Scenario Analysis: This scenario presents a common yet critical challenge in acute care surgery: managing unexpected intraoperative bleeding during a complex procedure. The surgeon must balance the immediate need for hemostasis with the potential risks associated with different energy devices and their application. Factors such as tissue type, proximity to vital structures, and the surgeon’s familiarity with specific devices contribute to the complexity. The professional challenge lies in making a rapid, informed decision that prioritizes patient safety and minimizes iatrogenic injury, all while adhering to established surgical principles and device safety guidelines. Correct Approach Analysis: The best approach involves a systematic assessment of the bleeding source and the judicious selection of an energy device with a proven safety profile for the specific tissue and anatomical location. This includes confirming the device is functioning correctly, using the lowest effective energy setting, and employing appropriate technique to isolate the bleeding vessel. This approach is correct because it aligns with fundamental surgical principles of meticulous dissection, hemostasis, and patient safety. Regulatory and ethical guidelines for surgical practice emphasize the surgeon’s responsibility to utilize equipment safely and effectively, minimizing harm. This proactive and informed selection process directly addresses the immediate surgical need while mitigating risks. Incorrect Approaches Analysis: Employing a high-energy setting on an untested or unfamiliar energy device without adequate assessment of the bleeding source or surrounding structures is professionally unacceptable. This approach disregards established safety protocols for energy devices, which mandate understanding their settings and limitations. It increases the risk of thermal injury to adjacent tissues, unintended damage to vital organs, and potential device malfunction, violating the ethical principle of non-maleficence. Choosing to proceed with manual compression alone without considering the utility of appropriate energy devices, especially when bleeding is significant and persistent, can also be professionally problematic. While manual compression is a foundational technique, its prolonged or exclusive use in the face of active, significant bleeding may be insufficient to achieve adequate hemostasis. This can lead to prolonged operative time, increased blood loss, and potential hemodynamic instability, failing to utilize available, effective tools for patient benefit. Opting for an energy device known to have a higher risk profile for the specific anatomical region or tissue type, without a clear indication or a thorough understanding of its limitations, is also professionally unsound. This demonstrates a failure to apply knowledge of surgical instrumentation and their associated risks, potentially leading to severe complications that could have been avoided with a more appropriate choice. Professional Reasoning: Professionals should employ a decision-making framework that begins with a rapid but thorough assessment of the surgical field and the nature of the bleeding. This should be followed by a consideration of available hemostatic modalities, prioritizing those with the best safety and efficacy profiles for the specific situation. A key element is the surgeon’s familiarity and comfort with the chosen device and technique. If there is any doubt regarding the safety or efficacy of a particular device or approach, consultation with colleagues or a change in strategy should be considered. Adherence to institutional protocols and manufacturer guidelines for energy device use is paramount.

This scenario is professionally challenging due to the inherent tension between patient autonomy, the urgency of a life-threatening condition, and the potential for rapid deterioration that may preclude informed consent. The need for swift surgical intervention in acute care settings often clashes with the ideal of comprehensive patient discussion and decision-making. Careful judgment is required to balance these competing ethical and practical considerations. The best approach involves prioritizing immediate life-saving intervention while simultaneously initiating the process of obtaining informed consent as soon as the patient’s condition permits. This entails clearly and concisely explaining the critical nature of the situation, the proposed surgical procedure, its risks and benefits, and available alternatives (even if limited in this emergent context). Crucially, it also involves assessing the patient’s capacity to understand and consent. If the patient lacks capacity, the decision-making process must then pivot to identifying and consulting with the appropriate surrogate decision-maker, adhering to established legal and ethical guidelines for emergency situations where consent cannot be obtained directly from the patient. This approach respects patient autonomy to the greatest extent possible under dire circumstances and ensures that medical interventions are medically indicated and ethically sound. Proceeding with surgery without any attempt to assess capacity or inform the patient or their surrogate decision-maker, even in an emergency, represents a significant ethical