The investigation demonstrates a scenario where a physician is seeking to understand the foundational principles and requirements for participating in the Comprehensive Latin American ECMO Transport Critical Care Fellowship Exit Examination. This is professionally challenging because misinterpreting or failing to adhere to the purpose and eligibility criteria can lead to significant professional setbacks, including wasted time, resources, and potential disqualification from a critical career advancement opportunity. Careful judgment is required to ensure alignment with the fellowship’s objectives and the governing regulatory framework. The correct approach involves a thorough understanding of the fellowship’s stated purpose and the specific eligibility criteria as outlined by the organizing body, which are designed to ensure that candidates possess the requisite knowledge, skills, and experience to advance in specialized ECMO transport critical care. This approach is correct because it directly addresses the core intent of the examination – to validate competency in a specific, advanced field of critical care transport. Adherence to these established criteria ensures fairness, maintains the integrity of the fellowship program, and guarantees that successful candidates meet the high standards expected for advanced practice in this specialized area. The purpose is to certify a level of expertise beyond general critical care, focusing on the unique demands of ECMO transport, and eligibility ensures that only those with relevant training and experience can undertake this rigorous assessment. An incorrect approach would be to assume that general critical care experience alone is sufficient for eligibility, without specific training or documented experience in ECMO transport. This fails to acknowledge the specialized nature of the fellowship and its exit examination, which is designed to assess advanced competencies not typically covered in general critical care training. Another incorrect approach would be to focus solely on the desire for career advancement without verifying if the candidate meets the prerequisite educational and practical requirements. This demonstrates a misunderstanding of the purpose of a fellowship exit examination, which is to confirm mastery of specific skills and knowledge, not merely to serve as a general credentialing tool. Finally, attempting to bypass or circumvent the stated eligibility requirements based on personal interpretation or perceived equivalency without formal validation would be a significant ethical and regulatory failure, undermining the structured and merit-based nature of the fellowship. Professionals should employ a decision-making framework that prioritizes meticulous review of official program documentation, including purpose statements, eligibility criteria, and any associated regulatory guidelines. This involves proactive inquiry with program administrators if any aspect is unclear and a commitment to meeting all stated requirements before investing time and effort in preparation for the examination. The process should be guided by a principle of transparency and adherence to established standards.

Scenario Analysis: This scenario presents a critical challenge in managing a patient requiring extracorporeal membrane oxygenation (ECMO) during interfacility transport. The primary difficulty lies in ensuring the continuity and safety of care while adhering to the specific regulatory requirements for patient transfer between institutions, particularly concerning the documentation and communication of critical patient data. Failure to comply with these regulations can lead to patient harm, legal repercussions, and breaches of patient confidentiality. Correct Approach Analysis: The best professional practice involves a comprehensive handover process that meticulously documents all aspects of the patient’s ECMO management, including circuit parameters, anticoagulation status, ventilator settings, and any recent interventions or complications. This documentation must be securely transmitted to the receiving facility’s ECMO team prior to or immediately upon arrival, ensuring they have all necessary information to seamlessly continue care. This approach aligns with general principles of patient safety and regulatory requirements for interfacility transfers, which mandate clear communication of patient status and treatment plans to prevent gaps in care and ensure continuity. While specific Latin American regulations may vary by country, the overarching ethical and professional obligation to ensure patient safety through thorough communication and documentation is universal and implicitly supported by any framework governing critical care transport. Incorrect Approaches Analysis: One incorrect approach involves relying solely on verbal communication of critical ECMO data during the handover. While verbal communication is important, it is insufficient on its own. It lacks a permanent record, is prone to misinterpretation or omission, and fails to meet the documentation standards expected for critical care transfers. This can lead to significant gaps in the receiving team’s understanding of the patient’s history and current status, increasing the risk of adverse events. Another unacceptable approach is to delay the transmission of detailed ECMO records until after the patient has been fully stabilized at the receiving facility. This creates a critical period where the receiving team is operating with incomplete information, potentially compromising patient safety during the crucial initial moments of transfer. Regulatory frameworks for patient care emphasize timely and complete information exchange to ensure immediate and appropriate management. Finally, an approach that involves omitting specific details about the ECMO circuit’s performance or the patient’s anticoagulation management from the handover documentation is highly problematic. These are vital parameters for ECMO patients. Their omission represents a failure to provide a complete picture of the patient’s condition and risks, directly contravening the principles of safe patient care and the implicit requirements for comprehensive medical reporting during transfers. Professional Reasoning: Professionals should adopt a systematic approach to interfacility ECMO transport. This begins with a thorough pre-transfer assessment and planning phase, ensuring all equipment and personnel are prepared. During the transfer, continuous monitoring and documentation of all critical parameters are essential. The handover process must be structured, utilizing standardized checklists and secure communication channels to transmit comprehensive documentation. This ensures that the receiving team has all the information needed to provide uninterrupted, high-quality care, thereby upholding professional standards and regulatory expectations for patient safety and continuity of care.

