Scenario Analysis: This scenario is professionally challenging because it requires a physician to navigate the complex and evolving landscape of board certification requirements while balancing personal career aspirations with the integrity of the certification process. Misinterpreting or misrepresenting eligibility criteria can lead to significant professional repercussions, including the invalidation of certification and damage to reputation. Careful judgment is required to ensure adherence to the established standards set by the certifying body. Correct Approach Analysis: The best professional practice involves a thorough and direct review of the official eligibility criteria published by the American Board of Internal Medicine (ABIM) for Pulmonary and Critical Care Medicine certification. This approach ensures that all requirements, including specific training pathways, examination prerequisites, and any recency of practice stipulations, are understood and met precisely as outlined by the ABIM. This direct engagement with the governing body’s guidelines is the most reliable method for confirming eligibility and preparing for the certification process, thereby upholding the standards of the profession. Incorrect Approaches Analysis: Pursuing certification based solely on anecdotal advice from colleagues, even experienced ones, is professionally unacceptable. While colleagues can offer valuable insights, their interpretations of eligibility requirements may be outdated, incomplete, or inaccurate. This reliance on informal information bypasses the definitive source of truth, the ABIM, and risks misinterpreting crucial criteria, potentially leading to wasted effort and resources, or worse, an invalid application. Relying on information from unofficial online forums or unofficial study groups, without cross-referencing with the ABIM’s official documentation, is also professionally unacceptable. These platforms can be a source of misinformation, speculation, or outdated advice. The dynamic nature of certification requirements necessitates consulting the most current and authoritative sources. Assuming that prior board certification in a related subspecialty automatically confers eligibility without explicit confirmation from the ABIM is professionally unacceptable. While related experience is often considered, specific pathways and requirements for each subspecialty certification are distinct. The ABIM has clearly defined criteria for each certification, and assuming equivalence without verification can lead to disqualification. Professional Reasoning: Professionals should adopt a systematic approach to board certification. This begins with identifying the relevant certifying board (in this case, the ABIM). Next, they must locate and meticulously review the most current official documentation outlining eligibility requirements, including any specific pathways for their training and practice history. If any aspect of the requirements remains unclear, the professional should proactively contact the ABIM directly for clarification. This proactive and evidence-based approach ensures compliance and a successful certification journey.

Scenario Analysis: This scenario is professionally challenging because it requires the physician to balance the immediate need for diagnostic information with the potential for patient harm from unnecessary radiation exposure and the financial implications of imaging choices. The physician must navigate the ethical imperative to provide appropriate care while also being mindful of resource stewardship and patient safety guidelines. This demands a systematic and evidence-based approach to diagnostic reasoning and imaging selection. Correct Approach Analysis: The best professional practice involves a systematic diagnostic reasoning workflow that prioritizes clinical information and patient factors to guide imaging selection. This approach begins with a thorough history and physical examination to generate a differential diagnosis. Based on this differential, the physician then considers the diagnostic yield and potential risks of various imaging modalities, consulting evidence-based guidelines and institutional protocols. The selection of imaging should be the least invasive and lowest radiation dose modality that can adequately answer the clinical question, with further imaging dictated by initial findings and evolving clinical status. This aligns with the principles of prudent use of medical resources and minimizing patient harm, as emphasized by professional medical societies and ethical codes that advocate for evidence-based, patient-centered care. Incorrect Approaches Analysis: One incorrect approach is to immediately order the most advanced or comprehensive imaging modality available without a clear clinical indication or prior consideration of less invasive options. This fails to adhere to the principle of judicious resource utilization and unnecessarily exposes the patient to higher radiation doses or contrast risks, potentially leading to iatrogenic harm and increased healthcare costs without a commensurate diagnostic benefit. It bypasses the crucial step of differential diagnosis and targeted investigation. Another