Scenario Analysis: This scenario presents a professional challenge due to the inherent risks and evolving nature of Natural Orifice Transluminal Endoscopic Surgery (NOTES) procedures. The surgeon must balance patient safety, the potential benefits of a less invasive approach, and the need for robust informed consent, especially when the procedure is novel or has limited established protocols. The ethical imperative to act in the patient’s best interest, coupled with the legal and professional obligations to ensure adequate understanding and consent, requires careful judgment. Correct Approach Analysis: The best professional practice involves a comprehensive discussion with the patient and their family, detailing the experimental nature of the NOTES procedure, outlining potential benefits and risks that may differ from traditional surgery, and clearly explaining the available alternatives, including their respective risks and benefits. This approach ensures that the patient can make a truly informed decision based on a complete understanding of the procedure’s current standing, potential outcomes, and the rationale for choosing NOTES over established methods. This aligns with the fundamental ethical principles of autonomy and beneficence, and the legal requirement for informed consent, which mandates that patients understand the nature, purpose, risks, and alternatives of any proposed medical intervention. Incorrect Approaches Analysis: Proceeding with the NOTES procedure after a brief overview of its general benefits, without thoroughly explaining its experimental status and potential unique risks compared to conventional surgery, fails to meet the standard for informed consent. This approach violates the patient’s autonomy by not providing them with the necessary information to make a truly voluntary and informed choice. It also potentially exposes the patient to unforeseen complications without their full comprehension. Opting for a traditional surgical approach solely because the NOTES procedure is less familiar, without a thorough discussion of the potential benefits of NOTES and the patient’s specific circumstances, may not be in the patient’s best interest. While risk-averse, this approach may deny the patient access to a potentially less morbid or faster recovery option, thereby potentially failing the principle of beneficence if NOTES is demonstrably a viable and potentially superior option for this specific patient. Performing the NOTES procedure without obtaining explicit consent for an experimental intervention, even if the patient generally agrees to surgery, is ethically and legally unacceptable. This constitutes a breach of trust and a violation of the patient’s right to self-determination. It bypasses the critical step of ensuring the patient understands and accepts the specific risks and uncertainties associated with a novel technique. Professional Reasoning: Professionals facing such decisions should employ a framework that prioritizes patient autonomy and safety. This involves a thorough assessment of the patient’s condition and suitability for various treatment options, including novel ones. A detailed, transparent, and honest communication process is paramount, ensuring the patient understands the procedure, its risks, benefits, alternatives, and its current standing in medical practice. When dealing with experimental or less established procedures, the emphasis on informed consent must be heightened, ensuring no ambiguity exists regarding the patient’s understanding and acceptance of the associated uncertainties.

The control framework reveals a scenario where a surgeon must interpret complex physiological data to guide therapeutic decisions, highlighting the challenge of translating intricate biological processes into actionable clinical management. This requires not only a deep understanding of gastrointestinal physiology but also the ability to integrate this knowledge with patient-specific factors and established best practices. The professional challenge lies in the potential for misinterpretation of subtle physiological cues, leading to suboptimal or even harmful interventions. The best approach involves a comprehensive assessment of the patient’s overall clinical presentation, integrating the observed physiological parameters with the patient’s history, physical examination findings, and other diagnostic data. This holistic view allows for a nuanced understanding of the underlying pathophysiology and guides the selection of the most appropriate management strategy. This approach is correct because it aligns with the fundamental principles of evidence-based medicine and patient-centered care, emphasizing the need to consider all relevant information before making a clinical decision. It reflects a commitment to thoroughness and accuracy in diagnosis and treatment planning, which is ethically mandated. An incorrect approach would be to solely focus on a single physiological parameter, such as a specific enzyme level, without considering its context within the broader clinical picture. This narrow focus risks misinterpreting the significance of that parameter, potentially leading to an incorrect diagnosis or an inappropriate treatment plan. Such an approach fails to acknowledge the interconnectedness of physiological systems and the multifactorial nature of many gastrointestinal conditions, thereby deviating from established medical standards and potentially compromising patient safety. Another incorrect approach would be to rely on anecdotal evidence or personal experience without corroborating it with current scientific understanding and established clinical guidelines. While experience is valuable, it should inform, not replace, a systematic and evidence-based decision-making process. Basing decisions on insufficient or outdated information can lead to suboptimal outcomes and represents a failure to uphold the professional responsibility to provide the highest standard of care. Professionals should employ a decision-making framework that begins with a thorough review of all available patient data, including physiological measurements, clinical history, and physical examination. This should be followed by a critical appraisal of the current scientific literature and relevant clinical guidelines pertaining to the patient’s presentation. Finally, the surgeon should synthesize this information to formulate a differential diagnosis and develop a personalized management plan, continuously reassessing as new information becomes available.

