This scenario is professionally challenging because it requires the sonographer to balance the need for thorough preparation with the practical constraints of time and access to resources, all while adhering to the standards expected for a proficiency verification exam. The pressure to perform well on an assessment that directly impacts their professional standing necessitates a strategic and well-informed approach to preparation. Careful judgment is required to select resources and allocate time effectively without compromising the depth of understanding or engaging in unethical practices. The best professional practice involves a structured, multi-faceted approach to preparation that prioritizes official guidelines and reputable resources. This includes thoroughly reviewing the official curriculum or syllabus provided by the examination body, engaging with recommended study materials, and practicing with realistic mock scenarios or question banks that mirror the exam format and difficulty. This approach ensures that the candidate is addressing the specific knowledge and skills assessed, aligning with the principles of professional competence and integrity expected in sonography. Adhering to official guidance is paramount as it directly reflects the regulatory and educational standards set for proficiency verification. An approach that relies solely on informal study groups without verifying the accuracy of information or focusing on outdated materials is professionally unacceptable. This can lead to the acquisition of incorrect knowledge or a misunderstanding of current best practices, potentially resulting in failure on the exam and a misrepresentation of their proficiency. Similarly, focusing exclusively on memorizing answers from past exams without understanding the underlying principles is a failure to demonstrate true competence and can be considered a form of academic dishonesty, as it circumvents the intended purpose of the assessment, which is to verify genuine understanding and skill. Relying on anecdotal advice from colleagues without cross-referencing with official resources also carries the risk of misinformation and deviation from established standards. Professionals should employ a decision-making framework that begins with identifying the official requirements and recommended resources for the proficiency verification. This should be followed by an assessment of personal learning style and available time to create a realistic study plan. Prioritizing resources that are directly linked to the examination body’s syllabus and guidelines ensures that preparation is targeted and relevant. Regular self-assessment through practice questions and mock exams is crucial to identify areas needing further attention. Finally, seeking clarification from official sources or experienced mentors when encountering uncertainties reinforces a commitment to accurate and ethical preparation.

Scenario Analysis: This scenario presents a professional challenge related to verifying the educational proficiency of sonographers within the Caribbean region. The core difficulty lies in ensuring that the verification process is both robust and ethically sound, adhering strictly to the established purpose and eligibility criteria for the Applied Caribbean Sonography Education Proficiency Verification. Misinterpreting or circumventing these requirements can lead to unqualified individuals practicing, potentially compromising patient care and undermining the credibility of the profession. Careful judgment is required to uphold the integrity of the verification system. Correct Approach Analysis: The best professional practice involves a thorough review of the applicant’s submitted documentation against the defined eligibility criteria for the Applied Caribbean Sonography Education Proficiency Verification. This approach ensures that only individuals who meet the established educational and experiential prerequisites are considered for verification. The justification for this approach is rooted in the fundamental purpose of the verification process: to confirm that sonographers possess the necessary foundational knowledge and skills acquired through recognized educational pathways. Adherence to these criteria safeguards the public by ensuring a minimum standard of competence. Incorrect Approaches Analysis: One incorrect approach involves accepting an applicant based solely on a letter of recommendation from a senior sonographer, without verifying if the applicant’s formal education meets the program’s specific requirements. This fails to address the core purpose of the verification, which is to assess educational proficiency, not just professional endorsement. It bypasses the essential step of confirming foundational knowledge and skills gained through accredited programs. Another unacceptable approach is to grant provisional verification based on the applicant’s stated intent to complete further training within a specified period, without confirming their current educational standing. This undermines the proficiency verification aspect, as it allows practice without confirmed current competence. The purpose of the verification is to confirm existing proficiency, not potential future proficiency. A further flawed approach is to prioritize applicants with extensive years of experience over those with formal education, even if the latter clearly meets the stated eligibility criteria. While experience is valuable, the Applied Caribbean Sonography Education Proficiency Verification is specifically designed to assess educational attainment. Prioritizing experience over documented educational qualifications deviates from the stated purpose and eligibility framework. Professional Reasoning: Professionals should approach this situation by first clearly understanding the stated purpose and eligibility requirements of the Applied Caribbean Sonography Education Proficiency Verification. This involves consulting the official documentation outlining the program’s objectives and the specific criteria for applicants. The decision-making process should then involve systematically evaluating each applicant’s submission against these defined criteria. If an applicant’s qualifications do not align with the established requirements, the application should be respectfully declined, with clear communication regarding the reasons for the decision. This systematic and criteria-driven approach ensures fairness, transparency, and adherence to the program’s integrity.

