This scenario presents a professional challenge due to the potential for misinterpretation of subtle neurological signs in a patient with a complex medical history, necessitating a thorough and systematic approach to clinical assessment. The physician must balance the need for efficient diagnosis with the ethical imperative to avoid premature conclusions that could lead to inappropriate management. Careful judgment is required to differentiate between symptoms directly related to the neurological complaint and those that may be secondary to other comorbidities or even unrelated. The best professional practice involves a comprehensive neurological examination that systematically evaluates all major functional domains, including mental status, cranial nerves, motor function, sensory function, coordination, and gait. This approach ensures that no critical findings are overlooked and allows for the identification of patterns of deficits that are characteristic of specific neurological conditions. This aligns with the ethical principles of beneficence and non-maleficence, as a thorough assessment minimizes the risk of diagnostic error and ensures that treatment is based on accurate findings. Furthermore, it adheres to professional standards of care, which mandate a systematic and complete evaluation of presenting symptoms. An approach that focuses solely on the most prominent symptom without a broader neurological survey risks missing other significant findings that could alter the differential diagnosis or management plan. This could lead to a failure to meet the standard of care, potentially resulting in harm to the patient. Similarly, relying heavily on a single diagnostic test without a thorough clinical correlation is professionally unacceptable. Diagnostic tests are adjuncts to clinical assessment, not replacements for it, and their interpretation requires careful consideration of the patient’s overall clinical picture. An approach that prioritizes patient self-reporting without objective neurological examination, while seemingly patient-centered, can be misleading. While patient history is crucial, subjective reports must be corroborated by objective findings to ensure diagnostic accuracy and avoid misdiagnosis. Professionals should employ a structured decision-making process that begins with a detailed history, followed by a systematic and comprehensive physical and neurological examination. This should then guide the selection of appropriate diagnostic investigations, with the understanding that these investigations are intended to confirm or refute hypotheses generated during the clinical assessment. Continuous re-evaluation of findings and the differential diagnosis is essential throughout the diagnostic process.

Scenario Analysis: This case presents a common challenge in clinical neurophysiology where a patient’s electrodiagnostic findings are discordant with their clinical presentation. The physician must reconcile these findings, considering potential underlying pathologies and the limitations of the diagnostic tools. The professional challenge lies in accurately interpreting the motor unit action potential (MUAP) morphology and amplitude in the context of the patient’s symptoms and history, ensuring that the diagnostic conclusion is both clinically relevant and ethically sound, avoiding over-reliance on a single finding or premature closure. Correct Approach Analysis: The best professional approach involves a comprehensive interpretation of the MUAP findings in conjunction with the complete clinical picture. This includes carefully reviewing the patient’s history, neurological examination, and any other relevant investigations. Specifically, the presence of increased MUAP duration and amplitude, along with polyphasia, in the context of subjective weakness and objective muscle atrophy, strongly suggests a neurogenic process, likely a motor neuron disease or a severe peripheral neuropathy. This approach is correct because it prioritizes a holistic diagnostic process, integrating electrophysiological data with clinical evidence to arrive at the most probable diagnosis, thereby fulfilling the physician’s duty of care to provide accurate and relevant diagnostic information. This aligns with the ethical principles of beneficence and non-maleficence, ensuring that the patient receives appropriate management based on a thorough evaluation. Incorrect Approaches Analysis: One incorrect approach would be to solely focus on the observed increased MUAP duration and amplitude as definitive evidence of a specific neurodegenerative disease without considering the possibility of other conditions that can cause similar electrophysiological changes, such as severe myopathies with secondary denervation or even technical artifacts. This approach fails to account for the complexity of electrophysiological interpretation and the potential for misdiagnosis if clinical correlation is neglected. Another incorrect approach would be to dismiss the electrophysiological findings entirely because they do not perfectly align with the initial clinical suspicion. This would involve attributing the observed MUAP abnormalities to non-pathological variations or technical errors without a systematic investigation into their cause. This approach risks overlooking a significant underlying pathology, potentially delaying crucial diagnosis and treatment, which is a failure in the physician’s duty to investigate thoroughly. A further incorrect approach would be to overemphasize the polyphasic nature of the MUAPs as the sole indicator of pathology, potentially leading to an inaccurate diagnosis if other critical parameters like MUAP amplitude and duration are not adequately considered in conjunction with the clinical context. This narrow focus can lead to misinterpretation and inappropriate diagnostic conclusions. Professional Reasoning: Professionals should approach such cases by first establishing a clear understanding of the patient’s presenting symptoms and neurological status. This is followed by a detailed review of the electrophysiological data, paying close attention to all parameters of the MUAPs, including duration, amplitude, shape, and number of phases. The next step is to critically correlate these electrophysiological findings with the clinical information, considering differential diagnoses that could explain both the symptoms and the observed abnormalities. If there is a discrepancy, further investigations or repeat testing may be warranted. The ultimate goal is to arrive at a diagnosis that is supported by both electrophysiological and clinical evidence, ensuring the patient receives the most accurate and beneficial care.

