted criminal defendants: preliminary examination of the attorney-client trust scale

The current study describes the development of the Attorney-Client Trust Scale (ACTS), a measure designed to assess a client's trust in his or her attorney. A sample of 307 male inmates completed the ACTS and provided information about their most recent case and attorney. Low ACTS scores were associated with having a court-appointed attorney, going to trial, and receiving a lengthy prison sentence. High ACTS scores were related to satisfaction with sentences and attorneys. In addition, findings suggest that perceptions about attorneys' interpersonal skills were as important as perceptions about legal skills in forming opinions about overall lawyering ability. It is recommended that attorneys employ a well rounded assortment of interpersonal skills to foster their clients' trust and to make better use of the limited amount of time they have to spend with clients.     

Legal briefing: The unbefriended: making healthcare decisions for patients without surrogates (Part 2)

This issue's "Legal Briefing" column continues coverage of recent legal developments involving medical decision making for unbefriended patients. These patients have neither decision-making capacity nor a reasonably available surrogate to make healthcare decisions on their behalf. This topic has been the subject of recent articles in JCE. It has been the subject of major policy reports. Indeed, caring for the unbefriended has even been described as the "single greatest category of problems" encountered in bioethics consultation. Moreover, the scope of the problem continues to expand, especially with rapid growth in the elderly population and with an increased prevalence of dementia. Unfortunately, most U.S.jurisdictions have failed to adopt effective healthcare decision-making systems or procedures for the unbefriended. "Existing mechanisms to address the issue of decision making for the unbefriended are scant and not uniform." Most providers are "muddling through on an ad hoc basis." Still, over the past several months, a number of state legislatures have finally addressed the issue. These developments and a survey of the current landscape are grouped into the following 14 categories. The first two categories define the problem of medical decision making for the unbefriended.The remaining 12 describe different solutions to the problem. The first six categories were covered in Part 1 of this article; the last eight categories are covered in this issue (Part 2). 1. Who are the unbefriended? 2. Risks and problems of the unbefriended. 3. Prevention: advance care planning, diligent searching, and careful capacity assessment. 4. Decision-making mechanisms and standards. 5. Emergency exception to informed consent. 6. Expanded default surrogate lists: close friends. 7. Private guardians. 8. Volunteer guardians. 9. Public guardians. 10. Temporary and emergency guardians. 11. Attending physicians. 12. Other clinicians, individuals, and entities. 13. Institutional committees. 14. External committees.     

Legal briefing: The unbefriended: making healthcare decisions for patients without surrogates (Part 1)

This issue's "Legal Briefing" column covers recent legal developments involving medical decision making for unbefriended patients. These patients have neither decision-making capacity nor a reasonably available surrogate to make healthcare decisions on their behalf. This topic has been the subject of recent articles in JCE. It has been the subject of major policy reports. Indeed, caring for the unbefriended has even been described as the "single greatest category of problems" encountered in bioethics consultation. Moreover, the scope of the problem continues to expand, especially with rapid growth in the elderly population and with an increased prevalence of dementia. Unfortunately, most U.S. jurisdictions have failed to adopt effective healthcare decision-making systems or procedures for the unbefriended. "Existing mechanisms to address the issue of decision making for the unbefriended are scant and not uniform". Most providers are "muddling through on an ad hoc basis". Still, over the past several months, a number of state legislatures have finally addressed the issue. These developments and a survey of the current landscape are grouped into the following 14 categories. The first two define the problem of medical decision making for the unbefriended. The remaining 12 categories describe different solutions to the problem. The first six of these solutions are discussed in this article (Part 1). The last eight solutions will be covered in the Summer 2012 issue of JCE (Part 2). 1. Who are the unbefriended? 2. Risks and problems of the unbefriended. 3. Prevention: advance care planning, diligent searching, and careful capacity assessment. 4. Decision-making mechanisms and standards. 5. Emergency exception to informed consent. 6. Expanded default surrogate lists: close friends. 7. Private guardians. 8. Volunteer guardians. 9. Public guardians. 10. Temporary and emergency guardians. 11. Attending physicians. 12. Other clinicians, individuals, and entities. 13. Institutional committees. 14. External committees.     