Scenario Analysis: This scenario is professionally challenging because it requires the sonographer to balance the immediate need for diagnostic imaging with the potential risks associated with contrast agents. Ensuring patient safety while adhering to established protocols and understanding the nuances of contrast pharmacology is paramount. The sonographer must make a rapid, informed decision that prioritizes patient well-being and regulatory compliance. Correct Approach Analysis: The best professional practice involves a thorough pre-procedure assessment of the patient’s contraindications and risk factors for contrast-induced adverse events, followed by the administration of the contrast agent by a qualified practitioner with appropriate monitoring and emergency preparedness. This approach is correct because it aligns with established patient safety guidelines and the principles of responsible medical practice. Regulatory frameworks, such as those governing medical device usage and patient care, mandate a risk-benefit assessment and the implementation of safety protocols. Ethically, this approach upholds the principle of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm). Incorrect Approaches Analysis: Administering the contrast agent without a comprehensive review of the patient’s medical history and potential contraindications is a significant regulatory and ethical failure. This bypasses essential safety checks designed to prevent severe adverse reactions, violating the principle of non-maleficence and potentially contravening guidelines on informed consent and patient screening. Proceeding with the scan and only documenting any adverse events that occur during or after the procedure, without proactive risk mitigation, demonstrates a reactive rather than a preventative safety approach. This fails to meet the standard of care expected in medical imaging and neglects the responsibility to anticipate and manage potential complications, which is a core tenet of patient safety regulations. Relying solely on the referring physician’s order without independently verifying the appropriateness of contrast administration for the specific patient’s condition and risk profile is a failure to exercise professional judgment. While physician orders are crucial, sonographers have a professional and ethical obligation to ensure the safety and appropriateness of all procedures they perform, including the use of contrast agents, in line with established protocols and best practices. Professional Reasoning: Professionals should employ a systematic decision-making process that begins with a comprehensive understanding of the pharmacological properties of the contrast agent and its potential adverse effects. This should be followed by a thorough patient assessment, including a review of medical history, allergies, renal function, and any known contraindications. Next, adherence to institutional protocols for contrast administration and emergency management is critical. Finally, continuous professional development and staying abreast of current guidelines and best practices in sonography and contrast agent usage are essential for ensuring optimal patient safety and care.

Scenario Analysis: This scenario presents a professional challenge in the application of advanced imaging modalities within the context of diagnostic sonography education and proficiency verification. The core difficulty lies in ensuring that the evaluation process accurately reflects an individual’s competence in utilizing complex technologies like CT, MRI, and hybrid imaging, while adhering to the specific educational and professional standards relevant to Caribbean sonography practice. Misjudging proficiency in these advanced areas can lead to misdiagnosis, suboptimal patient care, and a failure to meet established professional benchmarks. Careful judgment is required to balance the breadth of advanced modalities with the depth of understanding and practical application expected of a proficient sonographer. Correct Approach Analysis: The best professional approach involves a comprehensive assessment that integrates theoretical knowledge of advanced modalities with practical, hands-on simulation and case-based scenario evaluation. This approach is correct because it directly addresses the multifaceted nature of proficiency in CT, MRI, and hybrid imaging. It requires the candidate to not only understand the principles and applications of these technologies but also to demonstrate their ability to operate within simulated clinical environments, interpret complex images, and integrate findings with other diagnostic data. This aligns with the principles of robust professional verification, ensuring that individuals are equipped to handle the complexities of modern diagnostic imaging, thereby upholding patient safety and diagnostic accuracy, which are paramount ethical and professional obligations in healthcare. Incorrect Approaches Analysis: An approach that focuses solely on theoretical knowledge of CT, MRI, and hybrid imaging, without practical application or simulation, is professionally unacceptable. This fails to verify the candidate’s actual ability to operate the equipment, troubleshoot issues, or interpret images in a clinically relevant context. It neglects the practical skills essential for sonographers working with these advanced modalities, potentially leading