and regulatory failure. It bypasses fundamental principles of patient rights and can lead to legal repercussions and erosion of trust. Similarly, delaying essential life-saving surgery to exhaust all possible avenues of obtaining detailed, lengthy informed consent when the patient is rapidly deteriorating or unconscious is medically inappropriate and ethically indefensible. The primary duty in such a situation is to preserve life. Furthermore, relying solely on a presumed consent based on the emergency itself, without any effort to communicate with the patient or surrogate, is insufficient. While implied consent exists in true emergencies where no surrogate is available and the patient is incapacitated, active efforts to inform and involve the patient or surrogate are always preferred and often legally mandated when feasible. Professionals should employ a tiered decision-making framework in emergent surgical scenarios. First, rapidly assess the patient’s physiological status and the immediate threat to life. Second, determine the patient’s capacity to understand and consent. If capacity exists, proceed with a focused, urgent informed consent discussion. If capacity is absent, immediately identify and engage the appropriate surrogate decision-maker, providing them with the necessary information to make a decision in the patient’s best interest. If neither the patient nor a surrogate is available or can be reached in a timely manner, and the intervention is life-saving, proceed with the intervention based on the principle of necessity, documenting all efforts made.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate need for critical surgical intervention with the ethical and legal obligations to obtain informed consent from a patient who may be incapacitated. The urgency of acute care surgery often clashes with the time required for a thorough consent process, creating a high-stakes environment where patient autonomy, safety, and legal compliance must be meticulously navigated. The physician must exercise sound judgment to determine the appropriate course of action when a patient cannot provide consent directly. Correct Approach Analysis: The best professional practice involves proceeding with life-saving surgery under the doctrine of implied consent when a patient is unable to provide express consent due to their medical condition, and there is no available surrogate decision-maker or advance directive. This approach prioritizes the preservation of life and the prevention of serious harm, which are fundamental ethical principles in emergency medicine. Legally, this is often supported by the principle that a reasonable person would consent to necessary emergency treatment to save their life or prevent grave disability. The physician’s documentation must clearly articulate the patient’s inability to consent, the life-threatening nature of the condition, the lack of alternatives, and the rationale for proceeding without express consent. Incorrect Approaches Analysis: Delaying life-saving surgery until a surrogate decision-maker can be located or an advance directive is found, when the patient’s condition is immediately life-threatening and no such resources are readily available, is professionally unacceptable. This approach fails to uphold the primary duty to preserve life and prevent harm, potentially leading to irreversible damage or death. It prioritizes procedural formality over the patient’s immediate well-being in a critical emergency. Proceeding with surgery without attempting to ascertain the patient’s wishes or the existence of an advance directive, and without documenting the emergent circumstances, is also professionally unacceptable. This approach disregards the principle of patient autonomy and the legal requirement for informed consent, even in emergencies. It exposes the healthcare provider and institution to significant legal and ethical risks by bypassing established protocols for emergency treatment. Seeking consent from a distant family member who is not readily available and cannot provide immediate confirmation, while the patient’s condition deteriorates rapidly, is professionally unacceptable. While attempting to contact surrogates is important, the delay caused by an unavailable or distant contact in a life-threatening situation can be detrimental. The focus must remain on the patient’s immediate needs and the feasibility of obtaining consent within the critical timeframe. Professional Reasoning: In situations of acute surgical emergencies where a patient is incapacitated and unable to provide informed consent, professionals should follow a structured decision-making process. First, assess the patient’s capacity to consent. If capacity is absent, immediately determine if an advance directive or a designated healthcare proxy is available. If neither is immediately accessible and the condition is life-threatening, the physician should proceed with necessary life-saving interventions under the doctrine of implied consent, meticulously documenting the rationale and the emergent circumstances. The guiding principle is to act in the patient’s best interest to preserve life and prevent serious harm, while adhering to ethical and legal frameworks that permit emergency treatment in the absence of express consent.