Scenario Analysis: This scenario presents a common yet complex challenge in critical care transport: balancing the need for patient comfort and procedural tolerance with the risks of over-sedation, inadequate analgesia, and potential neurological sequelae. The critical care fellow must navigate individual patient variability, the dynamic nature of ECMO, and the ethical imperative to provide the highest standard of care while adhering to established best practices and institutional guidelines. The professional challenge lies in making real-time, evidence-based decisions that optimize patient outcomes in a high-stakes environment. Correct Approach Analysis: The best professional practice involves a multimodal approach to sedation, analgesia, delirium prevention, and neuroprotection, prioritizing patient-centered care and continuous reassessment. This includes utilizing validated assessment tools (e.g., RASS for sedation, CPOT for pain), employing a combination of short-acting agents for titration, incorporating non-pharmacological interventions, and implementing a delirium prevention protocol. This approach is ethically sound as it respects patient autonomy (to the extent possible), minimizes harm by avoiding unnecessary medication, and promotes recovery by actively addressing potential complications like delirium. It aligns with the principles of patient safety and quality improvement inherent in critical care medicine and ECMO transport. Incorrect Approaches Analysis: Administering a continuous infusion of a long-acting sedative without regular reassessment and titration risks profound over-sedation, leading to prolonged mechanical ventilation, increased risk of ventilator-associated pneumonia, and difficulty in neurological assessment. This approach fails to acknowledge the dynamic needs of the patient and the potential for adverse drug effects, violating the principle of minimizing harm. Relying solely on opioid administration for pain management without concurrent use of sedatives or non-pharmacological measures can lead to inadequate comfort and increased patient distress, potentially exacerbating physiological stress. Conversely, administering high doses of sedatives without adequate analgesia can mask pain, leading to physiological derangements and hindering effective pain management. Both scenarios represent a failure to provide comprehensive pain and comfort management. Implementing a rigid, one-size-fits-all sedation and analgesia regimen without considering patient-specific factors, ECMO circuit dynamics, or the potential for neurological injury neglects the individualized nature of critical care. This approach can lead to suboptimal outcomes, such as inadequate pain control or excessive sedation, and fails to proactively address potential neuroprotective strategies. Professional Reasoning: Professionals should adopt a systematic approach that begins with a thorough baseline assessment of the patient’s neurological status, pain, and comfort level. This should be followed by the selection of appropriate pharmacological agents, prioritizing those with predictable pharmacokinetics and pharmacodynamics suitable for transport. Crucially, continuous monitoring using validated scales and frequent reassessment are paramount. The integration of non-pharmacological interventions and a proactive delirium prevention strategy are essential components of comprehensive care. Decision-making should be guided by evidence-based guidelines, institutional protocols, and a collaborative approach with the ECMO team, always prioritizing patient safety and optimal recovery.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the need for consistent and fair assessment with the practical realities of a fellowship program. The fellowship director must ensure that the blueprint accurately reflects the learning objectives and that scoring is applied uniformly, while also considering the impact of retake policies on trainee progression and program reputation. Navigating these elements requires a deep understanding of the program’s accreditation standards and ethical considerations in evaluation. Correct Approach Analysis: The best professional practice involves a thorough review and validation of the blueprint against the fellowship’s stated learning objectives and competency domains. This ensures the blueprint is a valid and reliable measure of trainee knowledge and skills. Subsequently, the scoring methodology should be clearly defined, objective, and consistently applied to all trainees. Retake policies must be transparent, fair, and designed to support remediation and learning rather than simply punitive. This approach aligns with principles of fair assessment, educational best practices, and the ethical obligation to provide trainees with clear expectations and opportunities for success. Incorrect Approaches Analysis: One incorrect approach involves relying solely on historical blueprint data without re-evaluating its relevance to current ECMO transport critical care practices and fellowship objectives. This fails to ensure the blueprint remains a valid assessment tool and may lead to trainees being evaluated on outdated or irrelevant content. Another incorrect approach is to implement a scoring system that is subjective or inconsistently applied across different examiners or cohorts. This undermines the reliability and fairness of the assessment, potentially leading to biased outcomes and a lack of confidence in the evaluation process. A third incorrect approach is to establish retake policies that are overly punitive or lack clear remediation pathways. This can create undue stress for trainees, discourage them from seeking help, and fail to address the underlying reasons for assessment failure, ultimately hindering their professional development. Professional Reasoning: Professionals should approach assessment design and implementation with a commitment to validity, reliability, fairness, and transparency. This involves a cyclical process of blueprint development, validation, consistent application of scoring, and the establishment of clear, supportive retake policies. When faced with challenges, seeking input from faculty, trainees, and relevant accreditation bodies can help ensure that assessment practices are robust and ethically sound.

