Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate need for efficient resource allocation with the ethical imperative of providing individualized, high-quality care to a vulnerable geriatric population. Geriatric patients often have complex, multi-morbid conditions, and their care needs can be highly variable, making standardized, one-size-fits-all approaches potentially detrimental. The pressure to demonstrate efficiency can inadvertently lead to depersonalized care or the overlooking of subtle but critical signs of decline, which are hallmarks of advanced practice standards in geriatric medicine. Careful judgment is required to ensure that efficiency measures do not compromise the core principles of patient-centered care, autonomy, and beneficence. Correct Approach Analysis: The best professional practice involves a multidisciplinary team, including geriatricians, nurses, pharmacists, social workers, and allied health professionals, collaboratively developing and implementing individualized care plans. This approach is correct because it directly aligns with advanced practice standards in geriatric medicine, which emphasize holistic assessment, interprofessional collaboration, and patient-centered care. Regulatory frameworks and ethical guidelines in geriatric medicine consistently advocate for such comprehensive, team-based approaches to address the multifaceted needs of older adults. This ensures that all aspects of a patient’s physical, cognitive, social, and emotional well-being are considered, leading to more effective and dignified care. Incorrect Approaches Analysis: One incorrect approach involves relying solely on a single discipline, such as nursing staff, to manage all aspects of care and efficiency metrics without adequate input from geriatric specialists. This fails to leverage the unique expertise required for complex geriatric cases, potentially leading to missed diagnoses, inappropriate treatment, or a lack of consideration for the patient’s overall functional status and quality of life. It violates the principle of specialized geriatric care. Another incorrect approach is to implement standardized, protocol-driven interventions without sufficient individual patient assessment and adaptation. While protocols can be useful, rigid adherence in geriatric medicine can be harmful, as older adults rarely fit neatly into predefined categories. This approach disregards the heterogeneity of the geriatric population and the need for personalized care, potentially leading to suboptimal outcomes or adverse events. It overlooks the advanced practice standard of tailoring interventions to individual needs. A third incorrect approach is to prioritize cost-saving measures over patient needs, such as reducing staffing levels or limiting access to essential supportive services like physical therapy or social work. This approach is ethically unsound and professionally unacceptable as it directly compromises patient safety and well-being. It prioritizes financial efficiency over the fundamental duty of care and the specific needs of geriatric patients, who often rely heavily on these supportive services for maintaining independence and quality of life. Professional Reasoning: Professionals should employ a decision-making framework that begins with a thorough understanding of the patient’s individual needs, preferences, and goals. This should be followed by a comprehensive assessment utilizing validated geriatric tools and involving the patient and their family or caregivers. The next step is to engage the interdisciplinary team to develop a collaborative, patient-centered care plan that addresses all identified needs. Finally, ongoing monitoring and evaluation of the care plan are crucial, with flexibility to adapt interventions based on the patient’s evolving condition and response to treatment, always prioritizing patient well-being and dignity over purely efficiency-driven metrics.

This scenario is professionally challenging due to the inherent conflict between respecting a patient’s autonomy and ensuring their well-being, especially when cognitive impairment is suspected. The physician must navigate complex ethical principles, including beneficence, non-maleficence, and respect for autonomy, while adhering to legal and professional guidelines regarding capacity assessment and informed consent. The urgency of the situation, potentially involving a serious health risk, adds further pressure to the decision-making process. The best approach involves a systematic and documented assessment of the patient’s capacity to make decisions regarding their treatment. This entails evaluating their ability to understand the information presented, appreciate the consequences of their choices, reason through the options, and communicate their decision. If the patient is deemed to have capacity, their wishes, even if seemingly unwise to the clinician, must be respected, provided they do not harm others. If capacity is lacking, the physician must act in the patient’s best interests, which may involve seeking a surrogate decision-maker or, in urgent situations, proceeding with necessary treatment based on established clinical judgment and legal frameworks for incapacitated individuals. This aligns with the ethical imperative to act in the patient’s best interest while respecting their previously expressed wishes or values if known. An approach that immediately overrides the patient’s stated preference without a formal capacity assessment is ethically flawed. It disrespects patient autonomy and could lead to legal challenges if the patient is later found to have had capacity. Similarly, delaying necessary treatment due to a lack of immediate consensus on capacity, when the patient’s condition is deteriorating, could violate the principle of beneficence and potentially cause harm. Proceeding with treatment without attempting to involve the patient or their designated surrogate, even if capacity is questionable, bypasses crucial steps in ethical and legal decision-making. Professionals should employ a structured decision-making framework that prioritizes a thorough capacity assessment. This framework should include: 1) gathering information about the patient’s condition and proposed treatment; 2) assessing the patient’s understanding, appreciation, reasoning, and communication abilities; 3) documenting the assessment and its findings; 4) if capacity is present, obtaining informed consent; 5) if capacity is lacking, identifying and consulting with a surrogate decision-maker or acting in the patient’s best interests according to legal and ethical guidelines.