Scenario Analysis: This scenario presents a professionally challenging situation due to the inherent uncertainty in trauma resuscitation, the rapid deterioration of a patient, and the need for immediate, life-saving interventions. The challenge lies in balancing the urgency of treatment with the ethical imperative of obtaining informed consent, especially when the patient’s capacity is compromised. The critical nature of acute care surgery demands swift decision-making, often under extreme pressure, where delays can have catastrophic consequences. Careful judgment is required to navigate the legal and ethical boundaries of treating an incapacitated patient in a life-threatening emergency. Correct Approach Analysis: The best professional practice involves initiating life-saving resuscitation and surgical interventions immediately while simultaneously making diligent efforts to obtain consent from the next of kin or legal guardian. This approach prioritizes the patient’s immediate survival, which is the paramount ethical duty in an emergency. The legal framework in most jurisdictions, including those governing acute care surgery, recognizes the doctrine of implied consent in emergency situations where a patient is unable to consent and immediate treatment is necessary to preserve life or prevent serious harm. Simultaneously pursuing consent from available surrogates demonstrates respect for patient autonomy and legal requirements once the immediate crisis is managed. Incorrect Approaches Analysis: Delaying essential resuscitation and surgical interventions until formal consent is obtained from a surrogate, even if efforts are made to contact them, is ethically and legally unacceptable. This approach fails to recognize the urgency of the situation and the doctrine of implied consent in life-threatening emergencies. Such a delay could lead to irreversible harm or death, violating the fundamental duty to preserve life. Proceeding with definitive surgical interventions without any attempt to contact a surrogate or document the emergency nature of the situation, even if life-saving, may raise concerns regarding the thoroughness of the documentation and the adherence to established protocols for emergency consent. While the intervention itself might be justified by implied consent, a complete lack of documented effort to involve surrogates where feasible could be problematic. Focusing solely on stabilizing the patient without considering the need for subsequent communication with the family or legal guardian about the interventions performed and the patient’s prognosis is incomplete. While immediate life-saving measures are critical, the ethical and legal framework also mandates post-intervention communication and the eventual pursuit of informed consent for ongoing care or further procedures once the patient is stable. Professional Reasoning: Professionals in acute care surgery should employ a decision-making framework that prioritizes the patient’s immediate survival in emergency situations. This involves: 1. Rapid assessment of the patient’s condition and the life-threatening nature of their injuries. 2. Immediate initiation of evidence-based resuscitation protocols and necessary life-saving interventions, operating under the principle of implied consent when the patient is incapacitated. 3. Concurrently, making diligent and documented efforts to contact the patient’s next of kin or legal guardian to inform them of the situation and seek consent for ongoing or further treatment. 4. Thorough documentation of the patient’s condition, the interventions performed, the rationale for treatment, and all communication attempts with surrogates. This systematic approach ensures that the patient receives timely, life-saving care while respecting legal and ethical obligations.

Scenario Analysis: This scenario presents a common yet challenging situation in acute care surgery: managing a post-operative complication that deviates from the expected recovery trajectory. The professional challenge lies in balancing the immediate need for intervention with the imperative to maintain patient safety, adhere to established protocols, and ensure appropriate communication and documentation. The complexity is amplified by the potential for rapid deterioration and the need for swift, informed decision-making under pressure. Correct Approach Analysis: The best professional practice involves a systematic and evidence-based approach. This begins with a thorough clinical assessment to precisely identify the nature and extent of the complication. Following this, consultation with the senior surgical team is paramount, not only for collaborative decision-making but also to ensure adherence to institutional policies regarding complex post-operative management and potential re-intervention. This approach ensures that patient care is guided by expertise, institutional guidelines, and a commitment to patient safety, aligning with ethical principles of beneficence and non-maleficence. It also implicitly supports regulatory requirements for appropriate supervision and escalation of care. Incorrect Approaches Analysis: Initiating immediate re-operation without a comprehensive assessment and senior consultation is professionally unacceptable. This bypasses critical diagnostic steps, potentially leading to unnecessary surgery, increased patient risk, and failure to identify the root cause of the complication. It violates the principle of “first, do no harm” and disregards established surgical protocols for managing post-operative issues. Delaying definitive management and relying solely on conservative measures without a clear diagnostic rationale or senior input is also professionally unsound. This approach risks allowing a treatable complication to progress to a more severe, life-threatening state, failing the ethical duty of timely intervention and potentially violating regulatory expectations for diligent patient care. Performing further diagnostic imaging without a clear clinical indication or consultation, while seemingly proactive, can be inefficient and may delay necessary treatment. Without a focused differential diagnosis, extensive imaging can lead to incidental findings, increased patient radiation exposure, and unnecessary costs, without directly addressing the immediate clinical concern. This approach lacks the focused, evidence-based decision-making required in acute post-operative care. Professional Reasoning: Professionals should employ a structured approach to post-operative complications. This involves: 1. Thorough Clinical Assessment: Gather all relevant patient data, perform a focused physical examination, and review recent investigations. 2. Differential Diagnosis: Formulate a list of potential complications based on the clinical presentation and surgical procedure. 3. Consult Senior Colleagues: Discuss the case with experienced surgeons to leverage their expertise and ensure adherence to institutional best practices and protocols. 4. Evidence-Based Management: Develop a treatment plan based on current guidelines and the specific clinical context. 5. Documentation: Meticulously record all assessments, decisions, and interventions.