Scenario Analysis: This scenario presents a professional challenge in interpreting complex electrophysiological data in the context of a patient’s evolving neurological status. The physician must synthesize information from multiple sources, including patient history, clinical examination, and detailed electrophysiological recordings, to arrive at an accurate diagnosis and treatment plan. The difficulty lies in distinguishing subtle electrophysiological abnormalities that may or may not be directly attributable to a specific pathology, requiring a nuanced understanding of neuronal excitability, conduction, and synaptic transmission. Correct Approach Analysis: The best professional practice involves a comprehensive integration of the electrophysiological findings with the patient’s clinical presentation and diagnostic imaging. This approach acknowledges that electrophysiological tests are tools to investigate suspected neurological dysfunction and are most valuable when interpreted within the broader clinical context. Specifically, correlating the observed prolonged latencies and reduced amplitudes in the motor and sensory evoked potentials with the patient’s reported sensory deficits and motor weakness, while also considering the MRI findings of demyelination, allows for a robust diagnostic conclusion. This aligns with established clinical neurophysiology principles that emphasize the synergy between electrodiagnostic data and clinical observation for accurate diagnosis and patient management. Incorrect Approaches Analysis: One incorrect approach would be to solely rely on the electrophysiological data without adequately considering the clinical context. For instance, attributing the prolonged latencies and reduced amplitudes solely to a generalized neuronal dysfunction without correlating them with the patient’s specific symptoms of sensory loss and motor weakness would be a significant oversight. This fails to acknowledge that electrophysiological abnormalities must have clinical relevance to be diagnostically meaningful. Another incorrect approach would be to overemphasize the MRI findings and downplay the electrophysiological results. While MRI is crucial for visualizing structural lesions, it does not directly assess neuronal function. Ignoring or minimizing the electrophysiological evidence of impaired nerve conduction, even if the MRI shows demyelination, would lead to an incomplete or potentially inaccurate diagnosis. A further incorrect approach would be to make a definitive diagnosis based on isolated electrophysiological findings without considering the possibility of confounding factors or alternative explanations. For example, concluding a specific peripheral neuropathy solely based on evoked potential abnormalities without considering other potential causes or the possibility of technical artifacts would be professionally unsound. Professional Reasoning: Professionals should employ a systematic approach that begins with a thorough review of the patient’s history and physical examination. This is followed by a critical evaluation of all diagnostic test results, including electrophysiology and imaging, looking for concordant findings. When discrepancies arise, further investigation or consultation may be necessary. The ultimate goal is to formulate a diagnosis that is supported by the totality of the evidence and leads to an appropriate and effective treatment plan.

