Background: Family members are often required to act as substitute decision-makers when health care or research participation decisions must be made for an incapacitated relative. Yet most families are unable to accurately predict older adult preferences regarding future health care and willingness to engage in research studies. Discussion and documentation of preferences could improve proxies' abilities to decide for their loved ones. This trial assesses the efficacy of an advance planning intervention in improving the accuracy of substitute decision-making and increasing (...) the frequency of documented preferences for health care and research. It also investigates the financial impact on the healthcare system of improving substitute decision-making.Methods/DesignDyads (n = 240) comprising an older adult and his/her self-selected proxy are randomly allocated to the experimental or control group, after stratification for type of designated proxy and self-report of prior documentation of healthcare preferences. At baseline, clinical and research vignettes are used to elicit older adult preferences and assess the ability of their proxy to predict those preferences. Responses are elicited under four health states, ranging from the subject's current health state to severe dementia. For each state, we estimated the public costs of the healthcare services that would typically be provided to a patient under these scenarios. Experimental dyads are visited at home, twice, by a specially trained facilitator who communicates the dyad-specific results of the concordance assessment, helps older adults convey their wishes to their proxies, and offers assistance in completing a guide entitled My Preferences that we designed specifically for that purpose. In between these meetings, experimental dyads attend a group information session about My Preferences. Control dyads attend three monthly workshops aimed at promoting healthy behaviors. Concordance assessments are repeated at the end of the intervention and 6 months later to assess improvement in predictive accuracy and cost savings, if any. Copies of completed guides are made at the time of these assessments.DiscussionThis study will determine whether the tested intervention guides proxies in making decisions that concur with those of older adults, motivates the latter to record their wishes in writing, and yields savings for the healthcare system.Trial RegistrationISRCTN89993391. (shrink)
This paper suggests that certain traditional ways of analysing the self start off in situations that are abstract or detached from normal experience, and that the conclusions reached in such approaches are, as a result, inexact or mistaken. The paper raises the question of whether there are more contextualized forms of self- consciousness than those usually appealed to in philosophical or psychological analyses, and whether they can be the basis for a more adequate theoretical approach to the self. First, we (...) develop a distinction between abstract and contextualized actions and intentions by drawing on evidence from studies of rehabilitation after brain damage, and we introduce the notion of intentional attitude. Second, we discuss several interesting conclusions drawn from theoretically and experimentally abstract approaches. These conclusions raise some important issues about both the nature of the self and reflexive consciousness. At the same time they indicate the serious limita- tions concerning what we can claim about self and self-consciousness within such abstract frameworks. Such limitations motivate the question of whether it is possible to capture a sense of self that is more embedded in contextualized actions. Specifically, our concern is to focus on first-person approaches. We identify two forms of self-consciousness, eco- logical self-awareness and embedded reflection, that (1) function within the kinds of contextualized activity we have indicated, and (2) can be the basis for a theoretical account of the self. Both forms of self-consciousness are closely tied to action and promise to provide a less abstract basis for developing a theoretical approach to the self. (shrink)
Two models of consciousness are contrasted with regard to their treatment of subjective timing. The standard Cartesian Theater model postulates a place in the brain where "it all comes together": where the discriminations in all modalities are somehow put into registration and "presented" for subjective judgment. In particular, the Cartesian Theater model implies that the temporal properties of the content-bearing events occurring within this privileged representational medium determine subjective order. The alternative, Multiple Drafts model holds that whereas the brain events (...) that discriminate various perceptual contents are distributed in both space and time in the brain, and whereas the temporal properties of these various events are determinate, none of these temporal properties determine subjective order, since there is no single, constitutive "stream of consciousness" but rather a parallel stream of conflicting and continuously revised contents. Four puzzling phenomena that resist explanation by the standard model are analyzed: two results claimed by Libet, an apparent motion phenomenon involving color change (Kolers and von Grunau), and the "cutaneous rabbit" (Geldard and Sherrick) an illusion of evenly spaced series of "hops" produced by two or more widely spaced series of taps delivered to the skin. The unexamined assumptions that have always made the Cartesian Theater model so attractive are exposed and dismantled. The Multiple Drafts model provides a better account of the puzzling phenomena, avoiding the scientific and metaphysical extravagances of the Cartesian Theater. (shrink)
The significance of consciousness in modern science is discussed by leading authorities from a variety of disciplines. Presenting a wide-ranging survey of current thinking on this important topic, the contributors address such issues as the status of different aspects of consciousness; the criteria for using the concept of consciousness and identifying instances of it; the basis of consciousness in functional brain organization; the relationship between different levels of theoretical discourse; and the functions of consciousness.