to a gap between theoretical understanding and real-world performance. Another professionally unacceptable approach would be to evaluate proficiency in advanced modalities in isolation from core sonographic principles and patient management. Advanced imaging techniques are often complementary to, or integrated with, ultrasound. A fragmented evaluation does not reflect the holistic approach required in clinical practice, where the sonographer must understand how these modalities interact and contribute to the overall diagnostic pathway. This can lead to a superficial understanding and an inability to effectively integrate information for comprehensive patient assessment. An approach that relies on outdated or generic guidelines for advanced modality assessment, without specific reference to the current standards and best practices within the Caribbean region, is also professionally flawed. This risks evaluating candidates against irrelevant or insufficient benchmarks, failing to ensure they meet the specific requirements for practice in their intended professional environment. Adherence to region-specific educational and professional standards is crucial for maintaining the integrity of the verification process. Professional Reasoning: Professionals should employ a decision-making framework that prioritizes a holistic and practical evaluation of advanced modality proficiency. This framework should begin with understanding the specific learning outcomes and competency standards for advanced imaging within the relevant educational and professional context. Next, it involves designing assessment methods that authentically replicate clinical challenges, combining theoretical understanding with simulated practical application. This includes utilizing case studies, image interpretation exercises, and simulated procedural scenarios. Finally, professionals must ensure that the assessment criteria are clearly defined, objective, and aligned with current best practices and regulatory requirements, thereby guaranteeing a fair and rigorous evaluation of a candidate’s readiness to practice.

Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between a sonographer’s duty to provide accurate diagnostic information and the potential for that information to cause distress to a patient who has not yet received formal medical confirmation of their condition. The sonographer must navigate the ethical imperative of patient well-being and the professional responsibility to communicate findings appropriately, considering the sensitive nature of potential diagnoses and the established protocols for delivering such news. Careful judgment is required to balance transparency with the avoidance of undue anxiety or misinterpretation. Correct Approach Analysis: The best professional practice involves the sonographer documenting their findings meticulously in the official report and communicating these findings to the referring physician or appropriate healthcare provider. This approach is correct because it adheres to established medical communication pathways. Regulatory frameworks and professional ethical guidelines for sonographers universally mandate that diagnostic interpretations and findings are communicated through the designated medical channels, typically the referring physician. This ensures that the patient receives information within a supportive clinical context, allowing for appropriate counseling, further investigation, and management by qualified medical professionals. It respects the patient’s right to receive information from their primary care provider, who is best equipped to discuss implications and next steps. Incorrect Approaches Analysis: Communicating the potential diagnosis directly to the patient, even with the intention of being helpful, is professionally unacceptable. This bypasses the established medical hierarchy and can lead to patient anxiety, misinterpretation of findings, or premature self-treatment without proper medical guidance. It violates the principle of professional communication and can undermine the patient-physician relationship. Discussing the findings with the patient’s family members without the patient’s explicit consent is a breach of patient confidentiality. Professional ethics and privacy regulations strictly prohibit the disclosure of patient information to third parties without authorization, regardless of familial relationship. Delaying the documentation of findings in the official report until after the referring physician has spoken with the patient is also professionally unacceptable. Accurate and timely documentation is a cornerstone of medical practice, ensuring continuity of care and legal accountability. Findings must be recorded promptly to be available for review by the medical team. Professional Reasoning: Professionals should employ a decision-making framework that prioritizes adherence to established communication protocols and ethical principles. This involves understanding the scope of practice, recognizing the importance of the patient-physician relationship, and respecting patient confidentiality. When faced with sensitive findings, the professional should always consider the most appropriate and regulated channel for communication, ensuring that the patient receives information in a manner that is both informative and supportive, within the context of their overall medical care.