Scenario Analysis: This case presents a professional challenge due to the potential for misinterpreting complex neurophysiological data in the context of a patient’s subjective experience and the need to integrate findings with established mechanisms of synaptic transmission and plasticity. The physician must navigate the delicate balance between objective electrophysiological evidence and the subjective reporting of symptoms, ensuring that diagnostic and therapeutic decisions are grounded in sound scientific understanding and ethical practice. The complexity arises from the dynamic nature of synaptic function and plasticity, which can be influenced by numerous factors, making definitive conclusions difficult without careful consideration of all available information. Correct Approach Analysis: The best professional practice involves a comprehensive integration of the electrophysiological findings with the patient’s clinical presentation and known mechanisms of synaptic transmission and plasticity. This approach acknowledges that while synaptic dysfunction and altered plasticity are central to many neurological disorders, the specific pattern observed in the EEG and evoked potentials, when correlated with the patient’s symptoms, provides the most direct evidence for a diagnosis. Understanding how specific neurotransmitter systems (e.g., glutamate, GABA) and their receptor dynamics contribute to synaptic strength and plasticity, and how these processes are disrupted in conditions like epilepsy or sensory processing disorders, is crucial for interpreting the data. This method prioritizes a holistic, evidence-based assessment that directly links observed phenomena to underlying pathophysiology. Incorrect Approaches Analysis: One incorrect approach would be to solely focus on the electrophysiological abnormalities without adequately correlating them with the patient’s reported symptoms. This fails to acknowledge that EEG and evoked potential findings are manifestations of underlying neural activity, and their clinical significance is determined by their relationship to the patient’s experience. Without this correlation, the findings might be over-interpreted or misattributed, leading to an inaccurate diagnosis or inappropriate treatment. Another incorrect approach would be to overemphasize theoretical models of synaptic plasticity without sufficient grounding in the specific patient’s data. While understanding long-term potentiation (LTP) and long-term depression (LTD) is important, applying these concepts without direct evidence from the patient’s neurophysiological recordings and clinical presentation can lead to speculative conclusions. This approach risks divorcing theoretical knowledge from practical application, potentially leading to a diagnosis that is not supported by the individual case. A third incorrect approach would be to attribute the observed phenomena solely to a single neurotransmitter system without considering the interplay of various systems and modulatory influences. Synaptic transmission and plasticity are complex processes involving multiple neurotransmitters, receptors, and intracellular signaling pathways. Focusing on a single element in isolation, without considering how it interacts with other components, can lead to an incomplete or inaccurate understanding of the underlying pathology. Professional Reasoning: Professionals should approach such cases by first meticulously reviewing all available data, including patient history, physical examination, and all neurophysiological recordings. They should then critically evaluate the observed electrophysiological patterns in light of established knowledge of synaptic transmission and plasticity, considering how these fundamental processes might be altered to produce the observed phenomena. The next step is to synthesize these findings with the patient’s subjective and objective clinical manifestations, seeking the most parsimonious explanation that accounts for all aspects of the case. This iterative process of data integration, hypothesis generation, and validation against clinical reality is essential for sound clinical decision-making.

Scenario Analysis: This scenario presents a professional challenge due to the need to balance diagnostic accuracy with patient autonomy and the ethical imperative to avoid unnecessary or potentially harmful interventions. The physician must consider the limitations of various neurophysiological techniques, the patient’s specific clinical presentation, and the potential for misinterpretation or over-reliance on technology. Careful judgment is required to select the most appropriate diagnostic pathway that is both informative and respects the patient’s well-being and informed consent. Correct Approach Analysis: The best professional practice involves a systematic approach that begins with a thorough clinical assessment and history. This forms the foundation for selecting the most appropriate neurophysiological technique. In this case, given the focal neurological deficits suggestive of a structural lesion, an electroencephalogram (EEG) would be the most appropriate initial neurophysiological investigation. An EEG is highly sensitive in detecting abnormal electrical activity in the brain, which can be indicative of seizures, structural lesions, or other functional disturbances. Its non-invasive nature and broad applicability make it a suitable first-line test for evaluating suspected central nervous system pathology. This approach aligns with the principle of beneficence by seeking to diagnose the underlying cause of the patient’s symptoms efficiently and effectively, while also respecting the principle of non-maleficence by avoiding more invasive or less relevant tests initially. Incorrect Approaches Analysis: Proceeding directly to a nerve conduction study (NCS) and electromyography (EMG) would be inappropriate. NCS and EMG are primarily used to evaluate peripheral nerve and muscle disorders. While these techniques are valuable neurophysiological tools, they are not designed to assess focal brain lesions. Relying on these tests without a clear indication of peripheral involvement would be a failure to apply the correct diagnostic modality, potentially leading to a delayed or missed diagnosis of the underlying cerebral issue and a violation of the principle of competence. Initiating a polysomnography (PSG) without prior evidence of sleep-related disorders would also be professionally unacceptable. PSG is a comprehensive sleep study used to diagnose sleep disorders such as sleep apnea or narcolepsy. While seizures can sometimes occur during sleep, PSG is not the primary or most efficient method for investigating focal neurological deficits suggestive of a structural brain lesion. This approach demonstrates a lack of clinical reasoning and a misapplication of a specialized neurophysiological technique, potentially leading to unnecessary patient burden and cost without providing relevant diagnostic information. Opting for a transcranial Doppler (TCD) ultrasound as the initial investigation would be premature and potentially misleading. TCD is primarily used to assess blood flow in the major arteries of the brain and can help diagnose conditions like stroke or vasospasm. While a structural lesion could affect cerebral blood flow, TCD does not directly assess neuronal electrical activity or structural abnormalities in the same way as an EEG or neuroimaging. Using TCD as a first step for focal neurological deficits without a clear vascular concern would be a misallocation of resources and a failure to utilize the most direct diagnostic tools for the presenting symptoms. Professional Reasoning: Professionals should employ a diagnostic reasoning process that prioritizes clinical information. This involves: 1) Thoroughly gathering patient history and performing a comprehensive physical and neurological examination. 2) Formulating a differential diagnosis based on the clinical findings. 3) Selecting the most appropriate diagnostic tests, starting with those that are least invasive and most likely to yield relevant information for the suspected conditions. 4) Interpreting test results in the context of the clinical picture and adjusting the diagnostic and treatment plan accordingly. This systematic approach ensures that investigations are targeted, efficient, and patient-centered, adhering to ethical principles and professional standards of care.