The control framework reveals a complex clinical scenario requiring careful consideration of patient autonomy, physician responsibility, and the ethical implications of treatment decisions regarding colonic motility disorders. The professional challenge lies in balancing the patient’s expressed desire for a specific, potentially unproven or high-risk intervention with the surgeon’s duty to provide evidence-based, safe, and effective care. This requires a deep understanding of the current evidence base for motility disorders and the potential consequences of interventions. The best approach involves a thorough, multidisciplinary evaluation and a shared decision-making process grounded in established medical ethics and professional guidelines. This includes a comprehensive diagnostic workup to precisely define the nature and severity of the motility disorder, followed by a detailed discussion with the patient about all available treatment options. These options should encompass conservative management, established surgical interventions with known efficacy and risk profiles, and experimental or investigational therapies, clearly outlining the risks, benefits, and uncertainties associated with each. The surgeon must ensure the patient fully comprehends the information, allowing for an informed decision that aligns with their values and goals, while also adhering to the surgeon’s professional obligations to avoid harm and provide appropriate care. This aligns with the principles of beneficence, non-maleficence, and respect for patient autonomy, as emphasized by professional medical bodies and ethical codes. An approach that prioritizes the patient’s stated preference for a specific, unproven surgical technique without adequate exploration of alternatives or a thorough risk-benefit analysis is ethically unsound. This fails to uphold the surgeon’s duty of care and could lead to patient harm if the chosen intervention is ineffective or carries significant risks not fully understood by the patient. Similarly, dismissing the patient’s concerns and proceeding with a standard, but potentially suboptimal, treatment without engaging in a shared decision-making process disregards patient autonomy and can erode trust. Furthermore, recommending a treatment based solely on anecdotal evidence or personal experience, without robust scientific backing and without transparently communicating the limitations of such evidence, constitutes a failure to adhere to evidence-based medical practice and professional standards. Professionals should employ a systematic decision-making framework that begins with a comprehensive assessment of the patient’s condition. This is followed by an open and honest dialogue with the patient, exploring their understanding, values, and preferences. The surgeon then presents all viable treatment options, supported by the best available evidence, clearly articulating the potential outcomes, risks, and benefits of each. The decision is then collaboratively made, ensuring the patient’s informed consent is obtained. This process prioritizes patient well-being, ethical conduct, and adherence to professional standards of care.

This scenario is professionally challenging because it requires balancing the immediate need for diagnostic information with the potential for patient harm and the ethical obligation to obtain informed consent. The surgeon must consider the secretory functions of the colon, specifically the potential for fluid and electrolyte shifts, and how this might impact the patient’s overall condition and the safety of the proposed intervention. Careful judgment is required to determine the most appropriate course of action that prioritizes patient well-being and adheres to established medical standards. The best professional approach involves a thorough pre-operative assessment that specifically addresses the patient’s hydration status and electrolyte balance, considering the known secretory functions of the colon. This includes reviewing recent fluid intake, output, and any relevant laboratory values. Based on this assessment, the surgeon should then discuss the findings and the proposed surgical intervention with the patient, clearly explaining the risks, benefits, and alternatives, including the potential impact of altered colonic secretion on the procedure and recovery. This ensures informed consent is obtained and that the patient’s physiological state is optimized for surgery. This approach aligns with the fundamental ethical principles of beneficence, non-maleficence, and respect for patient autonomy, as well as the standard of care in surgical practice. An incorrect approach would be to proceed with surgery without adequately assessing the patient’s fluid and electrolyte status. This fails to acknowledge the significant role of colonic secretory functions in maintaining homeostasis and could lead to intraoperative or postoperative complications such as dehydration, electrolyte imbalances, or impaired wound healing. This approach violates the principle of non-maleficence by exposing the patient to unnecessary risks. Another incorrect approach would be to delay surgery indefinitely due to minor, correctable electrolyte abnormalities without attempting to optimize the patient’s condition. While caution is warranted, an overly conservative stance that deprives the patient of necessary surgical intervention, when the risks can be mitigated through appropriate management, is not in the patient’s best interest and could be considered a failure of beneficence. Proceeding with surgery while solely relying on intraoperative fluid management without a pre-operative assessment of the patient’s baseline secretory status is also professionally unsound. While intraoperative monitoring is crucial, it should supplement, not replace, a comprehensive pre-operative evaluation that accounts for the patient’s physiological state, including the potential impact of colonic secretory functions. This approach neglects a critical aspect of pre-operative optimization and increases the likelihood of unforeseen complications. The professional reasoning process should involve a systematic evaluation of the patient’s clinical presentation, considering the specific physiological implications of the condition being treated and the known functions of the involved organ system. This includes a detailed history, physical examination, and appropriate diagnostic tests. The surgeon must then weigh the risks and benefits of various management strategies, always prioritizing patient safety and informed decision-making.