Giving advice or making decisions in someone else's place: the influence of impression, defense, and accuracy motivation on the search for new information

When making decisions, people have been found predominantly to seek information supporting their preferred choice and to neglect conflicting information. In this article, the authors investigate to what extent different types of advisors, who recommend a choice to someone or make a decision on behalf of someone, show the same confirmatory information search. In Experiment 1, the authors presented participants, in the role of advisors, with a client's decision problem and found that when making a recommendation, advisors conducted a more balanced information search than participants who were making a decision for themselves. However, advisors who had to make a decision on behalf of their clients revealed an increased preference for information supporting their position. Experiment 2 suggested that this confirmatory information search was caused by impression motivation: The advisors bolstered their decision to justify it to the client. The results are discussed within the multiple motive framework of the heuristic systematic model.     

Consultant choice across decision contexts: are abortion decisions different?

A survey conducted among college students in the midwestern US indicated that abortion decision-making consultation patterns differ substantially from those associated with other types of decisions. Surveyed were 169 predominantly White, middle-income students (68 males and 101 females) 18-20 years of age recruited from an introductory psychology class. Participants were presented with vignettes that pertained to four types of decisions: abortion (unplanned pregnancy), medical (cancer treatment type), future (career move), and interpersonal (crisis with a friend). For each decision, students were asked who they would consult (specific family members, significant others, friends, various professionals) and the order in which they would consult them. The mean number of consultants selected was 3.72 for abortion, 5.54 for medical, 4.90 for future-oriented, and 2.41 for interpersonal decisions. Significant others were selected most often for all decision scenarios; however, the highest frequency of consultation and lowest mean rank order for the significant other was on the abortion decision. The next most important consultant for abortion decisions was friends, then family members, and, finally, professionals. The only gender difference was a greater tendency for females to consult their mothers. For every category of consultant (except best friend), the pattern differed depending on the type of decision. These findings underscore the importance of considering context and multifaceted approaches in the design of programs aimed at enhancing adolescents' decision-making skills.     

Perspectives on the role of the eyewitness expert

Extensive controversy over the appropriate application of expert knowledge regarding issues of eyewitness accuracy led to a conference and a special issue of taw and Human Behavior in 1986. Arguments were presented both in support of and against the eyewitness researcher as expert testifier. The current research explored the views of the general public (N = 50), defense attorneys (N = 14), and prosecutors (N = 10) with regard to the use of eyewitness expertise in each of four roles (court-appointed expert, consultant, researcher, expert tesdfier for the defense). Extensive differences of opinion were found across both samples and expert roles. In general, prosecutors held significantly more negative views of the usefulness of expert witnesses for the defense than did the public or defense attorneys. The role of court-appointed expert was viewed positively by all three groups and may present a useful alternative to the battles of experts that may result from current practices.     

Parental refusals of medical treatment: the harm principle as threshold for state intervention

Minors are generally considered incompetent to provide legally binding decisions regarding their health care, and parents or guardians are empowered to make those decisions on their behalf. Parental authority is not absolute, however, and when a parent acts contrary to the best interests of a child, the state may intervene. The best interests standard is the threshold most frequently employed in challenging a parent's refusal to provide consent for a child's medical care. In this paper, I will argue that the best interest standard provides insufficient guidance for decision-making regarding children and does not reflect the actual standard used by medical providers and courts. Rather, I will suggest that the Harm Principle provides a more appropriate threshold for state intervention than the Best Interest standard. Finally, I will suggest a series of criteria that can be used in deciding whether the state should intervene in a parent's decision to refuse medical care on behalf of a child.     

Doc, what would you do if you were me? On self-other discrepancies in medical decision making

Doctors often make decisions for their patients and predict their patients' preferences and decisions to customize advice to their particular situation. We investigated how doctors make decisions about medical treatments for their patients and themselves and how they predict their patients' decisions. We also studied whether these decisions and predictions coincide with the decisions that the patients make for themselves. We document 3 important findings. First, doctors made more conservative decisions for their patients than for themselves (i.e., they more often selected a safer medical treatment). Second, doctors did so even if they accurately predicted that their patients would want a riskier treatment than the one they selected. Doctors, therefore, showed substantial self-other discrepancies in medical decision making and did not make decisions that accurately reflected their patients' preferences. Finally, patients were not aware of these discrepancies and thought that the decisions their doctors made for themselves would be similar to the decisions they made for their patients. We explain these results in light of 2 current theories of self-other discrepancies in judgment and decision making: the risk-as-feelings hypothesis and the cognitive hypothesis. Our results have important implications for research on expert decision making and for medical practice, and shed some light on the process underlying self-other discrepancies in decision making.     