Scenario Analysis: This scenario is professionally challenging because it requires the fellow to balance the immediate need for comprehensive preparation with the ethical obligation to maintain patient safety and the integrity of the learning process. The pressure to perform well on a high-stakes exit examination can lead to shortcuts or an over-reliance on superficial resources, potentially compromising the depth of understanding necessary for critical care transport. Careful judgment is required to select resources that are both effective for exam preparation and aligned with the principles of continuous professional development and patient-centered care. Correct Approach Analysis: The best approach involves a structured, multi-modal preparation strategy that prioritizes foundational knowledge, evidence-based practice, and simulated application, directly aligning with the rigorous standards expected in Latin American ECMO transport critical care. This includes engaging with peer-reviewed literature, attending relevant didactic sessions or webinars focused on ECMO physiology and transport protocols, and actively participating in case-based discussions or simulation exercises that mimic real-world transport scenarios. This method ensures that preparation is not merely for the examination but for enhanced clinical competence, reflecting the ethical imperative to provide the highest standard of care. Regulatory and ethical guidelines in critical care emphasize evidence-based practice and continuous learning, which this approach directly supports. Incorrect Approaches Analysis: Focusing solely on past examination papers without understanding the underlying principles is an ethically flawed approach. While it might offer familiarity with question formats, it fails to build a robust knowledge base and can lead to rote memorization rather than true comprehension, potentially jeopardizing patient safety during critical transports. This neglects the ethical duty to be competent and knowledgeable. Relying exclusively on a single, unverified online forum for all preparation materials is professionally unsound. Such forums may contain outdated, inaccurate, or biased information, lacking the peer review and validation essential for critical care knowledge. This poses a significant ethical risk by potentially leading to the adoption of unsafe practices and violates the principle of using evidence-based resources. Prioritizing memorization of specific algorithms or protocols without understanding their physiological basis or indications for use is a superficial preparation method. While algorithms are important, their application requires a deep understanding of the underlying pathophysiology and patient-specific factors. This approach risks misapplication of protocols in complex or atypical patient presentations, which is ethically unacceptable in critical care where patient well-being is paramount. Professional Reasoning: Professionals should approach exam preparation as an extension of their commitment to lifelong learning and patient care. This involves a systematic evaluation of available resources, prioritizing those that are evidence-based, peer-reviewed, and directly relevant to the clinical practice of ECMO transport. A balanced approach that integrates theoretical knowledge with practical application through case studies and simulations, while adhering to ethical principles of competence and patient safety, is crucial for successful and responsible professional development.

