This scenario is professionally challenging because it requires the Certified Fitter-orthotics (CFo) to balance patient needs, clinical judgment, and the appropriate use of available orthotic resources within the scope of practice and regulatory guidelines. The core challenge lies in determining when a custom-fabricated orthotic is medically necessary and ethically justifiable versus when an off-the-shelf product can adequately meet the patient’s functional requirements. Misjudgment can lead to suboptimal patient outcomes, financial waste, and potential regulatory non-compliance. The approach that represents best professional practice involves a thorough clinical assessment to determine the specific biomechanical needs of the patient, followed by a recommendation for either a custom-fabricated orthotic or an appropriate off-the-shelf device based on that assessment. This is correct because it prioritizes patient well-being and functional improvement by tailoring the intervention to individual requirements. Regulatory and ethical guidelines for orthotic practice emphasize evidence-based decision-making and the provision of services that are medically necessary and appropriate. A comprehensive evaluation ensures that the chosen orthotic, whether custom or off-the-shelf, directly addresses the diagnosed condition and functional deficits, thereby maximizing therapeutic benefit and minimizing unnecessary expenditure. This aligns with the professional duty to act in the patient’s best interest. Recommending a custom-fabricated orthotic solely based on a patient’s preference for a higher-cost item, without a documented clinical need for its specific features, represents an ethical failure. It deviates from the principle of medical necessity and could be construed as upcoding or providing services that are not clinically justified, potentially violating payer policies and professional ethical codes. Suggesting an off-the-shelf orthotic for a complex condition that clearly requires the precise fit and specific material properties only achievable through custom fabrication is also professionally unacceptable. This approach fails to meet the patient’s medical needs, potentially leading to poor outcomes, discomfort, and a lack of functional improvement, thereby violating the duty of care. Recommending an off-the-shelf orthotic without a proper clinical assessment, assuming it will suffice for all patients with a particular diagnosis, is a procedural failure. It bypasses the critical step of individual patient evaluation, which is fundamental to providing effective orthotic care and ensuring that the chosen device is appropriate for the specific biomechanical presentation. The professional reasoning process for similar situations should involve a systematic approach: 1. Conduct a comprehensive patient evaluation, including history, physical examination, and functional assessment. 2. Identify the specific biomechanical issues and functional goals. 3. Consider the available orthotic options (custom vs. off-the-shelf) and their respective indications, contraindications, and limitations. 4. Determine which option best addresses the patient’s needs based on clinical evidence and professional judgment. 5. Document the rationale for the chosen intervention thoroughly. 6. Discuss the options, benefits, risks, and costs with the patient, involving them in the decision-making process.

The evaluation methodology shows that a Certified Fitter-orthotics (CFo) is faced with a common ethical dilemma when a patient presents with a condition that could be managed by orthotics, but the patient’s expressed desire for a specific, potentially suboptimal, solution conflicts with the CFo’s professional judgment. This scenario is professionally challenging because it requires balancing patient autonomy with the CFo’s duty of care and professional responsibility to provide the most appropriate and effective treatment. The CFo must navigate the patient’s preferences while ensuring the orthotic intervention is safe, effective, and aligned with best practices for the diagnosed condition. The best professional approach involves a thorough patient assessment, including understanding the patient’s goals and concerns, followed by a clear and comprehensive explanation of the diagnosed condition, the evidence-based orthotic treatment options, and the rationale behind the recommended course of action. This approach prioritizes informed consent and shared decision-making. The CFo should present the most clinically indicated orthotic solution, explaining its benefits and potential outcomes, while also acknowledging and addressing the patient’s initial request. If the patient’s preferred option is not clinically appropriate or poses risks, the CFo must explain these concerns clearly and ethically, offering alternatives that meet the patient’s needs while adhering to professional standards. This aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as the professional obligation to provide competent and evidence-based care. An incorrect approach would be to immediately dismiss the patient’s stated preference without a thorough assessment and explanation. This fails to respect patient autonomy and can lead to a breakdown in the therapeutic relationship. Another incorrect approach is to proceed with the patient’s preferred, but clinically inappropriate, orthotic intervention without adequately explaining the risks and potential for suboptimal outcomes. This violates the duty of care and could result in patient harm or dissatisfaction. Finally, a CFo should not pressure the patient into accepting a particular orthotic solution without fully exploring their concerns or providing sufficient information for them to make an informed decision. This undermines the principle of informed consent and can be perceived as coercive. Professionals should employ a decision-making framework that begins with a comprehensive patient evaluation, followed by a clear communication of findings and treatment options. This framework emphasizes active listening to the patient’s concerns, providing evidence-based information in an understandable manner, and engaging in shared decision-making. When there is a discrepancy between patient preference and clinical recommendation, the professional must ethically and clearly articulate the reasons for their recommendation, explore the patient’s underlying motivations, and collaboratively arrive at a plan that respects both the patient’s autonomy and the professional’s duty of care.