Scenario Analysis: This scenario is professionally challenging because it requires a nuanced understanding of the purpose and eligibility criteria for a specialized competency assessment. Misinterpreting these can lead to inappropriate applications, wasted resources, and potentially hinder the development of essential geriatric medicine expertise. The professional must balance the individual’s aspirations with the assessment’s intended scope and the broader goals of improving geriatric care. Correct Approach Analysis: The best approach involves a thorough review of the official documentation outlining the Critical Global Geriatric Medicine Competency Assessment. This documentation will detail the specific objectives of the assessment, such as identifying practitioners with advanced skills in managing complex geriatric conditions, promoting evidence-based practices, and fostering leadership in the field. It will also clearly define the eligibility criteria, which might include specific years of experience in geriatric medicine, prior certifications, or demonstrated contributions to the field. By aligning the individual’s profile and career goals with these documented requirements, the professional can accurately determine if the assessment is a suitable and appropriate next step. This aligns with the ethical principle of acting in the best interest of the individual while upholding the integrity and purpose of the assessment. Incorrect Approaches Analysis: One incorrect approach is to assume eligibility based solely on a general interest in geriatric medicine or a desire for professional advancement without verifying specific criteria. This fails to respect the defined purpose of the assessment, which is not a general professional development tool but a specific evaluation of advanced competencies. It can lead to individuals undertaking the assessment who are not adequately prepared or whose participation does not serve the assessment’s intended outcomes. Another incorrect approach is to base eligibility on anecdotal evidence or the experiences of colleagues who may have undergone similar, but not identical, assessments. This bypasses the official regulatory framework and guidelines governing this particular competency assessment. Relying on informal information can lead to significant misunderstandings of the assessment’s scope, prerequisites, and intended beneficiaries, potentially resulting in a misallocation of resources and a failure to meet the assessment’s objectives. A further incorrect approach is to prioritize the individual’s perceived need for the assessment over the established eligibility requirements, believing that any experience in geriatrics warrants consideration. This disregards the critical function of competency assessments in ensuring a standardized level of expertise and may undermine the credibility of the assessment process. It fails to acknowledge that specialized assessments are designed for a specific cohort of practitioners who have met predefined benchmarks. Professional Reasoning: Professionals should employ a systematic decision-making framework when evaluating an individual’s suitability for a specialized competency assessment. This framework should begin with clearly identifying the purpose and scope of the assessment by consulting official regulatory documents and guidelines. Next, the professional should meticulously assess the individual’s qualifications, experience, and career aspirations against these defined criteria. A critical step involves a direct comparison, highlighting any potential gaps or areas of alignment. Finally, the professional should provide clear, evidence-based guidance, explaining the rationale behind their recommendation, whether it be to proceed with the application, seek further experience, or consider alternative development pathways. This ensures transparency, fairness, and adherence to the established professional standards.

