The scenario presents a complex ethical and professional challenge stemming from a patient’s declining capacity and the potential for family influence to override the patient’s previously expressed wishes regarding renal replacement therapy (RRT). This situation demands careful navigation of patient autonomy, beneficence, non-maleficence, and the principles of informed consent within the context of health systems science, which emphasizes the efficient and equitable delivery of care. The core tension lies in balancing the patient’s right to self-determination with the family’s perceived best interests and the clinician’s duty of care. The correct approach involves a structured, multi-faceted process that prioritizes the patient’s established wishes and legal rights while acknowledging the family’s concerns. This begins with a thorough assessment of the patient’s current capacity to make decisions, utilizing validated tools and involving a multidisciplinary team. If capacity is found to be diminished, the next crucial step is to determine if an advance directive or a designated healthcare proxy exists. If an advance directive clearly outlines the patient’s wishes regarding RRT, it must be respected, provided it was made when the patient had capacity and is relevant to the current situation. Engaging in open, empathetic communication with the family, explaining the patient’s previously expressed wishes and the legal/ethical framework supporting them, is paramount. This communication should aim to educate and reassure the family, focusing on the patient’s well-being as defined by the patient themselves. Documenting all assessments, discussions, and decisions meticulously is essential for accountability and continuity of care. This approach aligns with the fundamental ethical principles of respect for autonomy and beneficence, as well as legal requirements surrounding informed consent and patient rights. An incorrect approach would be to immediately accede to the family’s demands without a thorough capacity assessment or verification of any advance directive. This fails to uphold the principle of patient autonomy and could lead to the provision of RRT against the patient’s wishes, constituting a violation of their rights and potentially causing them distress or harm. It also bypasses the established legal and ethical protocols for managing patients with fluctuating or diminished capacity. Another incorrect approach would be to dismiss the family’s concerns outright without attempting to understand their perspective or provide them with clear, empathetic explanations. While the patient’s wishes are paramount, alienating the family can create significant conflict and hinder collaborative care. Professionalism dictates a compassionate and communicative approach, even when delivering difficult news or upholding decisions that may be contrary to a family’s desires. Finally, an incorrect approach would be to delay decision-making indefinitely or to proceed with RRT without clear consent or a robust understanding of the patient’s wishes, perhaps due to discomfort with the ethical dilemma. This inaction can lead to suboptimal care, patient suffering, and potential legal repercussions. Health systems science emphasizes efficient and effective care delivery, and prolonged indecision undermines this principle. Professionals should employ a systematic decision-making process that includes: 1) assessing patient capacity; 2) identifying and verifying advance directives or healthcare proxies; 3) engaging in open and empathetic communication with the patient and family; 4) consulting with a multidisciplinary team, including ethics committees if necessary; and 5) documenting all steps and decisions thoroughly. This framework ensures that patient rights are protected, ethical principles are upheld, and care is delivered in a patient-centered and legally sound manner.

The review process indicates a complex ethical and professional challenge involving patient autonomy, informed consent, and the physician’s duty of care when a patient with advanced renal disease expresses a desire to discontinue dialysis. This scenario is professionally challenging because it requires balancing the patient’s right to self-determination with the physician’s responsibility to preserve life and ensure the patient understands the full implications of their decision. The physician must navigate potential cognitive impairment, coercion, and the patient’s understanding of their prognosis and available palliative care options. Careful judgment is required to ensure the patient’s decision is truly informed and voluntary. The best approach involves a comprehensive assessment of the patient’s capacity to make this decision, followed by a detailed discussion of all available alternatives, including palliative care and hospice services. This approach is correct because it upholds the principle of patient autonomy while fulfilling the physician’s ethical obligation to ensure informed consent. Regulatory frameworks and professional guidelines emphasize that a patient has the right to refuse medical treatment, even life-sustaining treatment, provided they have the mental capacity to understand the consequences of their decision. This involves a thorough evaluation of the patient’s understanding of their condition, the benefits and burdens of dialysis, and the likely outcomes of discontinuing treatment. Engaging a multidisciplinary team, including social workers and palliative care specialists, is crucial to provide holistic support and ensure all patient needs are addressed. An incorrect approach would be to immediately accede to the patient’s request without a thorough capacity assessment. This fails to uphold the physician’s duty to ensure informed consent and could lead to a decision made under duress or without full comprehension of the irreversible consequences. Another incorrect approach is to dismiss the patient’s request outright, asserting that dialysis is life-sustaining and therefore non-negotiable. This disregards the fundamental ethical principle of patient autonomy and the right to refuse treatment, potentially leading to a breakdown in the patient-physician relationship and a violation of the patient’s rights. Finally, proceeding with the discontinuation of dialysis based solely on a family member’s insistence, without independent confirmation of the patient’s capacity and wishes, is ethically unacceptable. This prioritizes the wishes of others over the patient’s autonomy and could constitute a breach of professional duty. The professional decision-making process for similar situations should involve a structured approach: first, assess the patient’s decision-making capacity. If capacity is present, engage in open and honest communication about the patient’s values, goals of care, and understanding of their illness and treatment options. Second, explore the reasons behind the patient’s desire to discontinue dialysis, identifying any reversible factors such as depression, pain, or lack of social support. Third, involve a multidisciplinary team to provide comprehensive support and address all aspects of the patient’s well-being. Fourth, document all discussions, assessments, and decisions meticulously. Finally, ensure the patient’s wishes are respected and that appropriate palliative and end-of-life care are provided.