The investigation demonstrates a common challenge in educational proficiency verification: balancing the need for rigorous assessment with the practical realities of candidate performance and program integrity. This scenario is professionally challenging because it requires careful judgment in interpreting and applying the Blueprint weighting, scoring, and retake policies of the Applied Caribbean Sonography Education Proficiency Verification program. The program’s policies are designed to ensure that certified sonographers possess the necessary skills and knowledge to practice safely and effectively, but their application must be fair and consistent. The best professional approach involves a thorough review of the candidate’s performance against the established Blueprint weighting and scoring criteria, coupled with a clear understanding of the retake policy’s intent and limitations. This approach prioritizes adherence to the program’s established standards while also considering the individual circumstances of the candidate within the defined policy framework. Specifically, it requires a meticulous examination of how the candidate’s errors align with the weighted importance of different sections of the assessment, as outlined in the Blueprint. If the candidate’s performance falls below the passing threshold, the retake policy should be applied as written, ensuring that the candidate understands the areas needing improvement and the process for re-assessment. This upholds the integrity of the certification process by ensuring that all candidates meet the same objective standards. An incorrect approach would be to arbitrarily adjust the scoring or retake conditions based on perceived effort or external factors not explicitly addressed by the policy. For instance, overlooking a significant deficiency in a highly weighted area because the candidate demonstrated strong performance elsewhere, or allowing a retake without requiring the candidate to address the specific areas of weakness identified, undermines the Blueprint’s weighting system and the purpose of the retake policy. This failure to adhere to the established scoring and retake protocols compromises the validity of the certification and could lead to the issuance of credentials to individuals who have not met the required proficiency standards. Another incorrect approach would be to apply a retake policy that is more lenient or more stringent than what is formally documented, without proper authorization or a clear rationale aligned with program goals. This inconsistency erodes trust in the program and can lead to perceptions of unfairness. Professionals should employ a decision-making framework that begins with a clear understanding of the program’s governing policies, including the Blueprint weighting, scoring methodology, and retake provisions. This framework necessitates objective evaluation of candidate performance against these established criteria. When faced with borderline cases or unique circumstances, professionals should consult the policy documentation for guidance on exceptions or appeals. If ambiguity exists, seeking clarification from program administrators or a designated review committee is crucial. The ultimate goal is to ensure that decisions are fair, consistent, transparent, and uphold the integrity and standards of the Applied Caribbean Sonography Education Proficiency Verification program.

This scenario presents a professional challenge due to the inherent tension between the need for timely and accurate information for patient care and the strict requirements for maintaining the integrity and security of educational assessment data. The proficiency verification process, as outlined by the Applied Caribbean Sonography Education Proficiency Verification framework, demands a high degree of confidentiality and adherence to established protocols to ensure the validity of the results. The professional is tasked with balancing the immediate needs of a colleague with the overarching responsibility to uphold the integrity of the examination process. Careful judgment is required to avoid compromising either patient care or the examination’s credibility. The best professional approach involves strictly adhering to the established procedures for accessing and disseminating examination-related information. This means recognizing that the examination results are confidential and are not to be shared outside of the official verification process. Instead, the professional should direct the colleague to the appropriate channels for obtaining official verification, which typically involves contacting the examination board or administrative body responsible for the Applied Caribbean Sonography Education Proficiency Verification. This approach upholds the principles of data privacy and the integrity of the assessment process, ensuring that all verifications are conducted through authorized and documented means, thereby preventing any potential for unauthorized access or manipulation of results. An incorrect approach would be to directly provide the colleague with the examination results, even if the intention is to be helpful. This action directly violates the confidentiality protocols governing assessment data. Such a breach could undermine the credibility of the verification process and potentially lead to situations where unqualified individuals gain access to credentials, impacting patient safety and the reputation of the sonography profession. Another incorrect approach would be to offer to “look up” the results for the colleague without following the official verification procedure. While seemingly helpful, this bypasses the established security measures designed to protect the integrity of the examination data. It creates a precedent for informal and potentially unauthorized access, which can be difficult to control and audit, thereby compromising the system’s reliability. A further incorrect approach would be to suggest that the colleague might have misinterpreted the examination requirements or that the results are not important. This dismisses the colleague’s legitimate need for verification and fails to provide a constructive path forward. It also avoids addressing the core issue of how to obtain official verification, leaving the colleague without a solution and potentially creating further professional difficulties. The professional decision-making process in such situations should involve a clear understanding of the regulatory framework governing examinations and professional conduct. Professionals must prioritize adherence to established policies and procedures, recognizing that these are in place to protect both individuals and the public. When faced with a request that potentially conflicts with these guidelines, the first step is to identify the relevant regulations and ethical obligations. The next step is to consider the potential consequences of various actions, both for the individual making the request and for the broader professional community. Finally, the professional should choose the course of action that best upholds the integrity of the profession and ensures compliance with all applicable rules and guidelines, even if it requires directing the requester to the appropriate, albeit less immediate, official channels.