This scenario presents a professionally challenging situation due to the inherent unpredictability of anatomical variations and congenital anomalies in surgical patients. The surgeon must balance the need for definitive treatment with the potential for unexpected intraoperative findings that could compromise patient safety or lead to suboptimal outcomes. Careful judgment is required to anticipate, identify, and manage these variations effectively, ensuring the patient receives the highest standard of care. The best professional practice involves a comprehensive preoperative assessment that includes a thorough review of imaging studies to identify potential anatomical variations or congenital anomalies. This approach allows for meticulous surgical planning, including the anticipation of potential difficulties and the preparation of necessary equipment or alternative strategies. When an anomaly is encountered during surgery, the surgeon should proceed with caution, utilizing their knowledge of embryology and anatomy to navigate the situation safely. If the anomaly significantly alters the planned procedure or poses an unacceptable risk, the surgeon should be prepared to modify the surgical approach or, in rare cases, abort the procedure to ensure patient safety. 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 standard of care that mandates thorough preparation and adaptive surgical technique. Proceeding with the planned surgery without adequately considering the identified anatomical variation is professionally unacceptable. This approach demonstrates a failure to adequately assess risk and a disregard for potential intraoperative complications. It violates the principle of non-maleficence by potentially exposing the patient to unnecessary harm due to unforeseen anatomical challenges. Assuming the anomaly is insignificant and proceeding without any modification to the surgical plan, while still performing the intended procedure, is also professionally unacceptable. Even if the anomaly appears minor, it could have implications for surgical access, instrument manipulation, or the integrity of surrounding structures. This approach neglects the potential for subtle but significant impacts on the surgical field and patient safety, failing to uphold the standard of meticulous surgical practice. Relying solely on intraoperative discovery and improvisation without prior consideration of known anatomical variations is professionally unacceptable. While surgeons are trained to adapt, a failure to proactively investigate and plan for known or suspected anomalies represents a lapse in due diligence and thorough preoperative preparation, potentially increasing operative time, complication rates, and patient morbidity. The professional reasoning framework for similar situations should involve a systematic approach: 1. Thorough preoperative evaluation, including detailed review of all imaging and patient history. 2. Development of a primary surgical plan, with contingency plans for anticipated variations. 3. Intraoperative vigilance, with continuous reassessment of the surgical field and patient status. 4. Adaptability and sound judgment in modifying or aborting the procedure if necessary to ensure patient safety.