This scenario presents a professional challenge because it requires balancing the patient’s expressed preferences with the orthotist’s clinical judgment regarding the optimal biomechanical solution for their gait impairment. The Certified Fitter-orthotics (CFo) must navigate potential conflicts between patient autonomy and the ethical imperative to provide effective and safe orthotic interventions, all within the framework of professional standards and patient-centered care. Careful judgment is required to ensure the patient’s well-being and functional outcomes are prioritized. The best professional approach involves a collaborative discussion with the patient, thoroughly explaining the biomechanical rationale behind the recommended orthotic design, including its potential impact on kinematics and kinetics. This approach prioritizes informed consent and shared decision-making. By clearly articulating how the proposed design addresses the underlying gait deviations and the expected improvements in movement efficiency and joint loading, the CFo empowers the patient to make an informed choice. This aligns with ethical principles of beneficence (acting in the patient’s best interest) and respect for autonomy, ensuring the patient understands the implications of their choices. Professional standards for orthotic practice emphasize patient education and involvement in treatment planning. An approach that dismisses the patient’s preference outright and unilaterally proceeds with the initially recommended design fails to respect patient autonomy. This can lead to patient dissatisfaction, non-compliance, and a breakdown of trust, potentially compromising the effectiveness of the orthotic intervention. Ethically, it bypasses the crucial step of informed consent and can be seen as paternalistic. Another unacceptable approach is to immediately concede to the patient’s preferred design without adequately explaining the potential biomechanical drawbacks or exploring alternative solutions that might better meet their functional goals. While accommodating patient preference is important, failing to provide expert clinical guidance on the implications for kinematics and kinetics could lead to an ineffective or even detrimental orthotic device, violating the duty of care and the principle of beneficence. Finally, an approach that involves implementing the patient’s preferred design without any further discussion or assessment of its biomechanical implications, simply to avoid conflict, is also professionally unsound. This approach prioritizes expediency over patient safety and optimal outcomes, neglecting the CFo’s responsibility to apply their specialized knowledge to ensure the orthotic device effectively addresses the patient’s condition and promotes healthy biomechanics. Professionals should employ a decision-making process that begins with active listening to the patient’s concerns and preferences. This should be followed by a clear, patient-friendly explanation of the orthotist’s clinical assessment, focusing on the biomechanical principles of gait and how different orthotic designs would influence kinematics and kinetics. The CFo should then present evidence-based options, discussing the pros and cons of each in relation to the patient’s goals and functional needs. The final decision should be a shared one, reached through open communication and mutual understanding.

Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between a patient’s expressed desire and the orthotist’s professional judgment regarding the biomechanical efficacy and safety of a proposed intervention. The orthotist must navigate the ethical obligation to respect patient autonomy while upholding their duty of care, which includes providing evidence-based and safe orthotic solutions. Misjudging this balance can lead to patient harm, erosion of trust, and potential regulatory non-compliance. Correct Approach Analysis: The best professional approach involves a thorough biomechanical assessment to understand the patient’s stated goals and the underlying functional limitations. This assessment should inform a discussion with the patient about the biomechanical principles at play, the potential benefits and risks of the requested orthotic intervention, and alternative, more biomechanically sound solutions that could achieve similar or better outcomes. This approach prioritizes patient education and shared decision-making, grounded in professional expertise and a commitment to the patient’s well-being. It aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm) by ensuring the proposed orthotic device is both appropriate and safe, while also respecting patient autonomy through informed consent. Incorrect Approaches Analysis: One incorrect approach involves immediately fabricating the orthotic device as requested by the patient without further biomechanical evaluation. This fails to uphold the orthotist’s professional responsibility to ensure the device is biomechanically appropriate and safe. It prioritizes patient demand over professional judgment and could lead to an ineffective or even harmful device, violating the duty of care. Another incorrect approach is to dismiss the patient’s request outright and refuse to consider their input, insisting solely on a pre-determined treatment plan. This disregards patient autonomy and can damage the therapeutic relationship. While professional judgment is crucial, a collaborative approach that educates and involves the patient is generally preferred. A third incorrect approach is to proceed with the fabrication of the requested orthotic device while omitting crucial biomechanical considerations, such as gait analysis or joint alignment assessment. This demonstrates a lack of due diligence and a failure to apply core principles of orthotic practice. It risks creating a device that exacerbates existing biomechanical issues or introduces new ones, leading to suboptimal outcomes and potential harm. Professional Reasoning: Professionals should employ a systematic decision-making process that begins with a comprehensive patient assessment, including biomechanical evaluation. This should be followed by open communication with the patient, explaining findings and treatment options in clear, understandable terms. The process should involve a collaborative discussion about the risks and benefits of different approaches, leading to an informed shared decision. If a patient’s request conflicts with professional judgment, the orthotist has a responsibility to educate the patient on the biomechanical rationale behind their recommendation and explore alternatives that align with both the patient’s goals and sound clinical practice. Documentation of the assessment, discussion, and decision-making process is also critical.

The control framework reveals that a Certified Fitter-orthotics (CFo) must navigate complex ethical considerations when patient needs intersect with potential financial incentives. This scenario is professionally challenging because the CFo is presented with a situation where a patient’s expressed desire for a specific, potentially unnecessary, orthotic device conflicts with the CFo’s professional judgment regarding the most appropriate and evidence-based treatment. The CFo must balance patient autonomy with their ethical obligation to provide competent and appropriate care, avoiding undue influence or financial gain. The best professional approach involves prioritizing the patient’s well-being and providing evidence-based recommendations. This means conducting a thorough biomechanical assessment, considering the patient’s functional goals, and explaining the rationale behind recommended orthotic interventions. If the patient’s requested device is not indicated or potentially harmful, the CFo must clearly and respectfully communicate this, offering alternative, more appropriate solutions. This aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as professional standards that mandate providing care based on clinical need and evidence, not solely on patient preference or potential profit. An incorrect approach would be to proceed with fabricating the requested orthotic device without further clinical justification, despite professional reservations. This fails to uphold the duty of care and could lead to patient harm or dissatisfaction if the device is ineffective or inappropriate. It also bypasses the ethical obligation to provide informed consent, as the patient may not fully understand why the requested device is not the optimal choice. Another incorrect approach is to dismiss the patient’s request outright without a thorough assessment and explanation. While the CFo may believe the request is inappropriate, a complete disregard for the patient’s expressed desires can damage the therapeutic relationship and lead to patient frustration or seeking care elsewhere without proper guidance. Professional practice requires a collaborative approach where patient concerns are heard and addressed, even if the ultimate recommendation differs. Finally, an incorrect approach would be to subtly pressure the patient into accepting a more expensive or complex device than necessary, perhaps by exaggerating the benefits of a particular product or downplaying the efficacy of simpler solutions. This constitutes a breach of ethical conduct, potentially violating principles of honesty and integrity, and could be seen as exploiting the patient’s trust for financial gain. Professionals should employ a decision-making process that begins with active listening to the patient’s concerns and goals. This is followed by a comprehensive clinical assessment to gather objective data. The CFo then synthesizes this information to formulate evidence-based treatment options, considering both efficacy and patient preference. Open and transparent communication is paramount, where all options, their risks, benefits, and costs, are discussed. The final decision should be a shared one, grounded in the patient’s best interests and the CFo’s professional expertise.