Scenario Analysis: This scenario presents a professional challenge because it requires a sonographer to balance the immediate need for diagnostic imaging with the imperative to maintain the highest standards of radiation safety and equipment performance. The pressure to provide timely patient care can sometimes conflict with the meticulous processes required for quality assurance. A failure in any of these areas can lead to suboptimal diagnostic images, unnecessary radiation exposure to patients and staff, and potential regulatory non-compliance. Careful judgment is required to prioritize actions that ensure both patient well-being and diagnostic accuracy. Correct Approach Analysis: The best professional approach involves immediately ceasing the scan and initiating a systematic troubleshooting process for the ultrasound machine’s image degradation. This begins with a thorough visual inspection of all transducer connections and the transducer itself for any physical damage or debris. Following this, the sonographer should consult the machine’s internal quality control logs and perform a series of standardized phantom scans to objectively assess image resolution, penetration, and artifact levels. If the phantom scans confirm persistent issues, the next step is to contact the equipment manufacturer’s technical support or the hospital’s biomedical engineering department for further diagnosis and repair. This approach directly addresses the observed image quality issue while adhering to established protocols for equipment maintenance and radiation safety, ensuring that any potential malfunction is identified and rectified before further patient scans are performed. This aligns with the fundamental principles of ALARA (As Low As Reasonably Achievable) for radiation exposure and the professional responsibility to utilize properly functioning diagnostic equipment. Incorrect Approaches Analysis: Continuing the scan without addressing the image degradation is professionally unacceptable. This approach risks producing non-diagnostic images, leading to misdiagnosis or the need for repeat scans, thereby increasing patient radiation exposure unnecessarily. It also bypasses the critical quality assurance protocols designed to ensure equipment reliability and patient safety. Attempting to compensate for the image degradation by excessively increasing power output or gain settings is also professionally unsound. While this might temporarily improve image visibility, it significantly increases the acoustic output and thus the radiation dose to the patient without resolving the underlying technical issue. This directly contravenes the ALARA principle and the ethical obligation to use diagnostic equipment responsibly. Assuming the issue is a temporary glitch and proceeding with the scan while making a mental note to report it later is a failure in immediate problem-solving and quality assurance. This approach delays the identification and resolution of a potential equipment malfunction, potentially exposing multiple patients to suboptimal imaging or unnecessary radiation. It also neglects the immediate professional responsibility to ensure the diagnostic integrity of the examination being performed. Professional Reasoning: Professionals facing such a situation should employ a structured decision-making process. First, recognize and acknowledge the deviation from expected performance. Second, prioritize patient safety and diagnostic accuracy by halting any procedure that may be compromised. Third, systematically investigate the cause of the problem, starting with the most immediate and controllable factors (e.g., connections, physical damage) and progressing to more complex diagnostics (e.g., phantom scans, system logs). Fourth, consult relevant resources and support personnel (e.g., manufacturer, biomedical engineering) when internal troubleshooting is insufficient. Finally, document all actions taken and ensure the equipment is fully functional and calibrated before resuming patient care. This methodical approach ensures that patient well-being and the integrity of diagnostic services are maintained.