Scenario Analysis: This scenario is professionally challenging because the candidate is seeking guidance on preparing for a high-stakes assessment in a specialized medical field. The challenge lies in balancing the candidate’s desire for efficient and effective preparation with the ethical and professional obligations of the assessor. Providing direct, tailored study materials or “insider” information could compromise the integrity of the assessment process and create an unfair advantage, potentially violating principles of fairness and objectivity. The assessor must navigate this request by offering appropriate, general guidance without crossing ethical boundaries. Correct Approach Analysis: The best professional approach involves providing the candidate with general, publicly available resources and a structured timeline recommendation that emphasizes broad competency development. This approach respects the integrity of the assessment by not offering preferential treatment or specific insights into the examination content. It aligns with ethical principles of fairness and equal opportunity for all candidates. By recommending a comprehensive study plan that covers all core competencies, the assessor empowers the candidate to prepare effectively through their own diligent effort, which is the intended outcome of a competency assessment. This also adheres to the spirit of professional development, where learning is an active and self-directed process. Incorrect Approaches Analysis: Offering to share specific past examination questions or detailed outlines of expected topics is ethically problematic. This constitutes providing an unfair advantage, undermining the validity of the assessment and violating principles of impartiality. It suggests that success is dependent on privileged information rather than demonstrated competency. Suggesting that the candidate focus only on areas where the assessor has particular expertise, or providing a condensed study guide based on the assessor’s personal knowledge of the exam’s focus, is also inappropriate. This creates a biased preparation path and does not ensure the candidate develops a comprehensive understanding of all required competencies. It prioritizes the assessor’s subjective view over the established assessment criteria. Recommending that the candidate defer preparation until closer to the exam date, or suggesting that minimal preparation is sufficient due to the candidate’s perceived existing knowledge, is professionally irresponsible. This approach fails to adequately guide the candidate towards achieving the required level of competency and could lead to a negative assessment outcome due to underpreparation. It neglects the assessor’s duty to support the candidate’s development in a structured and appropriate manner. Professional Reasoning: Professionals faced with such requests should adopt a framework that prioritizes ethical conduct, fairness, and the integrity of the assessment process. This involves: 1) Recognizing the request for guidance and the candidate’s motivation. 2) Identifying the ethical boundaries regarding the provision of information and support. 3) Formulating a response that is helpful yet impartial, focusing on general principles and resources. 4) Communicating the rationale for the approach taken, reinforcing the importance of fair assessment. 5) Documenting the interaction if necessary, to ensure transparency and accountability.

