The control framework reveals a scenario where an advanced practice gastroenterology nurse is managing a patient with a complex gastrointestinal bleed. This situation is professionally challenging due to the critical nature of the patient’s condition, the need for rapid and accurate assessment, and the potential for life-threatening complications. Advanced practice nurses in gastroenterology must possess a high degree of clinical judgment, diagnostic acumen, and the ability to initiate and manage interventions within their scope of practice, all while adhering to established standards and patient safety protocols. Careful judgment is required to differentiate between emergent and stable conditions, interpret diagnostic findings, and coordinate care effectively with the interdisciplinary team. The best professional approach involves the advanced practice nurse conducting a comprehensive, real-time assessment of the patient’s hemodynamic status, vital signs, and signs of active bleeding. This includes a focused history, physical examination, and prompt review of laboratory results (e.g., hemoglobin, hematocrit, coagulation studies) and imaging. Based on this assessment, the nurse should then initiate evidence-based interventions within their scope of practice, such as administering intravenous fluids, medications (e.g., proton pump inhibitors, vasopressors if indicated), and preparing the patient for potential endoscopic or surgical intervention. Crucially, this approach mandates clear and timely communication with the supervising physician and the gastroenterology team, documenting all findings and interventions meticulously. This aligns with advanced practice nursing standards that emphasize autonomous assessment, diagnosis, and management of acute and chronic conditions, as well as collaborative practice and patient advocacy, ensuring patient safety and optimal outcomes. An incorrect approach would be to solely rely on the patient’s subjective report of symptoms without a thorough objective assessment. This fails to acknowledge the potential for occult bleeding or rapid deterioration, violating the principle of comprehensive patient evaluation and potentially delaying critical interventions. Another professionally unacceptable approach is to delay consulting with the supervising physician or gastroenterology team until the patient’s condition has significantly worsened. This demonstrates a failure in collaborative practice and timely escalation of care, which is a cornerstone of advanced practice nursing and patient safety. Furthermore, initiating treatments without a clear diagnostic rationale or outside of established protocols and scope of practice would be ethically and regulatorily unsound, potentially leading to patient harm and professional misconduct. Professionals should employ a systematic decision-making process that begins with a thorough assessment, followed by differential diagnosis, identification of immediate risks, and the development of a management plan that includes evidence-based interventions and appropriate consultation. This process should be guided by established professional standards, institutional policies, and ethical principles, with a constant focus on patient safety and optimal outcomes.

This scenario is professionally challenging because it requires a nurse to navigate the specific eligibility criteria for a competency assessment designed to standardize and validate specialized gastroenterology nursing skills within a North American context. Misinterpreting or misapplying these criteria can lead to inappropriate participation, wasted resources, and a failure to accurately assess readiness for advanced practice in this field. Careful judgment is required to ensure that only qualified individuals are assessed, upholding the integrity of the assessment and the standards of gastroenterology nursing. The best approach involves a thorough review of the official documentation outlining the purpose and eligibility requirements for the Applied North American Gastroenterology Nursing Competency Assessment. This documentation, typically provided by the certifying body or professional organization, will detail the specific educational background, clinical experience, and any prerequisite certifications or licenses necessary for candidates. Adhering strictly to these published guidelines ensures that the assessment is administered to individuals who meet the established benchmarks for knowledge and skill in gastroenterology nursing, thereby fulfilling the assessment’s purpose of validating competency. This aligns with professional ethical obligations to maintain standards of practice and ensure patient safety by only allowing demonstrably competent individuals to practice in specialized areas. An incorrect approach would be to assume eligibility based on general nursing experience without verifying against the specific requirements of this particular assessment. This fails to acknowledge that specialized competency assessments have distinct criteria that go beyond general nursing qualifications. The regulatory and ethical failure here lies in bypassing established standards, potentially allowing underqualified individuals to proceed, which undermines the assessment’s validity and could compromise patient care. Another incorrect approach would be to rely on anecdotal information or informal recommendations from colleagues regarding eligibility. While peer advice can be helpful, it is not a substitute for official guidelines. The regulatory and ethical failure in this instance is the abdication of professional responsibility to seek out and adhere to authoritative sources of information, leading to a potential misinterpretation of eligibility and a disregard for the formal assessment process. A further incorrect approach would be to interpret eligibility based on the nurse’s perceived confidence in their own skills, regardless of formal qualifications. Competency assessments are objective measures designed to validate skills against established criteria, not subjective self-assessments. The regulatory and ethical failure is the prioritization of personal perception over established professional standards and assessment protocols, which are in place to ensure a consistent and reliable evaluation of competence. Professionals should employ a decision-making framework that begins with identifying the specific competency assessment in question. The next step is to locate and meticulously review the official documentation detailing its purpose and eligibility criteria. This should be followed by a self-assessment of one’s qualifications against these specific requirements. If there is any ambiguity, seeking clarification directly from the administering body is crucial. This systematic and evidence-based approach ensures compliance with regulatory expectations and upholds ethical standards in professional development and practice.