The monitoring system demonstrates a subtle decline in Mrs. Gable’s mobility and an increase in her reported pain levels over the past month. This scenario is professionally challenging because it requires a nuanced approach to diagnostic reasoning and imaging selection in an elderly patient, balancing the need for accurate diagnosis with the potential risks and benefits of investigations. Geriatric patients often present with atypical symptoms, multiple comorbidities, and a higher susceptibility to adverse effects from diagnostic procedures. Therefore, a systematic and evidence-based approach is crucial. The best professional practice involves a comprehensive clinical assessment that prioritizes non-invasive methods and considers the patient’s overall functional status and goals of care before resorting to advanced imaging. This approach begins with a thorough history, including detailed pain characterization and functional assessment, followed by a focused physical examination. Based on these findings, the clinician should then judiciously select the most appropriate imaging modality, considering factors such as diagnostic yield, radiation exposure, cost, and patient tolerance. For Mrs. Gable, this might involve initial plain radiography to assess for degenerative changes or fractures, followed by ultrasound for soft tissue assessment if indicated, or MRI if neurological involvement is suspected and the benefits outweigh the risks. This aligns with ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as professional guidelines that advocate for a stepwise, least invasive diagnostic pathway. An incorrect approach would be to immediately order a CT scan of the lumbar spine without a thorough clinical evaluation. This fails to consider the potential for significant radiation exposure in an elderly patient, which increases their vulnerability to long-term effects. It also bypasses less invasive and potentially equally diagnostic methods, violating the principle of proportionality in diagnostic workups. Another incorrect approach would be to rely solely on the patient’s subjective report of pain and delay any further investigation, assuming it is a natural part of aging. This neglects the clinician’s duty to investigate potentially treatable causes of pain and functional decline, potentially leading to missed diagnoses and prolonged suffering, which is a failure of the duty of care. A further incorrect approach would be to order an MRI of the entire spine without a clear clinical indication for specific regions. This is inefficient, costly, and exposes the patient to potential incidental findings that may not be clinically relevant, leading to unnecessary anxiety and further investigations. It also fails to demonstrate judicious resource utilization. Professionals should employ a decision-making framework that begins with a clear understanding of the patient’s presenting problem and their overall health status. This involves gathering comprehensive clinical data, formulating differential diagnoses, and then systematically evaluating the diagnostic utility and risks of various investigations. The framework should prioritize non-invasive and low-risk options first, escalating to more complex or invasive investigations only when clinically justified and when the potential benefits clearly outweigh the risks. This iterative process ensures that diagnostic decisions are patient-centered, evidence-based, and ethically sound.

This scenario is professionally challenging due to the complex interplay of a patient’s declining functional status, multiple comorbidities, and the need for a coordinated, evidence-based approach to care that respects patient autonomy and resource allocation. Geriatric patients often present with atypical symptoms, polypharmacy, and a higher risk of adverse events, necessitating a nuanced decision-making process. The core challenge lies in balancing immediate symptom management with long-term functional preservation and quality of life, all within the framework of established medical guidelines and ethical considerations. The best approach involves a comprehensive geriatric assessment to identify all contributing factors to the patient’s acute decline and to establish a baseline for future management. This assessment should integrate input from the patient, family, and a multidisciplinary team (e.g., physicians, nurses, therapists, social workers). Following this, a personalized, evidence-based care plan should be developed, prioritizing interventions that are most likely to improve the patient’s functional status and quality of life, while also considering the potential risks and benefits of each intervention. This plan should be regularly reviewed and adjusted based on the patient’s response and evolving needs. This aligns with the principles of patient-centered care, promoting shared decision-making and ensuring that interventions are tailored to the individual’s goals and preferences, as advocated by professional medical bodies and ethical guidelines emphasizing holistic care for older adults. An approach that focuses solely on aggressive pharmacological management of individual symptoms without a holistic assessment risks exacerbating polypharmacy and leading to iatrogenic harm. This fails to address the underlying geriatric syndromes that may be contributing to the patient’s decline and neglects the importance of functional assessment and patient-reported outcomes. Another incorrect approach would be to defer all major decisions to the patient’s family without ensuring the patient’s own voice and preferences are adequately considered, especially if the patient retains some capacity for decision-making. This can lead to care that is not aligned with the patient’s wishes and may not be in their best interest, potentially violating principles of autonomy and informed consent. A third unacceptable approach would be to limit interventions based on assumptions about the patient’s prognosis or quality of life without a thorough assessment and discussion with the patient and their family. This can lead to premature withdrawal of potentially beneficial care and does not reflect the dynamic nature of geriatric health, where functional status can often be improved with appropriate management. Professionals should employ a systematic decision-making framework that begins with a comprehensive assessment, followed by the development of a multidisciplinary, evidence-based care plan. This plan should prioritize patient-centered goals, involve shared decision-making, and include mechanisms for ongoing monitoring and adjustment. The framework should also consider the ethical principles of beneficence, non-maleficence, autonomy, and justice in all aspects of care planning and delivery.