This scenario presents a professional challenge due to the inherent complexity of correlating cross-sectional imaging findings with dynamic functional anatomy in a real-time clinical setting. The sonographer must not only identify anatomical structures but also interpret their physiological behaviour and potential abnormalities, all while adhering to established educational proficiency standards. Careful judgment is required to ensure accurate assessment and appropriate reporting, which directly impacts patient care and diagnostic outcomes. The best approach involves a systematic and integrated review of both static anatomical representations and their dynamic functional correlates. This means meticulously examining the cross-sectional images for structural integrity, size, echogenicity, and spatial relationships of organs and tissues. Simultaneously, the sonographer must correlate these findings with the observed functional aspects, such as blood flow patterns, tissue movement, and organ volume changes during physiological processes. This integrated interpretation allows for a comprehensive understanding of the patient’s condition, aligning with the core principles of proficiency verification in sonography education, which emphasizes the ability to synthesize diverse data points into a coherent diagnostic picture. This aligns with the educational framework’s goal of ensuring practitioners can apply theoretical knowledge to practical, real-world clinical situations, demonstrating a holistic understanding of anatomy and physiology. An incorrect approach would be to solely focus on identifying anatomical landmarks without adequately assessing their functional implications. This failure to correlate static anatomy with dynamic function leads to an incomplete diagnostic assessment, potentially missing critical information about organ performance or physiological dysfunction. It represents a deficiency in the comprehensive skill set expected of a proficient sonographer, as it neglects a crucial aspect of diagnostic ultrasound. Another incorrect approach is to prioritize the identification of gross anatomical abnormalities over subtle functional changes. While significant structural deviations are important, many pathological processes manifest initially as functional impairments before causing overt anatomical distortion. Overlooking these subtle functional alterations can lead to delayed diagnosis and treatment. This approach demonstrates a lack of depth in understanding the interplay between structure and function, which is a cornerstone of advanced sonographic interpretation. A further incorrect approach would be to rely solely on pre-programmed protocols without critical, real-time analysis of the acquired images and their functional context. While protocols provide a standardized framework, they cannot replace the sonographer’s ability to adapt, interpret, and integrate findings based on individual patient presentations and dynamic physiological responses. This rigid adherence to protocol without critical engagement signifies a failure to exercise professional judgment and adapt to the nuances of each examination, which is essential for true proficiency. Professionals should employ a decision-making framework that begins with a thorough understanding of the examination’s objectives and the patient’s clinical history. This should be followed by a systematic acquisition of high-quality images, ensuring both anatomical detail and functional assessment. Crucially, the sonographer must engage in continuous real-time interpretation, constantly correlating the static anatomical findings with the dynamic functional data being acquired. This iterative process of acquisition, interpretation, and correlation allows for a comprehensive and accurate assessment, ensuring that all relevant information is captured and understood within its physiological context.

The scenario presents a professional challenge due to the inherent conflict between a sonographer’s duty to provide accurate diagnostic information and the potential for that information to cause distress to a patient who has explicitly requested not to know certain findings. This situation requires careful judgment to balance patient autonomy, the sonographer’s professional responsibilities, and the ethical imperative to do no harm. The sonographer must navigate the complexities of informed consent, patient wishes, and the potential for adverse outcomes if critical information is withheld or revealed inappropriately. The best professional approach involves a multi-faceted strategy that prioritizes patient well-being and respects their autonomy while ensuring appropriate medical follow-up. This approach entails immediately consulting with the referring physician or a senior clinician to discuss the findings and the patient’s specific request. Simultaneously, the sonographer should document the patient’s explicit instructions and the findings thoroughly in the medical record. This collaborative approach ensures that the medical team is aware of the situation and can collectively determine the most ethical and medically sound course of action, which may involve discussing the findings with the patient in a sensitive manner, or ensuring the referring physician is equipped to handle the disclosure appropriately, respecting the patient’s stated wishes. This aligns with principles of patient-centered care and professional accountability, ensuring that decisions are made with the patient’s best interests at heart and in accordance with established medical ethics and potentially, institutional policies. An incorrect approach would be to unilaterally decide to withhold the information without consulting the referring physician. This fails to acknowledge the physician’s role in patient management and diagnosis, potentially leaving the patient without necessary medical advice or treatment if the withheld information is clinically significant. It also bypasses the opportunity for a coordinated and sensitive disclosure. Another incorrect approach would be to immediately disclose the findings to the patient despite their explicit request not to know. This directly violates the principle of patient autonomy and informed consent, potentially causing significant psychological distress and undermining the trust between the patient and the healthcare providers. The patient has the right to control what information they receive about their health. Finally, an incorrect approach would be to ignore the findings and proceed as if nothing significant was observed. This is a dereliction of professional duty. Sonographers are trained to identify and report abnormalities, and failing to do so, even when instructed, can have severe consequences for patient care and safety. It also represents a failure to uphold the integrity of the diagnostic process. Professionals should employ a decision-making framework that begins with understanding the patient’s request and its context. This should be followed by immediate consultation with the referring physician or a senior clinician to discuss the implications of the findings and the patient’s wishes. Thorough documentation of all communications and decisions is paramount. The ultimate goal is to achieve a resolution that respects patient autonomy, upholds professional ethical standards, and ensures the patient receives appropriate medical care, even if the disclosure of information is managed with extreme sensitivity and in accordance with their stated preferences.