The analysis reveals a scenario where a nurse is faced with a patient exhibiting symptoms suggestive of a gastrointestinal bleed, but the patient is also experiencing significant anxiety and expressing a desire to refuse further diagnostic procedures. This situation is professionally challenging because it requires balancing the nurse’s ethical and professional obligation to advocate for the patient’s well-being and safety with the patient’s right to autonomy and informed decision-making. The potential for serious harm from an untreated bleed necessitates careful judgment. The best professional approach involves a thorough assessment of the patient’s capacity to make decisions, coupled with clear, empathetic communication about the risks and benefits of the proposed interventions. This approach prioritizes understanding the patient’s concerns and fears, providing education in an accessible manner, and exploring alternatives or supportive measures to alleviate anxiety. This aligns with ethical principles of beneficence (acting in the patient’s best interest) and respect for autonomy (honoring the patient’s right to self-determination), as well as professional nursing standards that mandate patient advocacy and informed consent. It also implicitly adheres to regulatory frameworks that require healthcare providers to ensure patients understand their treatment options and the implications of their choices. An incorrect approach would be to proceed with diagnostic procedures without adequately addressing the patient’s anxiety and ensuring their understanding, thereby potentially violating the principle of informed consent and patient autonomy. This could lead to the patient feeling coerced or disrespected, undermining the therapeutic relationship and potentially leading to legal or ethical repercussions. Another incorrect approach would be to solely focus on the immediate medical need and dismiss the patient’s expressed wishes due to their anxiety. While the potential for a serious bleed is a critical concern, overriding a patient’s stated refusal without a comprehensive assessment of their decision-making capacity and a thorough attempt to address their concerns is ethically problematic. This fails to uphold the patient’s right to refuse treatment, even if that refusal seems medically inadvisable. A further incorrect approach would be to document the patient’s refusal without further investigation into the underlying reasons for their anxiety or exploring strategies to mitigate it. This reactive approach neglects the proactive nursing role in patient education, support, and advocacy, and fails to ensure the patient is making a truly informed decision. Professional reasoning in such situations requires a systematic approach: first, assess the patient’s understanding of their condition and proposed treatments; second, evaluate their capacity to make decisions, considering factors like pain, anxiety, and cognitive status; third, communicate information clearly, empathetically, and without coercion, addressing all their questions and concerns; fourth, explore the patient’s values and preferences; and fifth, document the entire process meticulously, including the assessment of capacity, the information provided, the patient’s responses, and the final decision.