This scenario presents a professional challenge due to the inherent tension between patient autonomy and the clinician’s duty of care, particularly when a patient’s decision-making capacity is in question. The need for a comprehensive and objective assessment of the patient’s understanding and voluntariness is paramount, requiring a structured and ethically sound approach. The correct approach involves a thorough, documented assessment of the patient’s capacity to make decisions regarding their renal replacement therapy. This includes evaluating their understanding of their condition, the risks and benefits of each treatment option (including no treatment), and the consequences of their choices. This approach aligns with the fundamental ethical principles of respect for autonomy and beneficence, as well as the legal requirements to ensure informed consent. Regulatory frameworks governing healthcare provision universally mandate that treatment decisions are made by competent individuals who have been adequately informed. This process ensures that the patient’s choice is respected and that the healthcare team has fulfilled its duty to provide appropriate information. An incorrect approach would be to proceed with a treatment plan based solely on the family’s expressed wishes without a formal capacity assessment. This disregards the patient’s right to self-determination and could lead to treatment being imposed against their will, violating ethical principles of autonomy and potentially legal statutes regarding patient rights. Another incorrect approach is to assume incapacity based on the patient’s age or the severity of their illness. Capacity is not determined by these factors but by the individual’s ability to understand and process information relevant to their decision. Making assumptions without a proper assessment is discriminatory and ethically unsound, failing to uphold the principle of treating each patient as an individual with inherent rights. A further incorrect approach would be to delay the capacity assessment due to time constraints or perceived urgency of the situation. While time is often a factor in clinical decision-making, the assessment of capacity is a prerequisite for any significant treatment decision, especially one as life-altering as renal replacement therapy. Delaying this assessment risks proceeding with or without treatment without proper consent, leading to ethical and legal breaches. Professionals should employ a decision-making framework that prioritizes patient-centered care. This involves first establishing a trusting relationship with the patient, then systematically assessing their decision-making capacity using validated tools or structured interviews, ensuring all relevant information is communicated clearly and understandably, and documenting the entire process meticulously. If capacity is found to be lacking, the framework dictates involving appropriate legal or ethical representatives and following established protocols for substitute decision-making.

Analysis of this scenario is professionally challenging due to the inherent tension between maintaining assessment integrity and supporting a candidate’s professional development. The blueprint weighting, scoring, and retake policies are designed to ensure a consistent and fair evaluation of advanced nephrology and renal replacement competency. Deviating from these established policies, even with good intentions, can undermine the credibility of the assessment process and create an inequitable experience for other candidates. Careful judgment is required to balance empathy for the candidate’s situation with adherence to the established regulatory framework governing the assessment. The best professional approach involves a thorough review of the candidate’s performance against the established blueprint weighting and scoring criteria, followed by a clear and transparent communication of the results and the applicable retake policies. This approach upholds the integrity of the assessment by ensuring that all candidates are evaluated under the same objective standards. The scoring rubric, directly derived from the blueprint weighting, provides the objective measure of competency. The retake policy, also a defined component of the assessment framework, outlines the process for candidates who do not meet the required standard. Adhering to these established procedures ensures fairness, consistency, and defensibility of the assessment outcomes. An incorrect approach would be to unilaterally adjust the scoring to accommodate the candidate’s perceived extenuating circumstances. This action directly violates the principle of equitable assessment, as it creates a preferential outcome not available to other candidates. It bypasses the established scoring mechanisms dictated by the blueprint weighting, rendering the assessment arbitrary and potentially biased. Furthermore, it disregards the defined retake policy, which is a crucial element of the competency assessment framework designed to provide a structured pathway for improvement. Another incorrect approach would be to offer the candidate an immediate re-assessment without a formal review of their original performance and without adhering to the established retake policy. This undermines the rigor of the initial assessment and suggests that the competency evaluation is not a definitive measure. It also fails to provide the candidate with constructive feedback based on their actual performance against the blueprint, which is essential for targeted learning and future success. The absence of a formal review process also raises concerns about the consistency and fairness of the overall assessment program. A third incorrect approach would be to dismiss the candidate’s performance as insufficient without providing a clear explanation of how their score relates to the blueprint weighting and scoring criteria, and without outlining the available retake options. This lacks transparency and can be demoralizing for the candidate. While adhering to policies is crucial, professional practice also demands clear communication and support within the established framework. Failing to explain the scoring in relation to the blueprint and the retake process leaves the candidate without understanding or a clear path forward. Professionals should employ a decision-making framework that prioritizes adherence to established assessment policies and regulatory guidelines. This involves: 1) Objective evaluation of candidate performance against the blueprint weighting and scoring criteria. 2) Transparent communication of results, clearly linking performance to the assessment standards. 3) Clear explanation of the applicable retake policies and procedures. 4) Providing constructive feedback based on the assessment results to guide future learning. 5) Escalating complex or exceptional circumstances to a designated assessment committee or authority for review, ensuring decisions are made consistently and fairly across all candidates.