Scenario Analysis: This scenario presents a critical ethical and regulatory challenge involving patient consent for a high-risk, life-saving procedure (ECMO transport) in a resource-limited, emergency setting. The core difficulty lies in balancing the urgent need for medical intervention with the patient’s right to informed consent, especially when the patient’s capacity to consent is compromised due to their critical condition. Navigating potential cultural sensitivities and ensuring equitable access to care while adhering to established ethical and legal frameworks for consent and patient autonomy is paramount. Correct Approach Analysis: The best professional practice involves obtaining consent from the legally authorized surrogate decision-maker, provided that the patient lacks the capacity to consent themselves. This approach prioritizes patient well-being by enabling life-saving treatment while respecting the principles of substituted judgment and best interests, as guided by established medical ethics and relevant national healthcare legislation concerning consent for incapacitated adults. This ensures that decisions are made in accordance with the patient’s presumed wishes or, failing that, their overall best interests, as determined by a trusted individual. Incorrect Approaches Analysis: Proceeding with ECMO transport without any form of consent, even in an emergency, is ethically and legally unacceptable. It violates the fundamental principle of patient autonomy and could lead to legal repercussions and a breach of trust between healthcare providers and the patient’s family. Seeking consent directly from the patient when their critical condition demonstrably impairs their capacity to understand the risks, benefits, and alternatives of ECMO transport is inappropriate. This approach fails to uphold the ethical requirement for informed consent, as the patient cannot provide a truly voluntary and informed decision under such circumstances. Delaying the ECMO transport to conduct an extensive search for a distant relative or legal guardian, when a readily available and appropriate surrogate decision-maker is present, is professionally unsound. While due diligence is important, in a time-sensitive emergency, prioritizing the patient’s immediate survival by engaging the most accessible and appropriate surrogate is ethically mandated. This delay could result in irreversible harm or death. Professional Reasoning: Professionals should employ a structured decision-making process that begins with an immediate assessment of the patient’s capacity to consent. If capacity is lacking, the next step is to identify the legally authorized surrogate decision-maker. This involves understanding the hierarchy of surrogacy as defined by local regulations. If a surrogate is available, the healthcare team must provide them with comprehensive information about the procedure, its risks, benefits, and alternatives, enabling them to make a decision based on substituted judgment or best interests. If no surrogate is available, the team must consult institutional ethics committees or legal counsel to determine the appropriate course of action, always prioritizing the patient’s life and well-being within legal and ethical boundaries.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate critical care needs of a post-ECMO patient with the long-term goals of survivorship, specifically focusing on nutrition, mobility, and liberation from mechanical ventilation. The complexity arises from the patient’s vulnerable state, the potential for rapid decompensation, and the need for a multidisciplinary, individualized approach that respects patient autonomy and promotes recovery. Effective judgment is required to integrate these bundles seamlessly into the patient’s care plan without compromising safety or delaying essential interventions. Correct Approach Analysis: The best professional practice involves a proactive, integrated, and multidisciplinary approach to nutrition, mobility, and liberation, initiated as soon as medically feasible and tailored to the individual patient’s recovery trajectory. This approach prioritizes early enteral nutrition to support gut integrity and reduce catabolism, early mobilization (even passive range of motion) to prevent deconditioning and delirium, and systematic assessment for liberation from mechanical ventilation, including spontaneous breathing trials, as soon as the patient demonstrates readiness. This aligns with ethical principles of beneficence (acting in the patient’s best interest for recovery) and non-maleficence (preventing harm from prolonged immobility and malnutrition), and implicitly supports patient autonomy by aiming to restore function and independence. While specific Latin American regulations may vary, the overarching ethical and professional standards of critical care globally emphasize these principles for optimal ICU survivorship outcomes. Incorrect Approaches Analysis: One incorrect approach involves delaying the initiation of nutritional support until the patient is fully extubated and hemodynamically stable. This failure to provide early enteral nutrition can lead to prolonged periods of catabolism, impaired immune function, and delayed wound healing, directly contradicting the principle of beneficence and potentially increasing morbidity. Another incorrect approach is to defer mobilization until the patient is discharged from the ICU. This overlooks the significant muscle atrophy and deconditioning that occur with prolonged immobility, increasing the risk of falls, prolonged hospital stays, and reduced functional recovery post-discharge. It fails to address the patient’s long-term survivorship needs. A third incorrect approach is to focus solely on weaning from mechanical ventilation without concurrently addressing nutritional status and mobility. This creates a fragmented care plan that does not holistically support the patient’s recovery. It may lead to a patient who is extubated but too weak and malnourished to participate effectively in rehabilitation, thus hindering overall survivorship. Professional Reasoning: Professionals should employ a framework that integrates evidence-based critical care bundles for nutrition, mobility, and liberation into a patient-centered care plan. This involves continuous assessment of the patient’s readiness for each component of the bundles, facilitated by a multidisciplinary team (physicians, nurses, respiratory therapists, dietitians, physical therapists). The decision-making process should prioritize early intervention, individualized tailoring of interventions based on patient response, and clear communication among team members and with the patient/family to ensure a coordinated and effective approach to ICU survivorship.