Scenario Analysis: This scenario presents a professional challenge related to the interpretation and application of the fellowship’s blueprint weighting, scoring, and retake policies. The core difficulty lies in balancing the need for objective assessment and maintaining program standards with the individual circumstances of a candidate who may be struggling. Misinterpreting or misapplying these policies can lead to unfair evaluations, potential legal challenges, and damage to the program’s reputation. Careful judgment is required to ensure fairness, consistency, and adherence to established guidelines. Correct Approach Analysis: The best professional approach involves a thorough review of the official fellowship blueprint, which explicitly details the weighting of different assessment components, the scoring methodology, and the defined retake policies. This approach is correct because it prioritizes adherence to the established, transparent, and agreed-upon framework for evaluating fellows. The blueprint serves as the governing document, ensuring objectivity and consistency in assessment. Any deviation from its stipulations without a clear, documented, and approved process would undermine the integrity of the evaluation system. Ethical considerations demand that all candidates are assessed against the same, pre-defined criteria. Incorrect Approaches Analysis: An approach that relies solely on the subjective impression of the program director regarding the candidate’s overall potential, without rigorous application of the blueprint’s weighting and scoring, is professionally unacceptable. This introduces bias and deviates from the objective standards designed to ensure fair evaluation. It fails to uphold the principle of consistent application of assessment criteria for all fellows. Another incorrect approach would be to unilaterally waive or significantly alter the retake policy based on a perceived need to “give the candidate another chance,” without consulting the established policy or seeking formal approval. This undermines the program’s established standards and can create a perception of favoritism, eroding trust within the program and among candidates. It also bypasses the structured process for addressing performance issues. Finally, an approach that involves seeking informal advice from colleagues outside the program’s formal governance structure regarding policy interpretation, without referring to the official blueprint, is also professionally unsound. While collegial discussion can be helpful, final decisions on policy application must be grounded in the official documentation and the program’s established decision-making processes to ensure accountability and consistency. Professional Reasoning: Professionals should approach such situations by first consulting the definitive policy documents (in this case, the fellowship blueprint). If ambiguity exists, the next step is to engage the established program governance or review committee for clarification and decision-making, ensuring all actions are documented. This structured approach ensures fairness, transparency, and adherence to regulatory and ethical standards.

This scenario presents a professionally challenging situation due to the inherent unpredictability of acute care surgery and the critical need for robust patient safety protocols. The challenge lies in balancing the urgency of surgical intervention with the imperative to thoroughly assess and mitigate potential risks, ensuring the best possible outcome for the patient while adhering to professional standards. Careful judgment is required to navigate the complexities of patient comorbidities, surgical invasiveness, and resource availability. The best professional approach involves a structured, multi-disciplinary pre-operative planning session that explicitly identifies potential intra-operative and post-operative complications. This session should involve the entire surgical team, including surgeons, anesthesiologists, nurses, and potentially intensivists or specialists relevant to the patient’s comorbidities. The focus should be on developing contingency plans for identified risks, such as having specific equipment readily available, pre-identifying blood product requirements, and establishing clear communication pathways for emergent situations. This aligns with ethical principles of beneficence and non-maleficence, as well as professional guidelines emphasizing thorough preparation and risk management in surgical practice. It promotes a culture of safety by proactively addressing potential adverse events. An incorrect approach would be to proceed with surgery based solely on the surgeon’s extensive experience without a formal, documented risk assessment and mitigation plan. While experience is valuable, it does not replace the systematic identification and planning for specific patient risks. This approach risks overlooking unique patient factors or rare but significant complications, potentially leading to adverse outcomes and failing to meet the standard of care expected in complex surgical cases. It also undermines the collaborative nature of modern acute care, where shared decision-making and team input are crucial. Another incorrect approach is to delegate the entire risk assessment and mitigation planning to a junior member of the surgical team without adequate senior oversight or a structured team discussion. While empowering junior staff is important, critical risk assessment and planning for complex acute care surgery require the collective experience and judgment of the entire team, particularly senior members. This can lead to incomplete or inaccurate risk identification and inadequate mitigation strategies, potentially jeopardizing patient safety. Finally, an incorrect approach would be to prioritize speed of operative intervention over a comprehensive pre-operative assessment and planning session, assuming that any complications can be managed reactively during the surgery. While time is often a critical factor in acute care, a rushed approach without adequate planning can lead to unforeseen challenges that are more difficult to manage effectively in the heat of the moment. This reactive strategy increases the likelihood of errors and adverse events, failing to uphold the principle of proactive risk management. Professionals should employ a decision-making framework that prioritizes a systematic and collaborative approach to operative planning. This involves: 1) Thorough patient assessment, including a detailed review of medical history, comorbidities, and imaging. 2) A structured team briefing to discuss the operative plan, identify potential risks, and develop specific mitigation strategies. 3) Clear communication and documentation of the plan and contingencies. 4) Continuous re-evaluation of the plan as new information becomes available. This framework ensures that patient safety is paramount and that the surgical team is well-prepared to manage the complexities of acute care surgery.