Scenario Analysis: This scenario is professionally challenging because it requires the clinician to balance the immediate, potentially life-saving intervention of initiating renal replacement therapy (RRT) with the ethical imperative of obtaining informed consent from a patient who may have impaired decision-making capacity due to their acute illness. The rapid deterioration of renal function necessitates prompt action, but bypassing the consent process, even with good intentions, carries significant ethical and potentially legal ramifications. Careful judgment is required to assess the patient’s capacity and to involve surrogates appropriately, ensuring the patient’s autonomy is respected as much as possible. Correct Approach Analysis: The best professional practice involves a multi-step approach that prioritizes assessing the patient’s capacity to make decisions about RRT. This begins with a direct conversation with the patient, explaining the diagnosis, the proposed treatment (RRT), its benefits, risks, alternatives, and the likely outcomes of no treatment. If the patient demonstrates capacity, their informed consent is obtained. If capacity is impaired, the next step is to identify and involve the legally authorized surrogate decision-maker. This surrogate should be provided with the same comprehensive information as the patient would have received, enabling them to make a decision in the patient’s best interest or according to the patient’s known wishes. This approach aligns with fundamental ethical principles of autonomy and beneficence, and regulatory frameworks that mandate informed consent for medical interventions. Incorrect Approaches Analysis: Initiating RRT without any attempt to assess the patient’s capacity or involve a surrogate decision-maker, even in a critical situation, represents a failure to uphold the principle of patient autonomy. While the intention may be to provide life-saving treatment, this bypasses a crucial ethical and legal requirement. This approach risks acting against the patient’s potential wishes or values, and could lead to legal challenges regarding battery or lack of consent. Delaying RRT indefinitely while attempting to definitively establish the patient’s capacity, especially if their condition is rapidly deteriorating, would be ethically problematic. While capacity assessment is important, prolonged delays in initiating necessary treatment when a patient is clearly suffering from severe, life-threatening renal failure and is unable to participate in decision-making, and no surrogate is immediately available, could violate the principle of beneficence. The focus should be on finding the most appropriate surrogate and proceeding with treatment in the patient’s best interest if capacity is absent. Relying solely on the opinion of a junior medical team member without independent assessment of the patient’s capacity or consultation with senior clinicians or ethics committees, particularly in complex cases, is insufficient. While junior staff play a vital role, the ultimate responsibility for ensuring informed consent and appropriate surrogate involvement rests with the attending physician, who must exercise their professional judgment and seek guidance when necessary. This approach may lead to inconsistent or inadequate decision-making. Professional Reasoning: Professionals should approach such situations by first performing a thorough clinical assessment to understand the urgency of the situation and the patient’s physiological status. Concurrently, they must assess the patient’s cognitive function and decision-making capacity. If capacity is present, informed consent is paramount. If capacity is impaired, the professional must identify the appropriate surrogate decision-maker, provide them with all necessary information, and facilitate a decision that aligns with the patient’s best interests or previously expressed wishes. In situations of extreme urgency where capacity is absent and no surrogate is immediately available, the professional must act in the patient’s presumed best interest, documenting the rationale meticulously and seeking to involve surrogates or ethics consultation as soon as feasible. This systematic approach ensures that patient autonomy, beneficence, and non-maleficence are all considered and upheld.