incorrect approach is to rely solely on patient preference for a specific imaging test, even if it is not the most appropriate or evidence-based choice for their condition. While patient autonomy is important, it must be balanced with the physician’s professional responsibility to recommend and provide care that is medically sound and safe. Uncritically accepting a patient’s request for a particular scan without clinical justification can lead to inappropriate testing, misdiagnosis, or delayed diagnosis of the actual underlying condition. A further incorrect approach is to delay imaging indefinitely due to concerns about cost or radiation, even when the clinical presentation strongly suggests the need for prompt diagnostic evaluation. While cost and radiation are important considerations, they should not supersede the physician’s duty to diagnose and treat potentially serious conditions in a timely manner. Delaying necessary imaging can lead to disease progression, poorer outcomes, and ultimately higher healthcare costs due to more complex interventions or prolonged hospital stays. Professional Reasoning: Professionals should employ a structured diagnostic reasoning process. This involves: 1) Gathering comprehensive clinical data (history, physical exam, initial labs). 2) Formulating a prioritized differential diagnosis. 3) Evaluating the diagnostic utility and risks of various imaging modalities in the context of the differential. 4) Selecting the most appropriate imaging test based on evidence-based guidelines, patient factors, and the principle of minimizing harm and resource utilization. 5) Interpreting imaging results in conjunction with clinical findings and adjusting the diagnostic and management plan accordingly. This iterative process ensures that imaging is used effectively and ethically.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate needs of a critically ill patient with the ethical and legal obligations surrounding patient consent and the involvement of surrogate decision-makers. The physician must navigate a complex situation where the patient’s capacity is compromised, and a family member is present but may not fully grasp the nuances of the proposed intervention or their role in the decision-making process. Careful judgment is required to ensure the patient’s best interests are served while respecting their autonomy and legal rights. Correct Approach Analysis: The best professional practice involves a thorough assessment of the patient’s decision-making capacity. If the patient is deemed to lack capacity, the physician must then identify and engage the appropriate surrogate decision-maker according to established legal and ethical guidelines. This involves clearly explaining the patient’s condition, the proposed intervention (including its risks, benefits, and alternatives), and the surrogate’s role in making decisions based on the patient’s known wishes or best interests. This approach is correct because it upholds the principles of patient autonomy (even when exercised through a surrogate) and beneficence, while adhering to legal requirements for informed consent in situations of diminished capacity. It prioritizes a structured, ethical, and legally sound process. Incorrect Approaches Analysis: Proceeding with the intervention based solely on the family member’s expressed desire, without a formal capacity assessment of the patient or clear identification of the surrogate, is ethically and legally flawed. This bypasses the necessary steps to ensure the patient’s rights are protected and that the decision is truly aligned with their values or best interests. It risks acting without proper authorization. Obtaining consent from the patient despite clear signs of confusion and inability to comprehend the information presented is also unacceptable. This constitutes a failure to obtain true informed consent and violates the ethical principle of respecting patient autonomy. The patient’s apparent willingness does not equate to capacity. Delaying the intervention indefinitely due to the perceived difficulty in obtaining consent from a potentially confused patient or their family member, when the patient’s condition is critical and time-sensitive, can be detrimental to the patient’s well-being. While consent is crucial, a complete failure to act in a life-threatening situation, without exploring all avenues for surrogate decision-making, can violate the principle of beneficence and potentially lead to harm. Professional Reasoning: Professionals should employ a systematic approach when faced with patients who may lack decision-making capacity. This involves: 1) assessing the patient’s capacity to understand and appreciate the relevant information and to communicate a choice; 2) if capacity is lacking, identifying the legally recognized surrogate decision-maker; 3) engaging in a comprehensive discussion with the surrogate, providing all necessary information for informed decision-making; and 4) documenting the capacity assessment, the identification of the surrogate, and the consent process thoroughly. This framework ensures that patient rights are respected and that medical interventions are ethically and legally sound.