The efficiency study reveals a common challenge faced by fellowship candidates: optimizing preparation resources and timelines for a high-stakes exit examination. This scenario is professionally challenging because inadequate preparation can lead to suboptimal performance, potentially impacting career progression and patient care outcomes. The pressure to balance demanding clinical duties with dedicated study time requires strategic planning and resource allocation. Careful judgment is required to identify the most effective and compliant preparation methods. The best approach involves a structured, multi-modal preparation strategy that integrates diverse learning resources with a realistic timeline, prioritizing foundational knowledge acquisition and application. This includes systematic review of core surgical texts, engagement with peer-reviewed literature relevant to acute care surgery, and active participation in case-based discussions or simulation exercises. Adherence to ethical guidelines for professional development, such as ensuring all study materials are obtained legitimately and that preparation does not compromise patient care responsibilities, is paramount. This method ensures comprehensive coverage, reinforces learning through active engagement, and respects professional obligations. An approach that relies solely on passive review of lecture notes without active recall or application is professionally unacceptable. This fails to adequately prepare the candidate for the analytical and problem-solving demands of an exit examination, potentially leading to superficial understanding and an inability to synthesize information under pressure. Furthermore, it may not align with best practices in adult learning and knowledge retention, which emphasize active engagement. Another professionally unacceptable approach is to prioritize preparation by neglecting essential clinical duties or patient care responsibilities. This directly violates ethical obligations to patients and professional conduct standards, which mandate that patient well-being is always the primary concern. Such an approach could lead to serious patient safety issues and professional disciplinary action. A third professionally unacceptable approach is to exclusively utilize outdated or unverified study materials. This risks exposure to inaccurate or irrelevant information, which can lead to misconceptions and a lack of preparedness for current best practices in acute care surgery. It also fails to demonstrate a commitment to continuous learning and staying abreast of advancements in the field, a core tenet of medical professionalism. Professionals should employ a decision-making framework that begins with a thorough self-assessment of knowledge gaps and learning style. This should be followed by the identification of evidence-based preparation resources and the development of a realistic, phased study plan that balances clinical duties with dedicated study time. Regular self-testing and seeking feedback from mentors or peers are crucial for monitoring progress and adjusting the strategy. Finally, a commitment to ethical conduct and patient safety must underpin all preparation activities.