Scenario Analysis: This scenario presents a professional challenge due to the potential for misdiagnosis and inappropriate treatment stemming from an incomplete or misinterpreted imaging study. The complexity arises from balancing the need for timely diagnosis with the judicious use of resources and patient safety, all within the framework of established diagnostic reasoning and imaging selection protocols. The physician must navigate the nuances of patient presentation, differential diagnoses, and the specific diagnostic capabilities and limitations of various imaging modalities. Correct Approach Analysis: The best professional practice involves a systematic diagnostic reasoning workflow that prioritizes the most appropriate imaging modality based on the initial clinical suspicion and the information sought. This approach begins with a thorough clinical assessment to formulate a differential diagnosis. Subsequently, the physician selects the imaging modality that offers the highest diagnostic yield for the suspected pathology, considering factors such as radiation exposure, cost, availability, and the need for contrast agents. Interpretation then follows a structured protocol, comparing findings against the clinical context and relevant anatomical structures. This aligns with ethical principles of beneficence and non-maleficence, ensuring that diagnostic efforts are both effective and minimize patient harm, and adheres to professional guidelines for evidence-based diagnostic pathways. Incorrect Approaches Analysis: One incorrect approach involves ordering a broad, non-specific imaging study without a clear diagnostic hypothesis. This can lead to incidental findings that are clinically insignificant, causing patient anxiety and unnecessary follow-up investigations, thereby violating the principle of minimizing harm and potentially misallocating healthcare resources. Another unacceptable approach is to rely solely on the radiologist’s interpretation without integrating it back into the clinical picture. While radiologists are experts, the referring physician holds ultimate responsibility for the patient’s care and must ensure the imaging findings are consistent with the clinical presentation. Failure to do so can result in diagnostic errors and inappropriate management, contravening the duty of care. A further flawed approach is to repeatedly order the same imaging modality for a changing clinical presentation without re-evaluating the diagnostic question. This demonstrates a lack of adaptive diagnostic reasoning and can delay the identification of new or evolving pathology, potentially leading to suboptimal patient outcomes. Professional Reasoning: Professionals should employ a structured diagnostic reasoning process. This involves: 1) gathering comprehensive clinical information, 2) formulating a prioritized differential diagnosis, 3) selecting the most appropriate diagnostic test based on its yield and risk profile, 4) critically interpreting the results in the context of the clinical presentation, and 5) developing a management plan informed by the integrated findings. This iterative process ensures that diagnostic investigations are targeted, efficient, and ultimately beneficial to the patient.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate needs of individual patients with the broader public health mandate of equitable resource allocation. The nephrology team must navigate potential biases, resource limitations, and the ethical imperative to provide care without discrimination, all within the framework of population health goals. Careful judgment is required to ensure that decisions are both clinically sound and ethically defensible, promoting health equity. Correct Approach Analysis: The best professional practice involves a systematic, data-driven approach that prioritizes equitable access to renal replacement therapy (RRT) based on established clinical criteria and population health needs. This includes actively identifying underserved populations, understanding the epidemiological drivers of kidney disease within those groups, and implementing targeted outreach and support programs. The justification lies in adhering to the principles of health equity, which mandate that everyone has a fair and just opportunity to be as healthy as possible. This approach aligns with public health goals of reducing disparities and improving overall population health outcomes by addressing the social determinants of health that disproportionately affect certain groups’ access to and outcomes from RRT. Incorrect Approaches Analysis: One incorrect approach involves focusing solely on the most readily available or easily managed patients, potentially overlooking those from marginalized communities who may face greater barriers to accessing or adhering to RRT. This fails to address the underlying health inequities and perpetuates disparities in care, violating the ethical principle of justice and the public health imperative to serve all segments of the population. Another incorrect approach is to allocate resources based on perceived patient compliance or socioeconomic status, rather than clinical need and potential benefit. This introduces bias and discrimination, directly contradicting the principles of equitable healthcare access and potentially leading to poorer health outcomes for vulnerable individuals. It also fails to acknowledge the systemic factors that may influence patient adherence. A third incorrect approach is to defer all complex access decisions to administrative bodies without active clinical input or consideration of the specific needs of diverse patient populations. While administrative processes are necessary, a purely bureaucratic approach can become detached from the realities of patient care and the nuances of health equity, potentially leading to decisions that are not clinically appropriate or ethically sound for all individuals. Professional Reasoning: Professionals should employ a decision-making framework that integrates clinical expertise with an understanding of population health and health equity. This involves: 1) Recognizing and actively mitigating personal and systemic biases. 2) Utilizing epidemiological data to understand disease prevalence and disparities within the patient population. 3) Engaging in proactive outreach and support for underserved groups. 4) Applying standardized, evidence-based clinical criteria for RRT access. 5) Collaborating with public health experts and community stakeholders to address social determinants of health impacting kidney disease. 6) Regularly reviewing and adapting strategies to ensure equitable outcomes.