This scenario presents a professional challenge because the Certified Fitter-orthotics (CFo) is faced with a situation where a patient’s expressed desire for an orthotic intervention may not align with the most appropriate clinical recommendation based on the presented pathology. The CFo must balance patient autonomy and satisfaction with their professional responsibility to provide evidence-based care and avoid unnecessary or potentially harmful interventions. Careful judgment is required to navigate the ethical considerations of patient preference versus clinical necessity, ensuring the patient’s well-being remains paramount. The best professional approach involves a thorough clinical assessment to confirm the diagnosis and the necessity of orthotic intervention. This includes gathering detailed patient history, performing a physical examination, and potentially consulting with the referring physician. If the assessment reveals that the orthotic intervention is not indicated for the diagnosed pathology, the CFo should clearly and empathetically communicate these findings to the patient, explaining the rationale behind their recommendation. This approach prioritizes patient safety and evidence-based practice, aligning with the ethical principles of beneficence and non-maleficence, which are fundamental to professional conduct for CFos. It also upholds the professional standard of providing care that is clinically justified and in the patient’s best interest, as expected within the scope of practice for orthotic fitters. An incorrect approach would be to proceed with fabricating and fitting the orthotic device solely based on the patient’s insistence, despite clinical findings suggesting it is not indicated. This would violate the ethical principle of non-maleficence by potentially exposing the patient to unnecessary costs, discomfort, and the risk of exacerbating their condition or creating new problems due to an ill-suited device. It also fails to uphold professional responsibility to provide evidence-based care. Another incorrect approach is to dismiss the patient’s concerns or desires outright without a comprehensive assessment and clear communication. This demonstrates a lack of respect for patient autonomy and can lead to a breakdown in the therapeutic relationship, potentially causing the patient to seek care elsewhere or feel unheard and unsupported. While the orthotic may not be indicated, the patient’s perception of their symptoms and their desire for relief warrant respectful consideration and explanation. Finally, an incorrect approach involves deferring the decision entirely to the referring physician without conducting an independent clinical assessment. While collaboration with physicians is crucial, the CFo has a professional obligation to perform their own evaluation to confirm the suitability of the orthotic intervention for the specific pathology and patient presentation. This ensures the CFo is providing their expert opinion and not simply acting as a passive conduit for another professional’s directive, especially when their own assessment may reveal nuances or contraindications. Professionals should employ a decision-making framework that begins with a comprehensive patient assessment, followed by a clear and evidence-based recommendation. This framework involves open communication with the patient, explaining the clinical reasoning and addressing any concerns. If there is a discrepancy between the patient’s wishes and the clinical recommendation, further discussion, potential consultation with the referring physician, and exploration of alternative non-orthotic management strategies should be considered, always prioritizing the patient’s health and well-being.

Scenario Analysis: This scenario presents a professional challenge because the Certified Fitter-orthotics (CFo) is faced with a patient exhibiting symptoms of a flatfoot deformity. The challenge lies in balancing the patient’s expressed desire for a specific, potentially non-evidence-based, intervention with the CFo’s ethical and professional responsibility to provide care that is medically sound, evidence-based, and in the patient’s best interest. The CFo must navigate potential conflicts between patient autonomy and the duty of care, ensuring that recommendations are grounded in clinical assessment and established best practices for orthotic management of flatfoot. Correct Approach Analysis: The best professional practice involves a thorough clinical assessment to confirm the diagnosis of flatfoot, determine its severity and etiology, and identify any associated symptoms or complications. This assessment should include a detailed patient history, physical examination, and potentially biomechanical gait analysis. Based on this comprehensive evaluation, the CFo should then discuss evidence-based orthotic treatment options with the patient, explaining the rationale, expected outcomes, and potential risks and benefits of each. If the patient’s preferred intervention is not supported by evidence or is deemed inappropriate, the CFo must clearly and respectfully explain why, offering alternative, clinically indicated solutions. This approach prioritizes patient safety, evidence-based practice, and informed consent, aligning with the ethical principles of beneficence and non-maleficence, and the professional standards expected of a CFo. Incorrect Approaches Analysis: Recommending a specific, unproven orthotic device solely based on the patient’s request, without a thorough clinical assessment and consideration of evidence-based practice, would be professionally unacceptable. This approach disregards the CFo’s duty to provide competent and appropriate care, potentially leading to ineffective treatment or even harm. It fails to uphold the principle of beneficence by not ensuring the chosen intervention is likely to be beneficial. Proceeding with a treatment plan that is not supported by clinical evidence, even if the patient insists, would also be professionally unsound. This approach prioritizes patient demand over clinical judgment and evidence, potentially exposing the patient to ineffective or detrimental interventions. It violates the ethical obligation to act in the patient’s best interest and could lead to a breach of professional standards. Ignoring the patient’s concerns and proceeding with a standard protocol without addressing their specific request or understanding their rationale would be a failure in patient-centered care. While adherence to protocol is important, it should be informed by a comprehensive understanding of the individual patient’s needs and preferences, and any deviations or explanations should be clearly communicated. This approach risks alienating the patient and failing to provide truly individualized care. Professional Reasoning: Professionals should employ a decision-making process that begins with a comprehensive assessment of the patient’s condition. This is followed by an evaluation of available evidence-based treatment options. Patient preferences and values should be considered and discussed openly, but ultimately, the recommended course of action must be clinically justified and aligned with professional standards and ethical obligations. Transparency, clear communication, and a commitment to patient well-being are paramount in navigating complex patient requests and ensuring optimal outcomes.