This scenario presents a professional challenge because it requires balancing the need for standardized assessment with the unique learning needs and circumstances of individual geriatric medicine trainees. The blueprint weighting, scoring, and retake policies are critical components of ensuring competency, but their rigid application without consideration for individual factors can lead to unfair outcomes and potentially hinder the development of skilled geriatricians. Careful judgment is required to uphold assessment integrity while also fostering a supportive learning environment. The best professional approach involves a transparent and consistently applied policy that allows for reasonable accommodations and appeals, grounded in principles of fairness and due process. This approach acknowledges that while standardized assessment is essential, exceptional circumstances may warrant review. It aligns with the ethical imperative to assess fairly and to support trainees in achieving competency. Such a policy would typically outline clear criteria for appeals, the process for review, and the potential outcomes, ensuring that decisions are based on objective evidence and established guidelines, rather than arbitrary discretion. This promotes trust in the assessment process and supports the development of competent practitioners. An incorrect approach would be to rigidly adhere to the stated retake policy without any provision for appeal or consideration of extenuating circumstances. This fails to acknowledge that unforeseen events, such as serious illness or personal emergencies, can significantly impact a trainee’s performance on an assessment, irrespective of their underlying knowledge or skill. Ethically, this approach can be seen as punitive and lacking in compassion, potentially leading to the disqualification of otherwise capable individuals. It also undermines the principle of equitable assessment by not accounting for factors beyond the trainee’s control. Another incorrect approach would be to allow for ad-hoc, subjective adjustments to scoring or retake eligibility based on personal relationships or perceived effort, without a defined policy. This introduces bias and inconsistency into the assessment process, eroding its credibility. It violates principles of fairness and equal treatment, as different trainees might receive different considerations for similar situations. Such an approach is ethically problematic as it can lead to perceptions of favoritism and can compromise the integrity of the entire competency assessment framework. A further incorrect approach would be to implement a policy that makes retakes excessively difficult or impossible to obtain, even for trainees who narrowly fail an assessment and demonstrate a clear commitment to improvement. This can create an insurmountable barrier to certification, even for individuals who possess the foundational knowledge and skills required for geriatric medicine practice. It prioritizes a strict adherence to policy over the ultimate goal of ensuring a sufficient pool of competent geriatricians, potentially leading to a shortage of qualified professionals. Professionals should employ a decision-making framework that prioritizes fairness, transparency, and evidence-based practice. This involves understanding the rationale behind assessment policies, recognizing the potential for individual variation, and establishing clear procedures for addressing exceptions. When faced with a situation requiring a decision on a trainee’s assessment outcome, professionals should consult relevant guidelines, consider all available evidence, and apply policies consistently and equitably, while also being prepared to advocate for reasonable accommodations when justified by objective circumstances.

The control framework reveals that preparing for the Critical Global Geriatric Medicine Competency Assessment requires a strategic and resource-informed approach. This scenario is professionally challenging because candidates often face time constraints, varying levels of prior knowledge, and the need to synthesize information from diverse global geriatric medicine contexts. Careful judgment is required to select preparation methods that are both effective and efficient, ensuring comprehensive coverage of the assessment’s scope without unnecessary expenditure of time or resources. The best approach involves a structured, multi-modal preparation strategy that prioritizes foundational knowledge acquisition, active learning, and exposure to diverse global perspectives. This includes utilizing a combination of reputable textbooks, peer-reviewed journals, and official assessment guidelines. Crucially, it necessitates engaging with case studies and practice questions that reflect the global nature of geriatric medicine, thereby reinforcing understanding and application of competencies. This method is correct because it aligns with the principles of adult learning, which emphasize active engagement and application of knowledge. It also directly addresses the “Global” aspect of the assessment by encouraging exposure to varied clinical scenarios and healthcare systems, a key competency for international practice. Furthermore, it promotes a systematic understanding of the assessment’s learning objectives, ensuring that preparation is targeted and comprehensive. An approach that solely relies on reviewing past examination papers without understanding the underlying principles is professionally unacceptable. This fails to build a robust foundation of knowledge and can lead to rote memorization rather than true competency. It neglects the critical need to understand the ‘why’ behind clinical decisions, which is essential for adapting to novel situations encountered in global geriatric medicine. Such a method also risks overlooking emerging best practices and research not reflected in older papers. Another professionally unacceptable approach is to focus exclusively on a single, highly specialized area of geriatric medicine, assuming it will cover the breadth of the assessment. This demonstrates a misunderstanding of the comprehensive nature of global geriatric medicine competencies. It creates significant knowledge gaps in other essential areas, such as palliative care, ethical considerations in diverse cultural contexts, or the management of common geriatric syndromes across different healthcare settings. Finally, an approach that prioritizes informal learning through anecdotal discussions with colleagues without structured study is also professionally deficient. While peer discussion can be valuable, it lacks the rigor and systematic coverage required for a competency assessment. It is prone to biases, misinformation, and an incomplete understanding of evidence-based practices. This method fails to ensure that all required competencies are addressed systematically and accurately. Professionals should adopt a decision-making framework that begins with a thorough review of the assessment’s official syllabus and learning objectives. This should be followed by an honest self-assessment of existing knowledge gaps. Based on this, a personalized study plan should be developed, incorporating a variety of high-quality resources and active learning techniques. Regular self-testing and seeking feedback are crucial components of this iterative process, ensuring continuous improvement and readiness for the assessment.