Scenario Analysis: This scenario is professionally challenging because it involves a critical decision regarding a candidate’s eligibility for a fellowship exit examination, which directly impacts their career progression and the standards of acute care surgery practice in the Pan-Asia region. The fellowship program’s purpose is to ensure a high level of competency in managing complex surgical emergencies, and the exit examination serves as the final gatekeeper. Misinterpreting eligibility criteria or applying them inconsistently can lead to unqualified surgeons entering practice or deserving candidates being unfairly excluded, both of which have serious implications for patient safety and professional integrity. Careful judgment is required to balance the need for rigorous standards with fairness to the applicant. Correct Approach Analysis: The best professional approach involves a thorough review of the candidate’s documented training and experience against the explicit eligibility criteria for the Advanced Pan-Asia Acute Care Surgery Fellowship Exit Examination. This means meticulously verifying that the candidate has completed the required number of years in an accredited surgical residency program, obtained the necessary board certifications or their equivalents as defined by the fellowship’s governing body, and successfully completed the stipulated advanced training modules or rotations in acute care surgery. The justification for this approach lies in upholding the integrity and purpose of the fellowship and its exit examination, which is to certify a standardized, high level of expertise. Adherence to established criteria ensures fairness, transparency, and objectivity in the selection process, preventing arbitrary decisions and maintaining public trust in the qualification. Incorrect Approaches Analysis: One incorrect approach involves relying on informal recommendations or perceived potential without concrete evidence of meeting the defined eligibility requirements. This fails to uphold the objective standards set by the fellowship, potentially allowing candidates who lack the foundational training to proceed, thereby compromising patient safety. Another incorrect approach is to interpret the eligibility criteria loosely or to make exceptions based on the candidate’s reputation or seniority in their current practice. This undermines the very purpose of a standardized exit examination, which is to ensure a baseline competency regardless of prior experience outside the fellowship’s defined pathway. Such flexibility can lead to inconsistencies in qualification standards across the region. A further incorrect approach is to defer the decision to a less experienced committee member without proper oversight or a clear mandate, which can result in inconsistent application of rules and a lack of accountability for the final decision. Professional Reasoning: Professionals should approach eligibility decisions by first understanding the fundamental purpose of the fellowship and its exit examination – to ensure a specific level of competence in acute care surgery. They must then consult the official documentation outlining the eligibility criteria and meticulously verify each requirement against the applicant’s submitted credentials. If any ambiguity exists, seeking clarification from the fellowship’s governing body or program director is paramount. The decision-making process should be guided by principles of fairness, objectivity, and a commitment to patient safety, ensuring that only those who demonstrably meet the established standards are permitted to take the examination.

Scenario Analysis: This scenario presents a professional challenge due to the inherent tension between immediate patient needs and the established protocols for managing critical surgical resources. The surgeon must balance the urgency of a life-threatening condition with the ethical and professional obligation to ensure equitable access to limited resources, particularly in a high-acuity setting where decisions have immediate and profound consequences. Careful judgment is required to navigate potential biases, ensure transparency, and uphold the principles of patient care and resource stewardship. Correct Approach Analysis: The best professional practice involves a structured, multidisciplinary approach to resource allocation when demand exceeds supply. This includes immediate consultation with the surgical team and relevant hospital administrators to review the established institutional guidelines for prioritizing emergent surgical interventions. The decision-making process should be transparent, objective, and based on pre-defined criteria that consider factors such as the likelihood of a favorable outcome, the severity of the condition, and the potential for irreversible harm. This approach ensures that decisions are not solely at the discretion of one individual, thereby mitigating bias and promoting fairness. It aligns with ethical principles of justice and beneficence, ensuring that the most critically ill patients with the highest probability of benefit receive priority, while adhering to institutional policies designed for such challenging situations. Incorrect Approaches Analysis: Prioritizing the patient based solely on the surgeon’s personal assessment of urgency without consulting established protocols or a multidisciplinary team is professionally unacceptable. This approach risks introducing personal bias, potentially overlooking other patients with equally or more compelling needs, and undermines the fairness and transparency of the resource allocation process. It fails to adhere to the principles of equitable care and may violate institutional policies designed to guide such decisions. Delaying the decision to operate until a more senior surgeon is available, without first initiating the established institutional process for resource allocation and urgent consultation, is also professionally unsound. While seeking senior input can be valuable, the immediate need for a decision in a life-threatening situation necessitates engaging the appropriate channels for urgent review and guidance according to existing protocols. Unnecessary delay in a critical surgical scenario can lead to irreversible patient harm and is a failure of timely professional responsibility. Allocating the surgical slot based on the patient’s social status or perceived ability to pay, even if implicitly, is a grave ethical and regulatory violation. This approach directly contravenes principles of non-discrimination and equitable access to healthcare, prioritizing financial considerations over medical necessity. It is a clear breach of professional ethics and likely violates numerous healthcare regulations and professional codes of conduct. Professional Reasoning: Professionals facing such dilemmas should first activate their institution’s established protocols for critical resource allocation. This typically involves immediate consultation with a multidisciplinary team, including senior surgical staff, ethics committees, or hospital administration, depending on the specific guidelines. The decision-making framework should be objective, evidence-based, and focused on maximizing patient benefit within the constraints of available resources. Transparency in the process and clear documentation of the rationale behind the decision are paramount.