The Effects of Cognitive Restructuring and Decision-Making Training on Career Indecision

The authors designed a cognitive restructuring intervention for individuals having difficulty with career decision making and compared the intervention to a decision skills intervention and a no-treatment control. The cognitive restructuring intervention was more effective than were both decision-making training and the control condition in reducing anxiety about career decision making and in encouraging vocational exploratory behavior. Cognitive restructuring clients also reported more use of the skills they had learned, were more satisfied with the decisions they made, and found the treatment program more useful in making career decisions than did clients in the other two groups.     

Transformations in Therapeutic Practice

In her training of therapists, Virginia Satir sought to change the way her trainees perceived themselves, their clients, and the therapeutic endeavor. The change she sought was a movement from hierarchical models of therapy where clients were diagnosed in terms of paradigms of how they ought to be to an organic model where the therapist attempts to understand the client by entering the client's internal context. Contemporary training in the Satir model attempts to bring about the same change. Research indicates that the trainers are succeeding.     

The clinical ethicist at the bedside

In this paper we attempt to show how the goal of resolving moral problems in a patient's care can best be achieved by working at the bedside. We present and discuss three cases to illustrate the art and science of clinical ethics consultation. The sine qua non of the clinical ethics consultant is that he or she goes to the patient's bedside to obtain specific clinical and ethical information. Unlike ethics committees, which often depend on secondhand information from a physician or nurse, clinical ethics consultants personally speak with and examine patients and review their laboratory data and medical records. The skills of the clinical ethics consultant include the ability to delineate and resolve ethical problems in a particular patient's case and to teach other health professionals to build their own frameworks for clinical ethical decision making. When the clinical situation requires it, clinical ethics consultants can and should assist primary physicians with case management.     

Counseling Adolescents and the Challenges for Genetic Counselors

Genetic counselors may have an important role in helping the adolescent make an informed decision with regard to genetic testing and in helping them to adjust to genetic risk information. However, counseling techniques that are used with adults may not be always be suited to the adolescent population. Adolescence is a time of development during which separation from the family and formation of identity is achieved. The process of this development may impact the genetic counseling relationship. Family relationships may have a strong influence on the client's decision to have genetic testing. Additionally, it may be difficult to engage the client as adolescents may not have the ability to think abstractly and consider the short and long term consequences of genetic testing. It is helpful therefore to discuss the counseling process and techniques that may be useful when counseling these clients. This paper presents two case studies that illustrate some of the difficulties that may occur when counseling adolescents for genetic testing. The authors' have reflected on their clinical experience with these clients and this is presented here to add to the growing literature on this subject.     

Training Community Clergy in Serious Illness: Balancing Faith and Medicine

Community-based clergy are highly engaged in helping seriously ill patients address spiritual concerns at the end of life (EOL). While they desire EOL training, no data exist in guiding how to conceptualize a clergy-training program. The objective of this study was used to identify best practices in an EOL training program for community clergy. As part of the National Clergy Project on End-of-Life Care, the project conducted key informant interviews and focus groups with active clergy in five US states (California, Illinois, Massachusetts, New York, and Texas). A diverse purposive sample of 35 active clergy representing pre-identified racial, educational, theological, and denominational categories hypothesized to be associated with more intensive utilization of medical care at the EOL. We assessed suggested curriculum structure and content for clergy EOL training through interviews and focus groups for the purpose of qualitative analysis. Thematic analysis identified key themes around curriculum structure, curriculum content, and issues of tension. Curriculum structure included ideas for targeting clergy as well as lay congregational leaders and found that clergy were open to combining resources from both religious and health-based institutions. Curriculum content included clergy desires for educational topics such as increasing their medical literacy and reviewing pastoral counseling approaches. Finally, clergy identified challenging barriers to EOL training needing to be openly discussed, including difficulties in collaborating with medical teams, surrounding issues of trust, the role of miracles, and caution of prognostication. Future EOL training is desired and needed for community-based clergy. In partnering together, religious–medical training programs should consider curricula sensitive toward structure, desired content, and perceived clergy tensions.     