Scenario Analysis: This scenario is professionally challenging because it requires the nurse to balance the immediate need for diagnostic information with the ethical and legal obligations to obtain informed consent, particularly when dealing with a vulnerable population like a pediatric patient. The urgency of the situation, coupled with the need for parental involvement and understanding, necessitates careful communication and adherence to established protocols. Failure to do so could result in legal repercussions, ethical breaches, and compromised patient care. Correct Approach Analysis: The best approach involves obtaining informed consent from the parents or legal guardians prior to initiating the diagnostic procedure. This approach respects the autonomy of the parents and the rights of the child. It ensures that the parents fully understand the purpose of the procedure, its potential risks and benefits, alternative options, and the implications of refusing consent. This aligns with the ethical principles of beneficence, non-maleficence, and respect for autonomy, as well as regulatory requirements for patient care and consent in North America, which mandate that healthcare providers obtain informed consent from individuals or their legal representatives before performing medical procedures. Incorrect Approaches Analysis: Proceeding with the diagnostic procedure without explicit parental consent, even if the child appears distressed, violates the fundamental right to informed consent and parental authority. This action disregards established legal and ethical frameworks governing healthcare for minors, potentially leading to accusations of battery or negligence. Delaying the diagnostic procedure indefinitely until the child can verbally consent, while seemingly child-centered, is impractical and potentially harmful. Children, especially young ones, may not possess the cognitive capacity to fully comprehend complex medical information or the implications of diagnostic tests. Furthermore, delaying necessary diagnostics can exacerbate the child’s condition and negatively impact their health outcomes, failing the principle of beneficence. Seeking consent solely from the child, regardless of their age or apparent understanding, is ethically and legally insufficient in most North American jurisdictions for invasive diagnostic procedures. While a child’s assent should be considered and encouraged, the ultimate legal responsibility for consent rests with their parents or legal guardians. This approach bypasses the established legal framework for pediatric consent. Professional Reasoning: Professionals should employ a decision-making framework that prioritizes patient safety and well-being while strictly adhering to legal and ethical mandates. This involves: 1) Assessing the patient’s condition and the urgency of the diagnostic need. 2) Identifying the appropriate individuals to provide consent (parents/legal guardians for minors). 3) Clearly and comprehensively explaining the procedure, its rationale, risks, benefits, and alternatives to the consenting parties. 4) Documenting the informed consent process thoroughly. 5) Involving the child in an age-appropriate manner to obtain their assent, fostering trust and cooperation. 6) Consulting with colleagues or ethics committees if complex consent issues arise.

The investigation demonstrates a scenario where a registered nurse is seeking clarification regarding the scoring and retake policies for the Applied North American Gastroenterology Nursing Competency Assessment. This situation is professionally challenging because it requires the nurse to navigate the established assessment framework accurately to ensure continued professional development and licensure. Misunderstanding these policies could lead to unnecessary anxiety, financial burden, or even a lapse in professional standing if the assessment is not successfully completed within the stipulated timeframe. Careful judgment is required to interpret the official guidelines and apply them to the individual’s situation. The best professional approach involves proactively consulting the official examination body’s published guidelines. This approach is correct because it directly accesses the authoritative source of information regarding the assessment’s blueprint, weighting, scoring, and retake policies. Adhering to these official guidelines ensures that the nurse is acting in accordance with the established standards and procedures set forth by the certifying body. This aligns with ethical principles of professional responsibility and accountability, as well as regulatory requirements that mandate competency maintenance. An incorrect approach would be to rely on informal discussions with colleagues or anecdotal evidence. This is professionally unacceptable because such information may be outdated, misinterpreted, or simply inaccurate, leading to a flawed understanding of the requirements. It fails to meet the standard of due diligence required when dealing with official competency assessments and could result in the nurse making decisions based on misinformation, potentially jeopardizing their assessment outcome. Another incorrect approach would be to assume that the policies are static and have not changed since the nurse last encountered a similar assessment. This is professionally unacceptable as it demonstrates a lack of proactive engagement with current professional standards. Regulatory frameworks and assessment policies are subject to updates, and failing to verify current procedures can lead to non-compliance. A final incorrect approach would be to contact the assessment provider with a vague inquiry without specifying the exact nature of the concern. This is professionally unacceptable as it is inefficient and may not yield the precise information needed. A clear and specific inquiry, referencing the official documentation, is more likely to result in accurate and actionable guidance, demonstrating a commitment to understanding and meeting the assessment requirements. Professionals should adopt a decision-making framework that prioritizes seeking information from primary, authoritative sources. When faced with questions about assessment policies, the first step should always be to consult the official documentation provided by the certifying or regulatory body. If clarification is still needed after reviewing the official materials, then a direct, specific, and documented inquiry to the assessment provider should be made. This systematic approach ensures accuracy, compliance, and professional integrity.