Scenario Analysis: This scenario is professionally challenging due to the inherent complexity of geriatric care, which often involves multiple comorbidities, polypharmacy, and potential cognitive impairment. The patient’s daughter’s insistence on a specific treatment, despite the physician’s clinical judgment, introduces an ethical and communication challenge. Balancing patient autonomy (or surrogate decision-maker autonomy when the patient lacks capacity), beneficence, and non-maleficence requires careful navigation. The physician must act in the patient’s best interest while respecting the family’s concerns and ensuring appropriate medical care. Correct Approach Analysis: The best professional practice involves a comprehensive assessment of the patient’s current clinical status, including their functional capacity, cognitive function, and overall prognosis, in conjunction with a thorough review of their existing medical conditions and current medications. This approach prioritizes evidence-based geriatric care principles and patient-centered decision-making. It involves open and empathetic communication with the patient (if capable) and their daughter, explaining the rationale behind the proposed treatment plan, addressing concerns, and exploring alternative options that align with the patient’s values and goals of care. This aligns with the ethical principles of beneficence (acting in the patient’s best interest) and respect for autonomy (or surrogate decision-making). Incorrect Approaches Analysis: One incorrect approach involves immediately deferring to the daughter’s request without a thorough independent assessment. This fails to uphold the physician’s primary duty of care to the patient and risks providing inappropriate or potentially harmful treatment, violating the principle of non-maleficence. It also bypasses the crucial step of evaluating the patient’s individual needs and risks. Another incorrect approach is to dismiss the daughter’s concerns outright and proceed with a treatment plan without adequately addressing her perspective or explaining the medical reasoning. This can lead to a breakdown in the therapeutic relationship, erode trust, and potentially result in non-adherence to the treatment plan, ultimately not serving the patient’s best interests. It neglects the importance of shared decision-making and family involvement in geriatric care. A third incorrect approach is to focus solely on the patient’s immediate symptoms without considering the broader context of their geriatric health, including potential side effects of the requested treatment in the context of polypharmacy or underlying frailty. This narrow focus can lead to suboptimal care and may not address the root causes of the patient’s condition or their overall well-being. Professional Reasoning: Professionals should employ a structured decision-making framework that begins with a comprehensive patient assessment, incorporating both objective clinical data and subjective patient/family input. This is followed by identifying potential treatment options, evaluating their risks and benefits in the specific geriatric context, and engaging in shared decision-making with the patient and their surrogate. Open, honest, and empathetic communication is paramount throughout this process, ensuring all parties understand the rationale and implications of the chosen course of action.