The control framework reveals a scenario where a surgeon must precisely identify the autonomic innervation of the colon and rectum to ensure the preservation of vital physiological functions during a complex pelvic dissection. This is professionally challenging because damage to specific nerve plexuses can lead to significant and potentially irreversible functional deficits, such as altered bowel motility, fecal incontinence, or sexual dysfunction. The surgeon’s judgment is critical in navigating anatomical variations and minimizing iatrogenic injury. The correct approach involves a thorough understanding of the sympathetic and parasympathetic innervation of the distal gastrointestinal tract. Specifically, the surgeon must recognize that the hypogastric plexus (superior and inferior) and the pelvic splanchnic nerves (sacral outflow) are paramount. The hypogastric plexus carries sympathetic fibers that generally inhibit colonic activity and facilitate rectal continence, while the pelvic splanchnic nerves carry parasympathetic fibers that stimulate colonic motility and rectal relaxation for defecation. Preserving these pathways, particularly the parasympathetic fibers responsible for defecation and the sympathetic fibers contributing to continence, is essential for maintaining postoperative bowel function. This approach aligns with the ethical principle of beneficence, aiming to maximize patient benefit and minimize harm, and the principle of non-maleficence, avoiding unnecessary injury. It also reflects the professional standard of care, which mandates a comprehensive knowledge of surgical anatomy and its functional implications. An incorrect approach would be to broadly ligate or resect any visible nerve structures in the pelvic region without specific identification of their origin and function. This fails to acknowledge the distinct roles of the sympathetic and parasympathetic systems in bowel control. Such an action would violate the principle of non-maleficence by causing indiscriminate harm and would fall below the professional standard of care due to a lack of precise anatomical knowledge and surgical technique. Another incorrect approach would be to prioritize the preservation of only one component of the autonomic innervation, for example, solely focusing on preserving parasympathetic fibers while disregarding the sympathetic supply. This would lead to an imbalance in autonomic control, potentially resulting in impaired continence mechanisms despite preserved motility. This approach demonstrates a superficial understanding of the integrated autonomic control of the colon and rectum and fails to uphold the principle of beneficence by not aiming for the best possible functional outcome. A third incorrect approach would be to rely solely on intraoperative neuromonitoring without a pre-operative understanding of the relevant nerve pathways. While neuromonitoring is a valuable adjunct, it is not a substitute for fundamental anatomical knowledge. Without knowing which nerves are being monitored and their expected responses, the interpretation of monitoring data can be flawed, leading to potentially incorrect surgical decisions. This approach risks overlooking critical structures or misinterpreting signals, thereby compromising patient safety and functional outcomes. The professional reasoning framework for such situations involves a multi-step process: 1) Pre-operative planning: Thorough review of patient anatomy and potential surgical challenges, including a detailed understanding of the relevant neuroanatomy. 2) Intra-operative vigilance: Meticulous dissection, constant awareness of anatomical landmarks, and precise identification of neural structures. 3) Judicious application of adjuncts: Utilizing tools like neuromonitoring judiciously, informed by a strong anatomical foundation. 4) Decision-making based on functional preservation: Prioritizing the preservation of neural pathways critical for maintaining bowel function, continence, and other vital physiological processes.

The control framework reveals a common clinical dilemma in managing patients with inflammatory bowel disease (IBD) where the role of the gut microbiome is increasingly recognized but not fully understood in terms of direct therapeutic intervention. This scenario is professionally challenging because it requires balancing established treatment protocols with emerging scientific evidence, considering patient-specific factors, and navigating the ethical implications of off-label or experimental interventions. Careful judgment is required to avoid premature adoption of unproven therapies while remaining open to advancements that could significantly improve patient outcomes. The best professional approach involves a thorough, evidence-based assessment of the patient’s condition and a discussion of all available, approved treatment options, including those that may indirectly influence the microbiome. This includes considering the use of specific dietary interventions or probiotics that have demonstrated some level of efficacy or safety in managing IBD symptoms, within the context of established guidelines. The justification for this approach lies in adhering to the principles of evidence-based medicine, prioritizing patient safety, and ensuring that any treatment plan is aligned with current medical understanding and regulatory approvals. It respects the patient’s autonomy by providing comprehensive information about both proven and potential therapeutic avenues. An incorrect approach would be to recommend or administer fecal microbiota transplantation (FMT) as a primary treatment for IBD without robust clinical trial data supporting its efficacy and safety in this specific patient population, and without adhering to established protocols for its use, which are still evolving and often restricted to specific indications like recurrent Clostridioides difficile infection. This fails to meet the standard of care and exposes the patient to potential risks without a clear, evidence-based benefit for their IBD. Another incorrect approach is to dismiss the patient’s interest in microbiome-targeted therapies entirely, without exploring any potential adjunctive roles for diet or specific supplements that might have some scientific backing, even if not considered first-line treatments. This can lead to patient dissatisfaction and a breakdown in the therapeutic relationship, potentially causing the patient to seek unverified or harmful interventions outside of medical supervision. A further incorrect approach involves recommending unproven or experimental microbiome manipulation techniques without proper informed consent regarding their investigational nature, potential risks, and lack of established efficacy for IBD. This violates ethical principles of patient autonomy and beneficence, as it involves subjecting the patient to interventions that have not undergone rigorous scientific validation for their intended purpose. The professional reasoning framework for such situations should involve: 1) Comprehensive patient assessment, including disease severity, history, and previous treatments. 2) Thorough review of current, evidence-based guidelines for IBD management. 3) Evaluation of emerging research on the microbiome’s role in IBD, distinguishing between established knowledge and speculative findings. 4) Open and honest communication with the patient about treatment options, including their risks, benefits, and limitations, as well as the current state of scientific understanding regarding microbiome-based therapies. 5) Collaborative decision-making with the patient, respecting their values and preferences while ensuring that treatment plans are safe and medically sound.