Scenario Analysis: This scenario is professionally challenging because it requires the candidate to navigate the complex landscape of professional development and resource utilization while adhering to the specific requirements of the Applied North American Gastroenterology Nursing Competency Assessment. The challenge lies in balancing personal learning preferences and time constraints with the need for evidence-based, relevant, and compliant preparation, ensuring that the chosen resources and timeline are both effective for skill enhancement and aligned with the assessment’s stated objectives and any implied regulatory or professional standards for continuing competency. Careful judgment is required to avoid superficial preparation or reliance on outdated or irrelevant materials, which could compromise patient care and professional standing. Correct Approach Analysis: The best professional practice involves a structured, multi-faceted approach to preparation. This includes thoroughly reviewing the official competency assessment guide to understand the specific knowledge domains and skills evaluated. Subsequently, candidates should identify reputable, evidence-based resources such as peer-reviewed journals, professional organization guidelines (e.g., from the American Society for Gastrointestinal Endoscopy or the Society of Gastroenterology Nurses and Associates), and accredited continuing education modules directly related to gastroenterology nursing competencies. A realistic timeline should be established, breaking down the review and practice into manageable segments, allowing for both in-depth study and spaced repetition. This approach ensures that preparation is targeted, current, and aligned with professional standards, directly addressing the assessment’s requirements and promoting the highest level of patient care. Incorrect Approaches Analysis: Relying solely on informal discussions with colleagues without cross-referencing with official assessment materials or evidence-based literature is professionally unacceptable. This approach risks incorporating anecdotal evidence or personal opinions that may not be accurate or aligned with current best practices or the assessment’s specific criteria, potentially leading to misinformation and inadequate preparation. Focusing exclusively on a single, broad textbook without considering the specific competencies outlined in the assessment guide is also problematic. This can lead to an inefficient use of time, covering material that is not directly relevant to the assessment, and potentially neglecting crucial, specialized competencies. Lastly, attempting to cram all preparation into the week immediately preceding the assessment is a significant failure. This method is unlikely to facilitate deep learning or retention, increasing the risk of errors and demonstrating a lack of professional commitment to thorough competency development. Professional Reasoning: Professionals should approach competency assessment preparation with a systematic and evidence-based mindset. This involves: 1) Understanding the assessment’s scope and objectives by consulting official documentation. 2) Identifying and utilizing high-quality, relevant, and current resources. 3) Developing a realistic and structured study plan that allows for comprehension and application of knowledge. 4) Incorporating self-assessment and practice to gauge readiness. This methodical approach ensures that preparation is not only compliant with assessment requirements but also contributes to genuine professional growth and improved patient outcomes.

Scenario Analysis: This scenario is professionally challenging because it involves a direct conflict between a patient’s stated preference and a physician’s clinical judgment, complicated by the potential for a serious adverse event. The nurse is positioned as the intermediary, requiring a delicate balance of patient advocacy, professional ethics, and adherence to clinical protocols. Navigating this requires a deep understanding of patient rights, informed consent, and the nurse’s role in facilitating communication and ensuring patient safety within the established regulatory framework. Correct Approach Analysis: The best professional approach involves facilitating a direct and informed conversation between the patient and the physician. This approach prioritizes patient autonomy and the principle of informed consent. The nurse’s role is to ensure the patient fully understands the risks and benefits of both proceeding with and refusing the procedure, and to clearly communicate the physician’s rationale. This aligns with the ethical principles of beneficence and non-maleficence, as it allows for a shared decision-making process that respects the patient’s values while ensuring they are making an informed choice based on accurate medical information. Regulatory frameworks in North America emphasize patient rights to self-determination and the requirement for physicians to obtain informed consent, which necessitates clear communication of all relevant information. Incorrect Approaches Analysis: One incorrect approach involves overriding the patient’s stated refusal and proceeding with the procedure based solely on the physician’s directive. This fails to respect patient autonomy and the fundamental right to refuse medical treatment, even if the treatment is deemed medically necessary by the physician. Ethically, this violates the principle of respect for persons. Legally, it could constitute battery. Another incorrect approach is to simply document the patient’s refusal without further engagement or ensuring the patient’s understanding of the implications. While documentation is crucial, it is insufficient when a patient’s decision may be based on incomplete information or misunderstanding of serious risks. This approach neglects the nurse’s professional responsibility to advocate for the patient and ensure their decision is truly informed. It also fails to uphold the principle of beneficence by not actively working to mitigate potential harm through further education and discussion. A third incorrect approach is to immediately escalate the situation to hospital administration without first attempting to facilitate communication between the patient and physician. While escalation may be necessary in some situations, bypassing direct communication in this instance undermines the collaborative nature of patient care and the nurse’s role in bridging communication gaps. It can also create unnecessary friction and distrust within the healthcare team. Professional Reasoning: Professionals should employ a decision-making framework that begins with assessing the situation and identifying the core conflict. This involves understanding the patient’s perspective, the physician’s clinical judgment, and the potential risks. The next step is to identify the relevant ethical principles and regulatory requirements, such as patient autonomy, informed consent, beneficence, and non-maleficence. The professional then evaluates potential courses of action against these principles and regulations, prioritizing approaches that uphold patient rights and safety while fostering effective communication and collaboration among the healthcare team. In this case, facilitating informed dialogue is the most ethically sound and professionally responsible initial step.