Scenario Analysis: This scenario presents a professional challenge due to the inherent complexity of geriatric medicine, where multiple comorbidities, polypharmacy, and age-related physiological changes can obscure the underlying pathology. Differentiating between primary disease processes and age-related functional decline, or identifying how these interact, requires a sophisticated understanding of both basic science and clinical presentation. The risk of misdiagnosis or delayed diagnosis is high, potentially leading to suboptimal treatment, increased morbidity, and reduced quality of life for the patient. Careful judgment is required to synthesize diverse information and arrive at an accurate and timely diagnosis. Correct Approach Analysis: The best professional practice involves a comprehensive approach that systematically integrates foundational biomedical sciences with the patient’s clinical presentation. This means considering the pathophysiology of potential diseases at a molecular and cellular level (e.g., understanding the mechanisms of neurodegeneration in Alzheimer’s disease, or the inflammatory pathways in rheumatoid arthritis) and then correlating this knowledge with the patient’s reported symptoms, physical examination findings, and diagnostic test results. For instance, understanding the altered pharmacokinetics and pharmacodynamics of medications in older adults is crucial when evaluating a patient presenting with new-onset confusion, rather than solely attributing it to a primary neurological condition. This integrated approach ensures that the diagnosis is not just descriptive but also explanatory, leading to more targeted and effective management. Incorrect Approaches Analysis: Focusing solely on the patient’s presenting symptoms without a deep understanding of the underlying biomedical mechanisms risks superficial diagnosis. For example, attributing fatigue in an elderly patient solely to “old age” without investigating potential biomedical causes like anemia (due to impaired erythropoiesis or chronic disease) or endocrine dysfunction (like hypothyroidism) is a failure to apply foundational knowledge. Another incorrect approach is to over-rely on diagnostic imaging or laboratory tests without critically appraising their relevance in the context of the patient’s overall clinical picture and age-related physiological changes. For instance, interpreting incidental findings on an MRI without considering their likelihood of being clinically significant in an elderly individual, or attributing abnormal lab values to disease without considering how age itself can alter reference ranges or metabolic processes, can lead to misdiagnosis or unnecessary interventions. Finally, approaching the case by treating each symptom in isolation without seeking an overarching unifying diagnosis that integrates biomedical principles with the clinical presentation is also professionally unsound. This fragmented approach can lead to polypharmacy and a failure to address the root cause of the patient’s decline. Professional Reasoning: Professionals should employ a systematic diagnostic process that begins with a thorough history and physical examination, followed by hypothesis generation based on foundational biomedical knowledge. Diagnostic investigations should be chosen judiciously to confirm or refute these hypotheses, always considering the patient’s age and comorbidities. The interpretation of all data must be integrated, linking basic science principles to clinical observations to arrive at a comprehensive and accurate diagnosis. This iterative process of hypothesis, investigation, and integration is key to effective geriatric medicine.

This scenario presents a significant professional challenge due to the inherent conflict between a patient’s expressed wishes, their perceived capacity, and the clinician’s ethical and legal obligations to ensure patient well-being and safety. The core tension lies in balancing patient autonomy with the duty of beneficence and non-maleficence, particularly when a patient’s decision-making capacity is in question. Careful judgment is required to navigate these complex ethical and legal waters, ensuring that any intervention respects the patient’s dignity while upholding professional standards. The best approach involves a systematic and documented assessment of the patient’s capacity to make decisions regarding their care. This includes clearly explaining the proposed treatment, its benefits, risks, and alternatives in a way the patient can understand, and then assessing their ability to weigh this information and communicate a choice. If capacity is confirmed, their informed consent must be obtained and respected, even if it differs from the clinician’s recommendation. This aligns with fundamental ethical principles of autonomy and informed consent, as well as legal frameworks that mandate patient involvement in their healthcare decisions. The process must be thoroughly documented, including the assessment of capacity, the information provided, and the patient’s expressed wishes. An approach that proceeds with treatment without a formal capacity assessment, assuming the patient understands and agrees based on past behavior or the clinician’s judgment, is ethically and legally flawed. It undermines patient autonomy and the principle of informed consent, potentially leading to treatment without genuine agreement. Similarly, overriding the patient’s stated refusal of treatment based solely on the clinician’s belief that it is “best” for the patient, without a rigorous capacity assessment and exploration of the patient’s reasoning, violates their right to self-determination and can be considered paternalistic. Finally, immediately involving family members to make decisions without first assessing the patient’s capacity and exploring their own decision-making process is premature and disrespects the patient’s primary right to consent or refuse. Professionals should employ a decision-making framework that prioritizes a thorough capacity assessment. This involves: 1) establishing rapport and clear communication, 2) providing information in an understandable format, 3) assessing the patient’s comprehension and ability to deliberate, 4) documenting the findings meticulously, and 5) if capacity is lacking, following established protocols for substitute decision-making, which may involve family or legal guardians, but only after the patient’s own capacity has been formally determined to be impaired.