The evaluation methodology shows that managing patients with complex pulmonary and critical care needs requires a nuanced approach that balances evidence-based guidelines with individual patient circumstances and stakeholder input. This scenario is professionally challenging because it involves a patient with multiple comorbidities and a history of non-adherence, necessitating a careful consideration of treatment efficacy, patient safety, and the patient’s capacity to participate in their care plan. The physician must navigate potential conflicts between recommended best practices and the patient’s expressed preferences or perceived ability to follow complex regimens. The best professional practice involves a comprehensive, multidisciplinary approach that prioritizes shared decision-making and patient education. This includes thoroughly assessing the patient’s understanding of their condition and treatment options, identifying barriers to adherence, and collaboratively developing a realistic and personalized management plan. Engaging other healthcare professionals, such as nurses, pharmacists, and social workers, is crucial to address the patient’s physical, psychological, and social needs. This approach aligns with ethical principles of patient autonomy, beneficence, and non-maleficence, and is supported by guidelines emphasizing patient-centered care and the importance of addressing social determinants of health in chronic disease management. An approach that solely focuses on escalating aggressive medical interventions without adequately addressing the patient’s adherence issues or involving them in the decision-making process is professionally unacceptable. This fails to respect patient autonomy and may lead to further non-adherence, adverse events, and a breakdown in the patient-physician relationship. It neglects the ethical imperative to understand and mitigate barriers to effective treatment. Another professionally unacceptable approach is to dismiss the patient’s concerns or preferences due to a perceived lack of understanding or adherence. This paternalistic stance undermines patient trust and can lead to resentment and further disengagement from care. It violates the principle of shared decision-making and fails to acknowledge the patient’s lived experience and potential capacity for self-management with appropriate support. Finally, an approach that relies solely on the patient’s self-reported adherence without objective verification or exploration of contributing factors is also professionally deficient. While patient self-reporting is a starting point, it is often inaccurate and does not provide the physician with the full picture needed to tailor interventions effectively. This can lead to misdiagnosis of treatment effectiveness and inappropriate adjustments to therapy. The professional reasoning process for similar situations should involve a systematic assessment of the patient’s clinical status, a thorough exploration of their understanding and beliefs about their illness, identification of barriers to adherence (including social, economic, and psychological factors), and a collaborative development of a treatment plan that is both evidence-based and tailored to the individual’s circumstances and preferences. This process requires strong communication skills, empathy, and a commitment to interdisciplinary collaboration.

Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between a physician’s duty to advocate for their patient’s best interests and the institutional pressures that may arise from resource allocation decisions. The physician must navigate complex ethical considerations, including patient autonomy, beneficence, and justice, while also understanding the practical limitations and guidelines governing critical care unit admissions. The need for timely and effective patient management necessitates a clear and well-justified approach to bed allocation. Correct Approach Analysis: The best professional practice involves a direct, transparent, and evidence-based discussion with the admitting intensivist. This approach prioritizes patient well-being by ensuring that the admitting physician has all the necessary clinical information to make an informed decision based on established admission criteria. It respects the admitting intensivist’s role and expertise while advocating for the patient. This aligns with ethical principles of beneficence (acting in the patient’s best interest) and professional integrity, fostering collaborative care and avoiding miscommunication that could delay or compromise patient care. It also implicitly adheres to principles of justice by seeking fair application of admission criteria. Incorrect Approaches Analysis: One incorrect approach involves bypassing the admitting intensivist and directly contacting hospital administration. This is professionally unacceptable because it undermines the established clinical decision-making process for ICU admissions, which is the responsibility of the critical care team. It can lead to administrative interference in clinical judgment, potentially resulting in inappropriate admissions or denials based on non-clinical factors, violating principles of justice and potentially compromising patient safety. Another incorrect approach is to present the patient’s case to the admitting intensivist with an ultimatum or a demand for admission. This confrontational tactic is unprofessional and counterproductive. It can create animosity, hinder open communication, and detract from a collaborative approach to patient care. It fails to respect the admitting intensivist’s role and the established protocols for ICU bed allocation, potentially leading to a less objective assessment of the patient’s needs. A third incorrect approach is to delay presenting the patient to the admitting intensivist while seeking alternative, less appropriate, levels of care. This is ethically problematic as it may expose the patient to suboptimal treatment and delay definitive critical care management. It fails to uphold the physician’s duty of beneficence by not promptly pursuing the most appropriate level of care for a critically ill patient. Professional Reasoning: Professionals should approach such situations by first understanding the established admission criteria for the critical care unit. They should then gather all relevant clinical data to support their patient’s need for admission. The primary step should always be direct, respectful, and evidence-based communication with the admitting intensivist. If disagreements arise, a structured escalation process within the clinical hierarchy, involving the attending physician or department chief, should be followed, rather than involving non-clinical administrators or resorting to unprofessional tactics. The focus must remain on patient advocacy within the established ethical and professional framework.