This scenario presents a common challenge in gastroenterology nursing: ensuring safe and effective medication administration, particularly when supporting prescribing decisions. The professional challenge lies in balancing the nurse’s role in patient care with the legal and ethical boundaries of their practice, especially concerning medication safety and adherence to prescribing protocols. Careful judgment is required to identify and address potential medication errors or deviations from best practices without overstepping professional scope. The best professional approach involves a proactive and collaborative strategy focused on identifying potential medication safety risks through a systematic review of prescribing practices and patient records. This includes verifying the appropriateness of prescribed medications against current guidelines, patient history, and potential drug interactions. By initiating a discussion with the prescribing clinician, presenting objective findings, and suggesting evidence-based alternatives or further investigations, the nurse acts as a crucial patient advocate and safety net. This aligns with the ethical imperative to provide competent and safe care, as well as regulatory requirements that emphasize interprofessional collaboration and the reporting of potential medication errors. The nurse’s role here is to support safe prescribing, not to prescribe independently, and to escalate concerns through appropriate channels. An incorrect approach would be to directly alter a prescribed medication without consultation, assuming the prescriber’s error. This violates the principle of professional accountability and the legal framework governing medication administration, as nurses are not authorized to independently change prescriptions. Such an action could lead to adverse patient outcomes and professional disciplinary action. Another incorrect approach would be to ignore a perceived discrepancy in a prescription, assuming the prescriber’s expertise. This failure to act constitutes a breach of the nurse’s duty of care and a violation of medication safety protocols. It neglects the nurse’s responsibility to advocate for the patient and to identify potential risks, potentially leading to patient harm and regulatory non-compliance. A further incorrect approach would be to document a concern about a prescription but take no further action to discuss it with the prescriber or escalate it. While documentation is important, it is insufficient if it does not lead to a resolution of the safety concern. This passive approach fails to actively protect the patient and uphold medication safety standards. The professional decision-making process for similar situations should involve a systematic assessment of the situation, identification of potential risks, consultation with relevant resources (e.g., drug information databases, institutional policies), and clear, respectful communication with the prescribing clinician. If concerns remain unresolved, escalation through established reporting mechanisms is essential. This process prioritizes patient safety, adheres to professional standards, and ensures compliance with regulatory requirements.

Scenario Analysis: This scenario presents a common challenge in gastroenterology nursing: ensuring accurate and compliant clinical documentation when faced with time pressures and multiple patient needs. The professional challenge lies in balancing the immediate demands of patient care with the long-term imperative of maintaining a legally sound and ethically defensible patient record. Inaccurate or incomplete documentation can lead to significant patient safety risks, regulatory penalties, and legal liabilities for both the nurse and the healthcare institution. Careful judgment is required to prioritize documentation tasks and ensure adherence to established standards. Correct Approach Analysis: The best professional practice involves immediately documenting the patient’s response to the prescribed medication, including any observed side effects or therapeutic outcomes, in the electronic health record (EHR) before attending to the next patient. This approach is correct because it adheres to the fundamental principles of timely and accurate clinical documentation, which are critical for patient safety and continuity of care. Regulatory frameworks, such as those governing healthcare record-keeping (e.g., HIPAA in the US, which mandates the privacy and security of health information and implies the need for accurate and complete records), emphasize the importance of contemporaneous documentation. Ethical guidelines for nursing practice also stress the nurse’s responsibility to accurately record all patient care activities and observations. Documenting promptly ensures that the information is fresh in the nurse’s mind, reducing the risk of omission or misremembering, and provides an immediate, reliable record for other healthcare professionals involved in the patient’s care. Incorrect Approaches Analysis: One incorrect approach is to delay documenting the patient’s response until the end of the shift. This is professionally unacceptable because it significantly increases the risk of forgetting crucial details, misremembering events, or inaccurately reconstructing the patient’s status. Such delays can compromise patient safety by providing outdated or incomplete information to other caregivers, potentially leading to inappropriate treatment decisions. It also falls short of regulatory expectations for timely record-keeping, which are designed to ensure the integrity and accuracy of patient