This scenario presents a professional challenge due to the inherent conflict between a patient’s expressed wishes and the orthotist’s professional judgment, particularly when those wishes might lead to suboptimal outcomes or potential harm. The evolution of orthotics has seen a shift towards patient-centered care, but this must be balanced with the ethical obligation to provide the best possible treatment based on evidence and expertise. Careful judgment is required to navigate this delicate balance, ensuring patient autonomy is respected while upholding professional standards. The correct approach involves a thorough and empathetic discussion with the patient, exploring the reasons behind their preference for the older technology. This includes educating them on the advancements in modern orthotic design and materials, highlighting the potential benefits for their specific condition, and addressing any concerns or misconceptions they may have about newer options. The orthotist must clearly articulate the evidence-based rationale for recommending the more advanced device, emphasizing improved function, comfort, and long-term outcomes. This approach respects patient autonomy by providing them with comprehensive information to make an informed decision, while also fulfilling the professional duty to advocate for the most effective treatment. This aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as the evolving standards of patient-centered care that prioritize shared decision-making. An incorrect approach would be to immediately dismiss the patient’s preference and insist on the newer technology without adequate exploration of their reasoning. This fails to acknowledge the patient’s autonomy and can lead to distrust and non-compliance. Ethically, it prioritizes the orthotist’s judgment over the patient’s expressed desires without sufficient justification, potentially violating the principle of respect for persons. Another incorrect approach would be to acquiesce to the patient’s request for the older technology simply to avoid conflict or to expedite the process, without thoroughly explaining the potential drawbacks or the benefits of the newer option. This neglects the professional responsibility to provide the most appropriate care and could lead to a suboptimal outcome for the patient, failing the principle of beneficence. A further incorrect approach would be to proceed with the older technology while subtly discouraging its use or expressing reservations to the patient. This creates an environment of uncertainty and can undermine the patient’s confidence in the chosen treatment, even if it aligns with their initial request. It is a failure of transparent communication and professional integrity. The professional decision-making process in such situations should involve active listening, empathetic communication, evidence-based reasoning, and a commitment to shared decision-making. Orthotists should strive to understand the patient’s perspective, educate them thoroughly, and collaboratively arrive at a treatment plan that balances patient preferences with professional expertise and ethical obligations.

Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between a patient’s stated preference and the certified fitter-orthotist’s professional judgment regarding the most appropriate and safe course of action for managing a diabetic foot complication. The certified fitter-orthotist must balance patient autonomy with their ethical and professional responsibility to provide care that prioritizes patient well-being and adherence to best practices in orthotic management for diabetic patients. This requires careful consideration of the potential risks and benefits of each option, informed by clinical expertise and an understanding of the specific needs of individuals with diabetes. Correct Approach Analysis: The best professional approach involves a thorough and empathetic discussion with the patient, clearly explaining the rationale behind recommending a specific orthotic intervention. This approach prioritizes patient education and shared decision-making. The certified fitter-orthotist should detail the potential risks associated with the patient’s preferred, less protective option, such as increased pressure points, skin breakdown, and potential for ulceration, which are critical concerns in diabetic foot care. Simultaneously, they must articulate the benefits of the recommended, more protective orthotic, emphasizing its role in offloading pressure, preventing injury, and supporting the healing process. This aligns with ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), while also respecting patient autonomy by providing them with the necessary information to make an informed choice. This approach also implicitly adheres to professional guidelines that advocate for comprehensive patient assessment and tailored treatment plans for individuals with diabetes. Incorrect Approaches Analysis: One incorrect approach involves immediately deferring to the patient’s preference without adequately explaining the risks or offering alternatives. This fails to uphold the professional’s duty of care and can lead to patient harm, as the patient may not fully understand the implications of their choice. It disregards the certified fitter-orthotist’s expertise and responsibility to guide the patient towards the safest and most effective treatment, potentially violating the principle of beneficence. Another incorrect approach is to dismiss the patient’s preference outright and insist on the recommended orthotic without engaging in a collaborative discussion. This undermines patient autonomy and can lead to non-compliance, as the patient may feel unheard or disrespected. While the intention might be to ensure the best outcome, the method fails to build trust and partnership, which are crucial for successful long-term management of chronic conditions like diabetes. A third incorrect approach involves proceeding with the patient’s less protective choice while making minimal or no effort to document the discussion of risks or to monitor the patient closely. This represents a failure in professional responsibility and documentation, leaving both the patient and the practitioner vulnerable. It neglects the proactive management required for diabetic foot complications and can be seen as a dereliction of duty, as it does not adequately mitigate foreseeable risks. Professional Reasoning: Professionals should employ a decision-making framework that begins with a comprehensive assessment of the patient’s condition and needs. This is followed by an open and honest dialogue where the professional clearly communicates their clinical judgment, including the rationale and potential risks and benefits of different orthotic options. The patient’s preferences and concerns should be actively solicited and addressed. The goal is to reach a shared decision that is both clinically sound and respects the patient’s autonomy, ensuring they are empowered to participate in their own care. If a patient insists on a course of action that the professional deems significantly harmful, further consultation with other healthcare providers or a referral may be necessary.

This scenario presents a professional challenge due to the inherent conflict between a patient’s stated preference and the orthotist’s professional judgment regarding the most appropriate and safe orthotic device. The Certified Fitter-orthotics (CFo) must navigate the ethical obligation to respect patient autonomy while upholding their duty of care and ensuring the patient receives a device that is therapeutically effective and safe, adhering to established professional standards. The best professional approach involves a thorough assessment and clear communication. This entails conducting a comprehensive evaluation of the patient’s condition, functional needs, and the specific limitations of each proposed orthotic device. The CFo must then engage in an open and honest dialogue with the patient, explaining the rationale behind their recommendation, detailing the potential benefits and risks associated with each option, and addressing any concerns the patient may have. This collaborative approach respects the patient’s right to make informed decisions while ensuring the CFo fulfills their responsibility to provide evidence-based care. This aligns with ethical principles of beneficence (acting in the patient’s best interest) and autonomy (respecting the patient’s right to self-determination), as well as professional guidelines that emphasize informed consent and patient-centered care. An incorrect approach would be to immediately acquiesce to the patient’s request for a less suitable device without further investigation or discussion. This fails to uphold the CFo’s duty of care to provide the most appropriate intervention and could lead to suboptimal outcomes or even harm. Ethically, this bypasses the professional’s responsibility to guide the patient towards the best possible care. Another incorrect approach would be to dismiss the patient’s preference outright and unilaterally decide on the orthotic device without adequate explanation or consideration of the patient’s perspective. This disregards patient autonomy and can erode trust, potentially leading to non-compliance with the prescribed device. It fails to engage in the necessary shared decision-making process. Finally, an incorrect approach would be to recommend a device based solely on its perceived ease of fitting or availability, without a thorough assessment of the patient’s specific needs and the device’s therapeutic efficacy. This prioritizes convenience over patient well-being and violates the professional obligation to provide individualized care. The professional reasoning process should involve a systematic approach: first, gather all necessary clinical information through assessment; second, identify all viable orthotic options and their respective pros and cons; third, communicate these options clearly and empathetically to the patient, addressing their concerns and preferences; fourth, collaboratively arrive at a decision that balances patient autonomy with professional expertise and ethical obligations; and fifth, document the entire process thoroughly.