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the integrity of a high-stakes certification process with the need for fairness and transparency for candidates. Decisions regarding blueprint weighting, scoring, and retake policies have significant implications for individuals’ careers and the perceived validity of the certification. Missteps can lead to legal challenges, damage to the board’s reputation, and erosion of trust among pulmonary and critical care physicians. Careful judgment is required to ensure these policies are equitable, evidence-based, and aligned with the board’s mission. Correct Approach Analysis: The best professional practice involves a comprehensive review and revision process that is informed by robust data and stakeholder input, particularly from recent candidates and practicing physicians. This approach prioritizes evidence-based decision-making, ensuring that blueprint weighting accurately reflects current clinical practice and knowledge domains, that scoring methods are psychometrically sound and fair, and that retake policies are designed to support candidate development while maintaining certification standards. This aligns with the ethical obligation of professional bodies to uphold the quality and relevance of their certifications and to treat candidates with fairness and respect. Such a process would typically involve a committee of subject matter experts, psychometricians, and potentially a review of candidate performance data and feedback. Incorrect Approaches Analysis: One incorrect approach involves making arbitrary changes to blueprint weighting and retake policies based solely on anecdotal feedback from a small, vocal group of board members without empirical validation or broad stakeholder consultation. This fails to uphold the principle of evidence-based practice in assessment design and risks creating policies that are not reflective of current clinical realities or are unfairly burdensome to candidates. It also neglects the ethical responsibility to ensure fairness and transparency in the certification process. Another incorrect approach is to maintain existing scoring and retake policies without any periodic review, even in the face of emerging data suggesting potential inequities or outdated content coverage. This demonstrates a lack of commitment to continuous improvement and can lead to a certification that no longer accurately assesses essential competencies. It also fails to address potential systemic issues that might disadvantage certain groups of candidates, violating principles of equity and fairness. A third incorrect approach is to implement drastic, unannounced changes to scoring thresholds or retake limits immediately before an exam cycle, based on a perceived need for increased rigor. This would be highly unfair to candidates who have prepared under different expectations and would violate principles of procedural fairness and transparency. Such a reactive and poorly communicated change undermines the trust placed in the certification board and can lead to significant distress and disadvantage for candidates. Professional Reasoning: Professionals involved in certification governance should adopt a systematic and data-driven approach. This involves establishing clear policies for policy review and revision, including regular cycles for examining blueprint content, scoring methodologies, and retake guidelines. When considering changes, it is crucial to gather and analyze relevant data, including candidate performance metrics, expert consensus on clinical practice, and feedback from a diverse range of stakeholders. Decisions should be made by a qualified committee with appropriate expertise in assessment, clinical practice, and psychometrics. Transparency in communication regarding policy changes and the rationale behind them is paramount to maintaining candidate trust and the credibility of the certification.

The performance metrics show that a significant number of candidates preparing for the Applied North American Pulmonary and Critical Care Medicine Board Certification are reporting suboptimal readiness despite dedicated study time. This scenario is professionally challenging because it highlights a potential disconnect between candidate effort and effective preparation, impacting both individual career progression and the overall quality of future critical care physicians. Careful judgment is required to identify the most effective and ethically sound preparation strategies. The best approach involves a structured, multi-modal study plan that integrates diverse learning resources and incorporates regular self-assessment and feedback loops. This strategy is correct because it aligns with best practices in adult learning and professional development, emphasizing active recall, spaced repetition, and application of knowledge. It acknowledges that board certification requires not just memorization but also the ability to synthesize complex information and apply it clinically. Such a comprehensive approach, when coupled with realistic timelines, maximizes the likelihood of deep understanding and retention, which are crucial for successful board examination performance and subsequent patient care. This aligns with the ethical imperative to be competent and prepared in medical practice. An approach that relies solely on passively reviewing lecture notes and textbooks without active engagement or practice questions is professionally unacceptable. This fails to address the active recall and application skills necessary for board certification and can lead to a false sense of security. It bypasses established principles of effective learning and can result in candidates being unprepared for the exam’s format and demands, potentially leading to failure and the need for repeated attempts, which is inefficient and can delay entry into specialized practice. Another professionally unacceptable approach is to cram extensively in the final weeks before the exam, neglecting consistent, spaced study throughout the preparation period. This method is often ineffective for long-term knowledge retention and can lead to burnout and increased anxiety. It does not allow for the consolidation of complex concepts or the identification and remediation of knowledge gaps. This strategy can result in superficial learning, making it difficult to recall and apply information under the pressure of an examination, and ultimately compromises the candidate’s ability to demonstrate the required level of competence. Finally, an approach that focuses exclusively on memorizing high-yield facts without understanding the underlying pathophysiology or clinical context is also professionally unacceptable. While certain facts may be important, board examinations typically assess the ability to integrate knowledge and apply it to clinical scenarios. A purely memorization-based strategy will likely prove insufficient for answering application-based questions and demonstrating the critical thinking skills expected of a pulmonary and critical care specialist. This can lead to a candidate passing the exam without possessing the depth of understanding necessary for safe and effective patient care. Professionals should adopt a decision-making framework that prioritizes evidence-based learning strategies, realistic goal setting, and continuous self-evaluation. This involves researching and selecting resources that promote active learning, creating a study schedule that allows for consistent progress and review, and seeking opportunities for practice and feedback. Regularly assessing one’s own strengths and weaknesses and adjusting the study plan accordingly is paramount to ensuring thorough preparation and achieving the desired outcome.