information. Another incorrect approach is to rely on verbal communication with a colleague to relay the patient’s response without making a contemporaneous written entry. While verbal communication is a component of team collaboration, it is not a substitute for proper clinical documentation. Verbal information is prone to misinterpretation, omission, or loss, and it does not create a legally binding record. Regulatory bodies and legal standards require that patient care be documented in the patient’s chart. Relying solely on verbal communication creates a significant gap in the official record, which can have serious legal and ethical ramifications. A further incorrect approach is to document the information in a personal notebook or on a scrap of paper with the intention of transferring it to the EHR later. This practice is unprofessional and non-compliant. Personal notes are not considered part of the official patient record and are not subject to the same security and privacy protections as the EHR. Furthermore, the delay in transferring the information to the EHR introduces the risk of the information being lost, forgotten, or inaccurately transcribed. This method bypasses established institutional policies and regulatory requirements for maintaining a secure and accurate electronic health record. Professional Reasoning: Professionals should employ a systematic approach to documentation, integrating it into their workflow rather than treating it as an afterthought. This involves understanding institutional policies and regulatory requirements for documentation, prioritizing tasks based on patient acuity and immediate needs, and utilizing available technology (like EHRs) efficiently. When faced with competing demands, nurses should assess which tasks are critical for immediate patient safety and legal compliance. In this case, documenting the patient’s response to medication is a critical safety and compliance task that should be performed promptly. If time is exceptionally constrained, a brief, accurate note indicating the action taken and the patient’s immediate response, followed by a more detailed entry as soon as feasible, is preferable to significant delay or omission.

Scenario Analysis: This scenario is professionally challenging because it requires the nurse to balance immediate patient comfort and perceived needs with established best practices and potential diagnostic limitations. The patient’s distress and insistence on a specific, potentially unnecessary, intervention create a conflict between patient autonomy and professional nursing judgment grounded in evidence-based care and resource stewardship. Careful judgment is required to avoid unnecessary procedures while ensuring the patient’s underlying concerns are addressed. Correct Approach Analysis: The best professional practice involves a thorough assessment to understand the patient’s symptoms and concerns, followed by a clear, empathetic explanation of the diagnostic rationale and the risks and benefits of the requested procedure. This approach prioritizes patient safety and evidence-based care. It aligns with ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as professional nursing standards that mandate informed consent and the judicious use of diagnostic resources. By explaining the current diagnostic plan and the rationale for not proceeding with the immediate endoscopy, the nurse upholds professional accountability and patient education. Incorrect Approaches Analysis: Proceeding immediately with the endoscopy without further assessment or explanation fails to adhere to best practices in diagnostic stewardship and patient education. This approach risks unnecessary resource utilization, potential patient harm from an unindicated procedure, and bypasses the opportunity to build trust through clear communication. It neglects the professional responsibility to evaluate the necessity of interventions. Administering a sedative to calm the patient and then performing the endoscopy, despite the physician’s initial assessment, disregards the established medical plan and the physician’s clinical judgment. This action constitutes a significant ethical and professional failure, potentially leading to patient harm and undermining the collaborative nature of patient care. It also bypasses the informed consent process for a procedure that may not be medically indicated at that moment. Dismissing the patient’s request and focusing solely on routine care without addressing their expressed concern or explaining the current plan is dismissive and unprofessional. This approach fails to acknowledge the patient’s subjective experience and can erode trust, potentially leading to patient dissatisfaction and a reluctance to communicate future concerns. It neglects the principle of patient-centered care. Professional Reasoning: Professionals should employ a systematic approach that begins with a comprehensive assessment of the patient’s current condition and expressed concerns. This should be followed by a review of the existing medical plan and diagnostic rationale. Open and empathetic communication with the patient is crucial to explain the findings, the rationale for the current plan, and the risks and benefits of any proposed interventions. When a patient requests a specific intervention, the professional must evaluate its necessity based on clinical evidence and the patient’s presentation, rather than simply acceding to the request or dismissing it. Collaboration with the physician is essential when there is a discrepancy between the patient’s wishes and the established medical plan.