This scenario presents a common yet critical challenge in clinical neurophysiology: interpreting subtle EEG findings in the context of a patient’s clinical presentation and making appropriate management decisions. The professional challenge lies in balancing the need for accurate diagnosis and patient safety with the potential for over-interpretation or under-interpretation of EEG data, which can lead to unnecessary interventions or missed diagnoses. Careful judgment is required to integrate waveform morphology, localization, and clinical context. The best approach involves a comprehensive review of the EEG recording in conjunction with the patient’s detailed clinical history and neurological examination findings. This integrated assessment allows for the most accurate interpretation of the observed waveforms. Specifically, identifying generalized slowing in the context of a known metabolic encephalopathy, or focal sharp waves in a patient with a history of stroke, requires correlating the EEG pattern with the underlying pathophysiology. This aligns with the ethical imperative to provide patient-centered care based on the totality of available information, ensuring that diagnostic and therapeutic decisions are well-founded and evidence-based. Regulatory guidelines in clinical practice emphasize the importance of thoroughness and accuracy in diagnostic interpretation. An incorrect approach would be to solely focus on the presence of a specific waveform without considering the clinical context. For instance, identifying brief, generalized spike-and-wave discharges and immediately initiating anti-epileptic drug therapy without assessing for clinical seizure activity or other potential causes of such discharges (e.g., certain medications, metabolic disturbances) would be a failure to apply clinical reasoning. This could lead to unnecessary medication side effects and a delay in addressing the true underlying issue. Another incorrect approach is to dismiss potentially significant findings due to their transient nature or subtle appearance, especially if they are not immediately alarming. For example, overlooking subtle focal slowing or intermittent epileptiform discharges in a patient with new-onset neurological symptoms could result in a missed diagnosis of a serious underlying condition, such as a structural lesion or an evolving seizure disorder. This would violate the professional duty to diligently investigate and diagnose. A further incorrect approach involves relying solely on automated EEG analysis software without critical human review. While these tools can be helpful, they are prone to false positives and negatives and cannot fully replicate the nuanced clinical judgment of an experienced neurophysiologist. Over-reliance on such technology without expert oversight can lead to misinterpretations and inappropriate clinical decisions. The professional reasoning process for similar situations should involve a systematic approach: first, thoroughly review the EEG data, noting all waveform characteristics, their distribution, and frequency. Second, meticulously gather and review the patient’s clinical history, including neurological symptoms, past medical history, medications, and recent changes. Third, correlate the EEG findings with the clinical presentation, considering differential diagnoses for the observed waveforms. Fourth, consult with the referring clinician to ensure a shared understanding of the findings and their implications. Finally, formulate a clear and concise interpretation that integrates all available information and provides actionable recommendations for patient management.