This scenario presents a professional challenge due to the inherent conflict between a physician’s duty to advocate for their patient’s best interests and the potential for financial incentives to influence treatment decisions. Careful judgment is required to ensure that patient care remains paramount and free from undue influence. The best professional practice involves a transparent and patient-centered approach. This means openly discussing all available treatment options, including their risks, benefits, and costs, with the patient and their family. It requires prioritizing the patient’s values and preferences in shared decision-making. Furthermore, physicians must adhere to ethical guidelines that prohibit accepting inducements that could compromise their professional judgment. This approach aligns with the core principles of medical ethics, such as beneficence, non-maleficence, and patient autonomy, and upholds the trust placed in physicians by their patients and society. An approach that prioritizes the financial benefits to the institution or physician over the patient’s needs is ethically unacceptable. This could involve steering patients towards more expensive treatments without clear clinical justification, thereby violating the principle of non-maleficence by potentially exposing the patient to unnecessary risks or financial burdens. Such actions could also contravene regulations designed to prevent healthcare fraud and abuse, which aim to ensure that medical decisions are based on clinical necessity rather than financial gain. Another professionally unacceptable approach is to withhold information about less expensive, equally effective treatment alternatives. This failure to provide comprehensive information undermines patient autonomy, as patients cannot make informed decisions if they are not aware of all viable options. It also breaches the physician’s duty of candor and can lead to a loss of patient trust. Finally, an approach that focuses solely on the physician’s personal financial gain, without adequate consideration for the patient’s well-being or institutional policies, is a clear ethical and professional failing. This demonstrates a disregard for the fiduciary duty physicians owe to their patients and can lead to severe professional repercussions, including disciplinary action and legal consequences. Professionals should employ a decision-making framework that consistently places patient welfare at the forefront. This involves a thorough understanding of available treatment options, their evidence base, and their cost-effectiveness. It necessitates open communication with patients, active listening to their concerns and preferences, and shared decision-making. Adherence to institutional policies and professional ethical codes, coupled with a commitment to continuous learning and critical self-reflection, are crucial for navigating complex situations and maintaining the highest standards of patient care.

The analysis reveals a scenario that is professionally challenging due to the inherent tension between a physician’s duty to provide optimal patient care and the financial realities of healthcare systems, particularly when considering the ethical implications of resource allocation and patient advocacy. Careful judgment is required to navigate these competing interests while upholding professional integrity and patient well-being. The approach that represents best professional practice involves a comprehensive, evidence-based assessment of the patient’s condition and treatment options, followed by a transparent and collaborative discussion with the patient and their family regarding the most appropriate and feasible care plan. This includes exploring all available treatment modalities, considering their efficacy, potential benefits, risks, and costs, and advocating for the patient’s needs within the established healthcare framework. This approach is correct because it prioritizes patient autonomy and beneficence, aligning with core ethical principles of medicine. It also adheres to professional guidelines that emphasize shared decision-making and the physician’s role as a patient advocate, ensuring that treatment decisions are informed, personalized, and ethically sound. An incorrect approach involves solely focusing on the most expensive or technologically advanced treatment options without a thorough evaluation of their necessity or the patient’s ability to benefit, potentially leading to unnecessary financial burden and suboptimal outcomes. This fails to uphold the principle of non-maleficence by exposing the patient to potential harm from overly aggressive or inappropriate interventions and violates the ethical duty to be a responsible steward of healthcare resources. Another incorrect approach is to defer entirely to institutional financial constraints without adequately exploring all possible avenues for patient care or advocating for exceptions when clinically warranted. This can be perceived as a failure to adequately represent the patient’s best interests and may lead to a denial of necessary care, undermining the physician’s fiduciary duty to the patient. A further incorrect approach involves making treatment decisions based on personal biases or assumptions about the patient’s financial status or willingness to undergo treatment, without direct communication or exploration of options. This infringes upon patient autonomy and can lead to discriminatory practices, violating fundamental ethical principles of justice and respect for persons. The professional reasoning process for similar situations should involve a systematic evaluation of the clinical situation, a thorough understanding of available treatment options and their evidence base, and an open dialogue with the patient and their family. Physicians should be adept at navigating institutional policies and financial considerations while remaining steadfast in their commitment to patient advocacy. This requires strong communication skills, ethical reasoning, and a willingness to explore creative solutions that balance clinical necessity with resource availability.