The relationship between guardian certification requirements and guardian sanctioning: a research issue in elder law and policy

This study investigated the relationship between guardian certification requirements and guardian sanctioning in the state of Washington. A total of 377 files were examined. Findings show that 52.4% of guardians with an undergraduate degree or higher education are likely to be sanctioned compared with 42.2% with an Associate of Arts (AA) or Technical (Tech) degree, and 36.9% with a high school diploma (HS) or equivalency (GED). Guardians with an undergraduate or higher education are 1.88 times more likely to be sanctioned compared with GED or HS graduates (p < 0.05). However, 83.3% of GED or HS graduates are likely to have more severe sanctions compared with 76.4% undergraduate or higher education, and 47.7% with an AA or Tech degree, respectively. Guardians with an AA or Tech degree are 0.28 times less likely to have more severe sanctions than guardians with an undergraduate degree or higher education (p < 0.01). The results are discussed with respect to guardian registration, licensing, certification and quality; licensing and regulation of other professions; the limitations of the study; and the need for further research.     

目标概念的辨析及其对决策的影响

目标对决策的影响过程包含了明晰目标的决策过程和在目标的动机作用下完成后续决策任务的过程。目标是个体期望实现的多个未来结果相互之间竞争动机作用的结果。依据对未来结果的渴望性和可行性等特征的认知, 个体抉择出某个未来结果作为自己的目标, 使其具有了动机作用。在明晰目标的过程中, 解释水平、自我控制的人格特质和成功经验都会产生重要影响。在明确了目标以后, 目标通过改变个体对有利于目标实现的决策备择方案的态度和选择性注意来影响个体的决策。未来研究可以从目标的意识程度对决策负面结果的影响, 对决策的心理过程进行直接测量等角度来探讨目标对决策的影响。     

Cognitive-Behavioral Treatment of Depression, Part IX: Confronting Predisposing Factors

Cognitive-behavioral therapy can help many depressed clients learn more effective ways of coping with problems in their lives. However, for many clients with chronic or recurrent depression, it can be helpful to examine the biological, psychological, and social/cultural factors that may predispose a person toward depressive episodes. In order to address possible biological predispositions, it is important to assess for a positive family history of depression, evaluate family members' response to previous treatments, and refer for medications when needed. In order to address possible psychological predispositions, it is useful to evaluate long-standing personality styles, identify negative events from childhood, examine the client's relationship with his or her parents, evaluate the history of abuse, and identify early loss experiences. Cultural factors may play an influential role in the etiology of depression, and can be useful to incorporate into a broad treatment plan. However, cultural factors are difficult to modify through individual psychotherapy. Hence, they are unlikely to play a central role in cognitive-behavioral therapy for depression. Overall, therapists working with depressed clients should be prepared to confront a broad range of biological, psychological, and environmental factors that can create or perpetuate a client's risk for depression.     

Does young adults’ preferred role in decision making about health,money, and career depend on their advisors’ leadership skills?

Few empirical data exist on how decision making about health differs from that in other crucial life domains with less threatening consequences. To shed light on this issue we conducted a study with 175 young adults (average age 19 years). We presented the participants with scenarios involving advisors who provided assistance in making decisions about health, money, and career. For each scenario, participants were asked to what extent they wanted the advisor to exhibit several leadership styles and competencies and what role (active, collaborative, or passive) they preferred to play when making decisions. Results show that decision making about health is distinct from that in the other domains in three ways. First, most of the participants preferred to delegate decision making about their health to their physician, whereas they were willing to collaborate or play an active role in decision making about their career or money. Second, the competencies and leadership style preferred for the physician differed substantially from those desired for advisors in the other two domains: Participants expected physicians to show more transformational leadership—the style that is most effective in a wide range of environments—than those who provide advice about financial investments or career. Finally, participants’ willingness to share medical decision making with their physician was tied to how strongly they preferred that the physician shows an effective leadership style. In contrast, motivation to participate in decision making in the other domains was not related to preferences regarding advisors’ leadership style or competencies. Our results have implications for medical practice as they suggest that physicians are expected to have superior leadership skills compared to those who provide assistance in other important areas of life.     

The Spirits of Capitalism and Christianity and Their Impact on the Formation of Healthcare Leaders

In this article, I portray how the ethos of Christianity, broadly speaking, and the mores of capitalism intersect in the formation of healthcare leaders and the difficult decisions they make in insuring the viability of healthcare institutions. More particularly, I argue that healthcare leaders in Christian healthcare institutions are largely formed by and dependent on a capitalistic ethos in making decisions and less so by a Christian ethos. There are key differences in these two meaning systems, and these differences, in part, reveal an incompatibility between them. This incompatibility does not imply a rejection of capitalism, if that is even possible, but rather a recognition of its effects and limits vis-à-vis the formation of healthcare leaders and their decision-making process. Finally, I offer an approach that deals with the spirits of capitalism and Christianity in forming healthcare leaders and their decision-making.