This scenario presents a professional challenge due to the potential for misinterpretation of EMG findings in a patient with complex neurological symptoms and a history of prior, potentially unrelated, neurological events. The physician must navigate the diagnostic process with precision, ensuring that the EMG study is not only technically sound but also interpreted within the full clinical context to avoid misdiagnosis or inappropriate treatment. Careful judgment is required to distinguish between active pathology, residual effects of past conditions, and normal physiological variations. The best professional approach involves a comprehensive review of the patient’s complete medical history, including all prior neurological evaluations and imaging studies, before interpreting the EMG results. This holistic review allows for the contextualization of the EMG findings, enabling the physician to differentiate between new neuromuscular abnormalities and sequelae of previous conditions. This approach is ethically mandated by the principle of beneficence, ensuring that the patient receives care based on a thorough and accurate understanding of their condition. It aligns with professional standards of practice that emphasize integrated diagnostic reasoning, where electrodiagnostic studies are viewed as one component of a broader clinical assessment. An incorrect approach would be to solely rely on the EMG findings without considering the patient’s extensive medical history. This failure to integrate all available clinical data risks misattributing EMG abnormalities to a current, active process when they may be historical or unrelated. This violates the ethical duty to provide competent care and could lead to inappropriate diagnostic or therapeutic interventions, potentially causing harm. Another incorrect approach is to dismiss the EMG findings as inconclusive without further investigation or consultation, especially if they appear to contradict the initial clinical suspicion. While acknowledging uncertainty is important, abandoning the diagnostic process prematurely without exhausting all reasonable avenues for clarification is professionally negligent. This neglects the physician’s responsibility to pursue a definitive diagnosis and can leave the patient without necessary treatment. A further incorrect approach would be to interpret the EMG findings in isolation, focusing only on the most striking abnormalities and overlooking subtle but potentially significant findings that, when considered with the history, might point to a different diagnosis. This narrow focus can lead to diagnostic errors and suboptimal patient management. The professional reasoning framework for such situations involves a systematic approach: 1) Thoroughly gather all relevant patient information, including history, physical examination, and prior investigations. 2) Formulate a differential diagnosis based on this comprehensive data. 3) Select and perform appropriate diagnostic tests, such as EMG, ensuring technical quality. 4) Interpret test results within the established clinical context, integrating them with all other available information. 5) Re-evaluate the differential diagnosis and formulate a management plan based on the most accurate and complete understanding of the patient’s condition. If uncertainty persists, seek consultation or further investigation.

The review process indicates a common challenge in clinical neurophysiology: interpreting complex quantitative EEG (qEEG) data in the context of a patient’s clinical presentation, particularly when the data appears discordant with initial clinical impressions. This scenario is professionally challenging because it requires the clinician to synthesize objective neurophysiological findings with subjective clinical information, navigate potential biases, and ensure that diagnostic and treatment decisions are evidence-based and patient-centered, adhering to the standards of practice and ethical considerations for patient care. Careful judgment is required to avoid over-reliance on any single data point and to ensure that the interpretation serves the patient’s best interest. The best approach involves a comprehensive integration of the qEEG findings with the complete clinical picture, including the patient’s history, neurological examination, and any other relevant diagnostic information. This approach prioritizes a holistic understanding of the patient’s condition. Specifically, it entails a detailed review of the qEEG metrics (e.g., spectral power, coherence, connectivity) in relation to the patient’s symptoms, cognitive deficits, and behavioral observations. If the qEEG findings are unexpected or contradictory to the clinical presentation, this approach mandates further investigation, such as re-evaluation of the clinical data, consideration of artifactual influences on the EEG, or consultation with colleagues. This aligns with the ethical principle of beneficence, ensuring that patient care is based on the most accurate and complete understanding of their condition, and the principle of non-maleficence, by avoiding premature or incorrect diagnoses and treatments. It also reflects the professional standard of care in neurophysiology, which demands rigorous interpretation of neurophysiological data within its clinical context. An incorrect approach would be to solely rely on the qEEG report’s automated interpretation or a single quantitative metric without critically evaluating its clinical relevance. This fails to acknowledge the inherent limitations of automated analysis and the crucial role of clinical correlation. Ethically, this can lead to misdiagnosis or inappropriate management, violating the duty of care. Another incorrect approach is to dismiss the qEEG findings entirely because they do not align with the initial clinical hypothesis, without a systematic investigation into the discrepancy. This can result in overlooking significant neurophysiological abnormalities that might explain the patient’s symptoms or suggest an alternative diagnosis. This approach risks confirmation bias and can be detrimental to patient care by delaying or preventing appropriate interventions. A further incorrect approach involves selectively presenting or emphasizing qEEG data that supports the pre-existing clinical impression while downplaying or ignoring contradictory findings. This represents a significant ethical lapse, as it compromises the objectivity of the interpretation and can lead to biased clinical decision-making, ultimately harming the patient by not providing a complete and accurate assessment. The professional reasoning process for such situations should involve a systematic evaluation framework: 1) Thoroughly review all available clinical data. 2) Critically analyze the qEEG data, understanding the methodologies and potential limitations. 3) Identify any discrepancies between clinical and qEEG findings. 4) Investigate the causes of discrepancies, considering artifacts, technical issues, or genuine neurophysiological correlates of the clinical presentation. 5) Formulate a differential diagnosis that integrates all evidence. 6) Communicate findings and recommendations clearly and comprehensively to the referring physician and patient, ensuring shared decision-making.