Scenario Analysis: This scenario presents a professionally challenging situation due to the inherent instability of a patient with advanced cardiogenic shock requiring ECMO support during interfacility transport. The critical nature of ECMO necessitates meticulous monitoring and rapid, informed decision-making to prevent catastrophic decompensation. The challenge lies in balancing the need for timely transfer with the imperative to maintain hemodynamic stability and organ perfusion, all while adhering to established protocols and ensuring patient safety. The risk of ECMO circuit complications, patient-specific physiological responses to transport stressors, and the potential for unforeseen clinical deterioration demand a proactive and risk-stratified approach. Correct Approach Analysis: The best professional practice involves a comprehensive pre-transport risk assessment and stabilization protocol tailored to the ECMO patient. This includes a thorough review of the patient’s current hemodynamic status, ECMO parameters (flow, sweep, pressures, anticoagulation), vasoactive and inotropic support, renal and neurological function, and any potential transport-related stressors (e.g., vibration, positional changes, temperature fluctuations). A detailed plan for managing potential ECMO circuit issues (e.g., air embolism, circuit thrombosis, bleeding) and patient decompensation (e.g., refractory hypotension, arrhythmias, hypoxia) must be established. This approach is correct because it aligns with the ethical principles of beneficence and non-maleficence, prioritizing patient safety and well-being. It also reflects best practice guidelines for ECMO management and critical care transport, emphasizing proactive risk mitigation and preparedness. Regulatory frameworks governing critical care transport and patient safety mandate such thorough evaluations and planning to ensure continuity of care and minimize iatrogenic harm. Incorrect Approaches Analysis: Initiating transport without a comprehensive pre-transport assessment and stabilization plan, relying solely on the receiving facility’s readiness, is ethically and professionally unacceptable. This approach fails to adequately address the patient’s immediate risks during transit and could lead to delayed or inadequate interventions if complications arise, violating the principle of non-maleficence. It also disregards the responsibility of the transferring team to ensure the patient is stable enough for transport. Proceeding with transport based on a superficial review of ECMO settings without a detailed assessment of the patient’s overall physiological status and potential transport-related risks is also professionally deficient. This overlooks the complex interplay of factors affecting ECMO patients and increases the likelihood of unexpected deterioration, potentially leading to adverse outcomes and contravening the duty of care. Relying solely on the expertise of the transport team to manage any emergent issues during transit without a pre-established, patient-specific management plan is a significant ethical and professional failing. While transport teams are skilled, ECMO management is highly specialized, and a lack of pre-planning for specific ECMO-related complications during transport can lead to critical delays in appropriate interventions, potentially resulting in irreversible harm. This approach neglects the proactive risk management essential for this vulnerable patient population. Professional Reasoning: Professionals should adopt a systematic, risk-stratified approach to ECMO transport. This involves a multi-disciplinary team discussion to evaluate the patient’s stability, identify potential transport-related risks, and develop a detailed, individualized management plan. This plan should encompass pre-transport optimization, in-transit monitoring parameters, contingency plans for common and critical ECMO complications, and clear communication channels between the transferring team, transport team, and receiving facility. The decision to transport should be based on a clear benefit-to-risk assessment, ensuring that the potential benefits of transfer outweigh the inherent risks. Continuous reassessment of the patient’s condition throughout the transport process is paramount.