Scenario Analysis: This scenario is professionally challenging because it requires the surgeon to balance immediate patient needs with the long-term implications of surgical intervention on a fundamental physiological process. The defecation reflex, while seemingly straightforward, involves complex neural and muscular coordination. Understanding the nuances of its disruption and the potential impact of surgical modifications is critical for optimal patient outcomes and avoiding iatrogenic complications. The surgeon must make a decision that prioritizes functional recovery and quality of life while addressing the immediate surgical indication. Correct Approach Analysis: The best approach involves a thorough preoperative assessment to identify the specific components of the defecation reflex that are compromised. This includes evaluating anorectal sensation, rectal compliance, anal sphincter function, and pelvic floor coordination. Based on this comprehensive understanding, the surgical plan should be tailored to address the underlying pathology while minimizing disruption to the neural pathways and muscular structures essential for normal defecation. This might involve techniques that preserve nerve function, reconstruct sphincter integrity, or optimize rectal capacity, always with the goal of restoring or improving the reflex arc. This approach aligns with the ethical principle of beneficence, ensuring that the intervention provides the greatest benefit to the patient by aiming for functional restoration. It also adheres to the principle of non-maleficence by actively seeking to avoid unnecessary harm to the defecation mechanism. Incorrect Approaches Analysis: One incorrect approach would be to proceed with a standard surgical procedure without a detailed preoperative assessment of the defecation reflex. This fails to acknowledge the specific functional deficits the patient may have and risks exacerbating them. It represents a failure in due diligence and could lead to postoperative incontinence or severe constipation, violating the principle of non-maleficence. Another incorrect approach would be to prioritize speed of surgical completion over meticulous preservation of neural and muscular structures involved in defecation. This might involve techniques that are technically easier but have a higher likelihood of damaging critical nerves or muscle fibers. Such an approach disregards the long-term functional consequences for the patient and is ethically unsound, as it prioritizes surgical expediency over patient well-being. A third incorrect approach would be to assume that all defecation reflex issues are similar and can be treated with a one-size-fits-all surgical solution. This ignores the individual variability in anatomy and physiology and the diverse etiologies of defecation disorders. It demonstrates a lack of personalized care and a failure to apply a nuanced understanding of the defecation reflex, potentially leading to suboptimal or detrimental outcomes. Professional Reasoning: Professionals should employ a systematic decision-making framework that begins with a comprehensive understanding of the patient’s specific defecation dysfunction. This involves detailed history, physical examination including anorectal manometry and potentially neurophysiological testing, and imaging. The surgeon should then consider all available surgical options, evaluating their potential benefits, risks, and impact on the defecation reflex. A multidisciplinary approach, involving gastroenterologists and pelvic floor physical therapists, can also be invaluable. The decision should be a shared one with the patient, ensuring they understand the implications of the chosen surgical strategy on their bowel function.