This scenario presents a professional challenge due to the need to balance diagnostic accuracy with patient safety and the ethical imperative to obtain informed consent for invasive procedures. The physician must consider the potential risks and benefits of each diagnostic pathway, particularly when a patient exhibits symptoms that could be attributed to multiple neurological conditions. Careful judgment is required to select the most appropriate and least invasive diagnostic strategy that will yield the necessary information for effective management. The best approach involves a systematic, stepwise diagnostic process that prioritizes non-invasive methods before proceeding to more invasive electrophysiological testing. This begins with a thorough clinical evaluation, including a detailed history and neurological examination, to formulate a differential diagnosis. Based on this initial assessment, appropriate imaging studies, such as MRI, should be considered to rule out structural lesions or other significant pathologies. If these initial investigations do not provide a definitive diagnosis or if there is a strong suspicion of a peripheral nerve or muscle disorder, then an electrodiagnostic study, such as EMG/NCS, would be indicated. The decision to proceed with EMG/NCS must be preceded by a clear explanation to the patient about the procedure, its purpose, potential risks (e.g., pain, bruising, infection, nerve injury), benefits, and alternatives, ensuring that informed consent is obtained. This aligns with the ethical principles of beneficence, non-maleficence, and patient autonomy, as well as the standard of care in neurological diagnostics. An incorrect approach would be to immediately proceed with EMG/NCS without first conducting a comprehensive clinical assessment and considering less invasive diagnostic options. This bypasses crucial steps in the diagnostic algorithm, potentially exposing the patient to unnecessary risks and discomfort associated with an invasive procedure when a diagnosis might have been achievable through other means. It also fails to adequately explore alternative diagnoses that might not be amenable to EMG/NCS. Another incorrect approach is to rely solely on imaging studies without considering the utility of electrodiagnostic testing when clinical signs and symptoms strongly suggest a peripheral nerve or muscle disorder. While imaging is vital for assessing structural abnormalities, it may not detect or characterize functional deficits in nerve conduction or muscle activity, which are the primary targets of EMG/NCS. Finally, proceeding with EMG/NCS without obtaining informed consent is a significant ethical and regulatory violation. Patients have the right to understand and agree to medical interventions. Failing to provide adequate information about the procedure, its risks, benefits, and alternatives undermines patient autonomy and can lead to legal and professional repercussions. The professional reasoning process should involve a structured approach: first, gather all relevant clinical information; second, formulate a differential diagnosis; third, prioritize diagnostic tests based on invasiveness, risk, and diagnostic yield, starting with the least invasive; fourth, ensure all necessary prerequisites for invasive procedures, including informed consent, are met.

This scenario is professionally challenging because it requires the clinician to balance the immediate need for diagnostic information with the ethical obligation to obtain informed consent, especially when the patient’s capacity to consent is in question. The use of nerve conduction studies (NCS) involves a degree of discomfort and potential risk, necessitating a thorough understanding of the procedure by the patient. Navigating situations where a patient’s cognitive state might impair their ability to provide truly informed consent demands careful ethical and professional judgment. The best approach involves a multi-faceted strategy to ensure the patient’s rights and well-being are prioritized. This includes a comprehensive assessment of the patient’s capacity to understand the nature, purpose, risks, and benefits of the NCS. If capacity is deemed present, then proceeding with a detailed explanation and obtaining explicit consent is appropriate. However, if capacity is impaired, the clinician must engage with the legally authorized representative to discuss the procedure and obtain consent on the patient’s behalf, while still involving the patient to the greatest extent possible in the decision-making process. This aligns with ethical principles of beneficence, non-maleficence, and respect for autonomy, as well as regulatory guidelines that mandate informed consent for medical procedures. Proceeding with the NCS without a thorough assessment of capacity and without obtaining consent from a legally authorized representative if capacity is lacking is ethically and regulatorily unacceptable. This bypasses the fundamental right of the patient to self-determination and exposes the clinician to potential legal and professional repercussions. Similarly, assuming capacity without a formal assessment, or proceeding based solely on the family’s wishes without legal authorization, fails to uphold the patient’s rights and the clinician’s professional responsibilities. Professionals should employ a structured decision-making framework when faced with potential capacity issues. This framework should include: 1) assessing the patient’s current mental state and ability to comprehend information relevant to the procedure; 2) if capacity is questionable, conducting a formal capacity evaluation; 3) if capacity is impaired, identifying and consulting with the legally authorized representative; 4) ensuring that the patient, to the extent of their ability, is involved in discussions and decisions; and 5) documenting all assessments, discussions, and consent obtained meticulously.