Scenario Analysis: This scenario presents a professionally challenging situation due to the inherent complexity of managing a critically ill patient requiring extracorporeal membrane oxygenation (ECMO) during interfacility transport. The challenge lies in balancing the need for continuous, high-level critical care with the logistical constraints and potential for unforeseen complications during transit. Ensuring patient safety, maintaining the integrity of the ECMO circuit, and coordinating care across multiple institutions require meticulous planning, clear communication, and adherence to established protocols. The decision-making process must prioritize patient well-being while navigating the ethical considerations of resource allocation and inter-professional collaboration. Correct Approach Analysis: The best professional practice involves a comprehensive, multidisciplinary pre-transport assessment and planning phase. This includes a thorough review of the patient’s clinical status, ECMO parameters, and transport requirements by both the referring and receiving ECMO teams. A detailed transport plan should be collaboratively developed, outlining specific protocols for circuit management, hemodynamic monitoring, ventilation settings, medication adjustments, and emergency contingency measures. This plan should be clearly communicated to all involved personnel, including transport staff, and documented meticulously. This approach aligns with ethical principles of beneficence and non-maleficence by proactively identifying and mitigating risks, ensuring continuity of care, and optimizing patient outcomes. It also reflects professional accountability by emphasizing collaborative decision-making and adherence to best practices in critical care transport. Incorrect Approaches Analysis: Initiating transport without a detailed, collaboratively developed plan, relying solely on the referring team’s assessment, fails to adequately address the complexities of ECMO transport. This approach risks overlooking critical transfer parameters, potential equipment incompatibilities, or specific needs of the receiving facility, thereby compromising patient safety and potentially leading to adverse events. It also demonstrates a lack of professional diligence in ensuring a smooth and safe transition of care. Transferring the patient with a generic transport protocol that does not specifically address ECMO management, assuming standard critical care transport procedures are sufficient, is also professionally unacceptable. ECMO requires specialized monitoring and intervention strategies that differ significantly from conventional mechanical ventilation. This oversight can lead to critical misinterpretations of circuit data or delayed recognition of ECMO-related complications, violating the duty of care owed to the patient. Relying on the receiving ECMO team to provide all necessary guidance and protocols only upon arrival at the destination, without prior collaborative planning, creates a significant gap in care during transit. This reactive approach places the patient at undue risk during the transport phase and demonstrates a failure in proactive risk management and inter-institutional coordination, which are fundamental to safe patient transfers. Professional Reasoning: Professionals should adopt a systematic, risk-stratified approach to patient transport, particularly in complex cases like ECMO. This involves: 1) Comprehensive assessment of patient stability and transportability. 2) Collaborative development of a detailed, patient-specific transport plan with clear roles and responsibilities. 3) Robust communication channels between all involved teams. 4) Establishment of contingency plans for foreseeable emergencies. 5) Meticulous documentation throughout the process. This framework ensures that patient safety and optimal care are prioritized at every stage of the transfer.

The review process indicates that this scenario presents a significant professional challenge due to the inherent emotional distress experienced by families during critical care transport, coupled with the complex medical realities of ECMO. Balancing the need for clear, honest communication with empathy and respect for family autonomy is paramount. The ethical imperative to involve families in shared decision-making, especially concerning prognostication and potential withdrawal of care, requires a delicate approach that respects their values and understanding. The correct approach involves a structured, empathetic, and transparent conversation with the family. This entails clearly explaining the child’s current condition, the rationale for ECMO, the potential benefits and significant risks, and the realistic prognosis based on available data and expert opinion. Crucially, it requires actively listening to the family’s concerns, values, and goals of care, and then collaboratively developing a plan that aligns with these factors. This aligns with ethical principles of beneficence, non-maleficence, autonomy, and justice, as well as professional guidelines emphasizing patient-centered care and informed consent. The focus is on empowering the family with accurate information to make decisions that are best for their child and their family unit, acknowledging the profound emotional and spiritual impact of such a situation. An incorrect approach would be to present a purely clinical update without adequate emotional support or an opportunity for family input. This fails to acknowledge the family’s emotional state and their right to participate in decisions about their child’s care, potentially leading to feelings of disempowerment and distrust. Another incorrect approach is to offer overly optimistic or definitive prognoses without acknowledging the inherent uncertainties of ECMO and critical illness. This can create false hope or lead to significant distress if the outcome differs from the prediction, and it violates the principle of honesty in prognostication. Finally, avoiding difficult conversations about prognosis or potential outcomes, or making decisions without meaningful family consultation, constitutes a failure to uphold the principles of shared decision-making and respect for autonomy, and can lead to significant ethical and legal ramifications. Professionals should approach these situations by first establishing a rapport and assessing the family’s current understanding and emotional state. They should then present information in a clear, concise, and compassionate manner, using language that is understandable. Active listening and encouraging questions are vital. Prognostication should be framed within realistic probabilities, acknowledging uncertainties. Shared decision-making should be a continuous process, involving ongoing dialogue and reassessment of goals of care as the clinical situation evolves.