This scenario presents a significant professional challenge due to the inherent conflict between a physician’s duty to advocate for their patient’s best interests and the financial realities and resource allocation decisions within a healthcare system. The physician must navigate complex ethical considerations, including patient autonomy, beneficence, non-maleficence, and justice, while also respecting the operational constraints of the hospital. Careful judgment is required to balance these competing demands without compromising patient care or professional integrity. The best approach involves a multi-faceted strategy that prioritizes open communication and collaborative problem-solving. This includes thoroughly explaining the rationale for the recommended treatment to the patient and their family, clearly outlining the potential benefits and risks, and exploring all available alternatives, including less expensive but still effective options. Simultaneously, the physician should engage with hospital administration and the relevant care management or ethics committee to advocate for the patient’s needs, presenting a compelling case for the necessity of the proposed intervention and exploring potential avenues for financial assistance or alternative resource allocation. This approach upholds the principles of informed consent by ensuring the patient is fully aware of their options and can make an autonomous decision. It also aligns with the ethical obligation of beneficence by seeking the best possible outcome for the patient, while also acknowledging the systemic considerations of resource stewardship. An approach that solely focuses on the patient’s immediate financial limitations without exploring all clinical alternatives or advocating for systemic solutions is ethically flawed. This fails to fully inform the patient about all medically appropriate options and may lead to a suboptimal treatment decision based on financial constraints rather than clinical need. Furthermore, it neglects the physician’s role as an advocate within the healthcare system. Another unacceptable approach involves unilaterally overriding the patient’s financial concerns and proceeding with the most expensive treatment without adequate discussion or exploration of alternatives. This violates the principle of patient autonomy and informed consent, as the patient’s financial situation and preferences are not adequately considered. It also demonstrates a lack of respect for the patient’s circumstances and can erode trust. Finally, an approach that involves simply deferring the decision to the hospital’s financial department without active physician involvement or advocacy fails to fulfill the physician’s ethical obligations. While financial considerations are important, the physician’s primary responsibility is to the patient’s well-being, and they must actively participate in finding solutions that balance clinical necessity with resource availability. Professionals should approach such situations by first understanding the patient’s values, preferences, and financial situation. This should be followed by a comprehensive clinical assessment and discussion of all medically appropriate treatment options, including their risks, benefits, and costs. The physician should then act as a patient advocate, engaging with hospital administration, ethics committees, and social work to explore all possible avenues for support and resource allocation, ensuring that the final decision is a shared one, made with full information and respect for all parties involved. QUESTION: Comparative studies suggest that physicians often face ethical dilemmas when recommended treatments exceed a patient’s financial capacity. In such a scenario, what is the most ethically sound and professionally responsible course of action for a pulmonary and critical care physician? OPTIONS: a) Engage in open and transparent communication with the patient and family about the recommended treatment, its rationale, potential benefits, risks, and all available alternatives, while simultaneously advocating with hospital administration and relevant committees for the patient’s needs and exploring financial assistance options. b) Inform the patient that the recommended treatment is too expensive and suggest they explore alternative, less effective treatments that are within their financial means. c) Proceed with the most clinically indicated treatment regardless of the patient’s financial concerns, assuming the hospital’s financial department will manage the cost issues. d) Defer the decision entirely to the hospital’s financial department and social work services, without actively participating in the discussion or advocacy for the patient.