Scenario Analysis: This scenario presents a common challenge in nephrology where a patient with advanced chronic kidney disease (CKD) faces a significant treatment decision with potentially life-altering consequences. The professional challenge lies in balancing the patient’s autonomy and values with the clinical realities of their condition and the available treatment options, while also considering the role and needs of their primary caregiver. Ensuring the patient and caregiver are adequately informed and empowered to participate in the decision-making process is paramount. Correct Approach Analysis: The best professional practice involves a comprehensive, patient-centered approach to shared decision-making. This begins with a thorough assessment of the patient’s understanding of their condition, prognosis, and the implications of each treatment option (dialysis modalities, conservative management, transplantation). It requires clear, jargon-free communication of risks, benefits, and burdens, tailored to the patient’s health literacy. Crucially, it necessitates actively involving the patient and their identified caregiver in exploring their values, preferences, and goals of care. This approach respects patient autonomy, promotes informed consent, and aligns treatment with the patient’s overall well-being and quality of life. Regulatory frameworks and ethical guidelines consistently emphasize the importance of patient involvement in treatment decisions, particularly for significant interventions. Incorrect Approaches Analysis: One incorrect approach involves presenting the options as a fait accompli, focusing solely on the medical indications and the clinician’s preferred course of action. This fails to acknowledge the patient’s right to self-determination and can lead to a decision that is medically sound but not aligned with the patient’s values or capacity to manage. It disregards the ethical imperative of informed consent and patient autonomy. Another incorrect approach is to delegate the decision entirely to the caregiver, assuming they will make the “best” choice for the patient. While caregivers are vital, the ultimate decision rests with the patient, provided they have the capacity to make it. Over-reliance on the caregiver can undermine the patient’s agency and may not reflect the patient’s personal wishes or priorities. This can also create undue burden on the caregiver. A third incorrect approach is to provide a superficial overview of the options without probing the patient’s understanding, fears, or personal circumstances. This can lead to a decision based on incomplete information or misunderstandings, rendering the “shared” aspect of the decision-making process ineffective. It fails to meet the standard of providing adequate information necessary for truly informed consent. Professional Reasoning: Professionals should adopt a structured approach to shared decision-making. This involves: 1. Establishing rapport and trust. 2. Assessing the patient’s and caregiver’s understanding and readiness for decision-making. 3. Clearly presenting all relevant options, including the option of no active intervention, along with their risks, benefits, and burdens, using understandable language. 4. Eliciting the patient’s and caregiver’s values, preferences, and goals of care. 5. Collaboratively exploring the options in light of these values and goals. 6. Reaching a mutually agreed-upon decision. 7. Documenting the decision-making process and the chosen course of action.

This scenario is professionally challenging due to the inherent complexity of managing patients with advanced kidney disease, where multiple comorbidities, treatment options, and patient preferences must be carefully weighed. The need for evidence-based practice is paramount, but its application requires nuanced judgment, especially when dealing with potentially life-altering decisions. The ethical imperative to respect patient autonomy while ensuring optimal clinical outcomes creates a delicate balance. The best approach involves a comprehensive, multidisciplinary assessment that integrates the latest evidence with the patient’s individual circumstances and values. This includes a thorough review of the patient’s medical history, current renal function, comorbidities, and psychosocial status. Crucially, it necessitates an open and honest discussion with the patient and their family about all available renal replacement therapy (RRT) options, including their risks, benefits, and expected outcomes, as well as conservative management. This shared decision-making process, grounded in evidence and respecting patient autonomy, aligns with ethical principles and best practice guidelines for managing chronic kidney disease. An approach that solely focuses on initiating dialysis without a thorough exploration of all treatment modalities and patient preferences is ethically flawed. It risks overriding patient autonomy and may not align with the patient’s goals of care, potentially leading to suboptimal outcomes and patient distress. Another incorrect approach would be to defer all complex treatment decisions solely to a specialist without actively involving the patient in the discussion. This fails to uphold the principle of shared decision-making and can leave the patient feeling disempowered and uninformed about their own care. Finally, an approach that relies on outdated or anecdotal evidence rather than current, high-quality research to guide treatment recommendations is professionally unacceptable. This can lead to the implementation of suboptimal or even harmful interventions, failing to meet the standard of care expected in advanced nephrology. Professionals should employ a structured decision-making process that begins with a comprehensive assessment, followed by an evidence-based evaluation of all viable treatment options. This should then be followed by a transparent and empathetic discussion with the patient and their family, facilitating shared decision-making. Regular reassessment and adaptation of the treatment plan based on evolving clinical status and patient preferences are also critical components of effective care.