The control framework reveals a scenario demanding careful judgment due to the inherent complexity of managing a patient with a newly diagnosed, potentially aggressive colorectal malignancy, coupled with significant comorbidities that impact treatment tolerance and surgical risk. The challenge lies in balancing the urgency of oncological treatment with the patient’s overall health status and their informed preferences, necessitating a multidisciplinary and patient-centered approach. The best professional practice involves a comprehensive, multidisciplinary evaluation and shared decision-making process. This approach prioritizes a thorough assessment of the patient’s overall health, including a detailed review of their comorbidities and their impact on potential treatment modalities (surgery, chemotherapy, radiation). It necessitates open and honest communication with the patient and their family regarding all available treatment options, their risks, benefits, and expected outcomes, tailored to their specific clinical situation. Crucially, it involves integrating the expertise of various specialists (oncology, surgery, gastroenterology, anesthesia, palliative care) to formulate a consensus treatment plan that aligns with the patient’s values and goals of care. This aligns with ethical principles of beneficence, non-maleficence, and patient autonomy, as well as professional guidelines emphasizing evidence-based, individualized care. An approach that solely focuses on immediate surgical intervention without adequately assessing and managing the patient’s comorbidities or engaging in shared decision-making is professionally unacceptable. This failure to consider the patient’s overall health status could lead to increased perioperative morbidity and mortality, violating the principle of non-maleficence. Furthermore, proceeding without thorough patient discussion and consent disregards patient autonomy. Another professionally unacceptable approach is to defer definitive treatment indefinitely due to the patient’s comorbidities, without exploring all feasible options for optimizing their condition for treatment or considering palliative measures. This can lead to disease progression and missed opportunities for potentially curative or life-extending interventions, failing the principle of beneficence. Finally, an approach that relies solely on the opinion of a single specialist without broader multidisciplinary input risks overlooking critical aspects of the patient’s care and may not represent the most optimal or safest treatment strategy. This can lead to suboptimal outcomes and potentially compromise patient safety. The professional reasoning framework for such situations involves a systematic process: 1. Thoroughly assess the patient’s clinical condition, including the extent of the malignancy and all comorbidities. 2. Engage in open and empathetic communication with the patient and their family to understand their values, preferences, and goals of care. 3. Convene a multidisciplinary team meeting to discuss all treatment options, risks, benefits, and potential complications. 4. Develop a personalized treatment plan collaboratively, prioritizing patient safety and well-being. 5. Continuously reassess the patient’s response to treatment and adjust the plan as necessary.

Scenario Analysis: This scenario presents a common challenge in managing inflammatory bowel disease (IBD) where a patient’s symptoms are not adequately controlled by standard first-line therapy. The physician must balance the need for effective treatment with the potential risks and side effects of escalating therapy, while also ensuring the patient is fully informed and involved in the decision-making process. This requires careful consideration of the patient’s individual circumstances, disease severity, and personal preferences, all within the ethical and regulatory framework governing medical practice. Correct Approach Analysis: The best professional practice involves a comprehensive discussion with the patient about the limitations of the current treatment, the rationale for considering a biologic agent, the potential benefits, risks, and alternatives. This includes a detailed explanation of the proposed biologic, its mechanism of action, expected outcomes, monitoring requirements, and potential side effects. Shared decision-making is paramount, ensuring the patient understands the information and actively participates in choosing the next course of action. This approach aligns with ethical principles of patient autonomy and informed consent, as well as regulatory expectations for patient-centered care. Incorrect Approaches Analysis: Considering an immediate escalation to a biologic without a thorough discussion of the current treatment’s limitations and the patient’s understanding of the rationale for change is ethically problematic. It bypasses the crucial step of ensuring the patient is fully informed and has had the opportunity to express concerns or preferences regarding the proposed escalation. This could be seen as paternalistic and a failure to uphold the principle of informed consent. Proceeding with a biologic agent without adequately exploring all available non-biologic advanced therapies or optimizing current non-biologic regimens would be a deviation from standard clinical guidelines and potentially lead to unnecessary exposure to the risks and costs associated with biologics. It fails to demonstrate a systematic and evidence-based approach to treatment escalation. Delaying the discussion about advanced therapies until the patient’s condition significantly deteriorates risks prolonging the patient’s suffering and potentially leading to more severe complications. While caution is necessary, undue delay in offering effective advanced therapies when indicated is not in the patient’s best interest and could be considered a failure to provide timely and appropriate care. Professional Reasoning: Professionals should employ a structured decision-making framework that prioritizes patient understanding and shared decision-making. This involves: 1) Thoroughly assessing the patient’s current disease status and response to therapy. 2) Clearly communicating the findings and the rationale for considering treatment escalation. 3) Presenting all viable treatment options, including their respective benefits, risks, and alternatives, in an understandable manner. 4) Actively listening to and addressing the patient’s concerns, values, and preferences. 5) Collaboratively developing a treatment plan that the patient understands and agrees to.