The efficiency study reveals a significant gap in post-discharge palliative care follow-up for patients with complex chronic conditions, leading to increased hospital readmissions and patient distress. This scenario is professionally challenging because it pits the imperative of efficient resource allocation against the ethical and regulatory obligations to ensure continuity of care and patient well-being. Balancing cost-effectiveness with the fundamental right to quality palliative care requires careful ethical deliberation and adherence to established professional standards. The best approach involves proactively engaging the patient and their family in developing a comprehensive, individualized discharge plan that explicitly outlines post-discharge palliative care services, including clear communication channels with the hospice team and primary care providers. This approach is correct because it directly addresses the identified gap by ensuring seamless transitions and sustained support, aligning with the principles of patient-centered care and the ethical duty to promote patient autonomy and dignity. Regulatory frameworks, such as those governing continuity of care and patient rights in palliative settings, mandate such proactive planning and communication to prevent adverse outcomes and ensure that care needs are met beyond the acute care episode. This also supports population health promotion by establishing a model for effective chronic disease management and palliative care integration. An incorrect approach would be to rely solely on standard discharge instructions without a dedicated palliative care follow-up mechanism. This fails to acknowledge the unique needs of patients with complex chronic conditions requiring palliative support and neglects the ethical obligation to ensure continuity of care, potentially leading to preventable readmissions and a decline in quality of life. Another incorrect approach would be to delegate all post-discharge palliative care coordination to the patient’s family without adequate professional oversight or support. This places an undue burden on caregivers and risks overlooking critical care needs, violating the principle of providing appropriate professional support and potentially leading to patient neglect. Finally, an approach that prioritizes cost savings by reducing the scope of post-discharge palliative care services, even if technically compliant with minimum standards, would be ethically unsound. It would fail to uphold the commitment to providing high-quality, comprehensive palliative care and would disregard the potential negative impact on patient outcomes and well-being, contravening the core ethical tenets of beneficence and non-maleficence. Professionals should employ a decision-making process that begins with identifying the patient’s comprehensive needs, including their palliative care requirements and psychosocial support. This should be followed by a thorough review of relevant regulatory guidelines and ethical principles governing continuity of care and patient rights. Collaborative planning with the patient, family, and interdisciplinary team is crucial, ensuring that the discharge plan is realistic, achievable, and addresses potential barriers to care. Ongoing evaluation and adaptation of the plan based on patient progress and evolving needs are essential components of effective palliative care delivery.

The efficiency study reveals a critical juncture in palliative care delivery, presenting a significant ethical dilemma for the nursing team. The challenge lies in balancing the imperative to provide high-quality, individualized patient care with the organizational pressure to optimize resource allocation and meet performance metrics. This scenario is professionally challenging because it pits the core nursing value of patient advocacy and holistic care against the economic realities and operational demands of a healthcare system. Nurses are ethically bound to prioritize patient well-being and dignity, which may conflict with efficiency targets that could inadvertently compromise care. Careful judgment is required to navigate these competing interests without sacrificing patient safety or the ethical integrity of the nursing profession. The approach that represents best professional practice involves advocating for the patient’s needs while seeking collaborative solutions that address both care quality and efficiency. This entails a thorough assessment of the patient’s specific requirements, understanding the limitations imposed by the efficiency study, and engaging in open communication with the interdisciplinary team and management. By presenting evidence-based arguments for necessary resources or adjustments to care plans that directly benefit the patient, and by proposing alternative, equally effective but potentially more resource-conscious methods, the nurse acts as a patient advocate and a problem-solver. This approach aligns with ethical principles of beneficence (acting in the patient’s best interest), non-maleficence (avoiding harm), and justice (fair allocation of resources), while also respecting professional autonomy and accountability. It upholds the professional standard of care by ensuring that patient needs are met without compromising their quality of life or dignity, even within a framework of efficiency. An approach that prioritizes meeting the efficiency targets without fully considering the patient’s unique needs and potential negative impacts would be professionally unacceptable. This failure to adequately assess and advocate for the patient’s specific situation could lead to suboptimal care, increased patient distress, and a violation of the ethical duty to provide individualized care. It neglects the principle of patient-centered care and could result in harm by overlooking crucial aspects of the patient’s comfort, pain management, or emotional support. Another professionally unacceptable approach would be to unilaterally alter the care plan to strictly adhere to the efficiency study’s recommendations without consulting the patient, family, or the interdisciplinary team. This bypasses essential communication and collaboration, undermining the holistic approach to care and potentially leading to a breakdown in trust. It disregards the expertise of other team members and the patient’s right to be involved in decisions about their care. Finally, an approach that involves simply refusing to implement any changes suggested by the efficiency study without offering constructive alternatives or engaging in dialogue would also be professionally problematic. While it may stem from a desire to protect patient care, it fails to acknowledge the organization’s need for operational improvement and misses an opportunity to collaboratively find solutions that benefit both patients and the system. This can lead to an adversarial relationship and hinder progress. Professionals should employ a decision-making framework that begins with a comprehensive understanding of the patient’s needs and values. This should be followed by an objective assessment of the proposed changes in light of these needs. Open and honest communication with the patient, family, and the interdisciplinary team is paramount. If conflicts arise, nurses should seek to understand the rationale behind the efficiency study’s recommendations and explore potential modifications or alternative strategies that can achieve similar efficiency goals without compromising patient care. Escalation to appropriate channels within the organization should be considered if patient well-being remains at risk.

This scenario presents a professional challenge due to the inherent conflict between a patient’s expressed wishes and the perceived best interests of their family, complicated by the sensitive nature of end-of-life care and the potential for differing interpretations of quality of life. Navigating these differing perspectives requires a delicate balance of empathy, clear communication, and adherence to ethical principles and professional standards. The best professional approach involves prioritizing open, empathetic communication with the patient and their family, actively seeking to understand all perspectives, and collaboratively developing a care plan that respects the patient’s autonomy while addressing the family’s concerns. This approach is correct because it upholds the fundamental ethical principle of patient autonomy, which dictates that competent individuals have the right to make decisions about their own medical care, even if those decisions differ from what others might choose. It also aligns with palliative care principles that emphasize holistic care, involving the patient and their loved ones in decision-making to ensure comfort, dignity, and alignment with personal values. Regulatory frameworks in hospice and palliative care universally support shared decision-making and patient-centered care. An incorrect approach would be to unilaterally prioritize the family’s expressed desire for aggressive interventions over the patient’s stated wishes for comfort-focused care. This fails to respect patient autonomy, a cornerstone of ethical medical practice. It also risks causing distress to the patient and undermining the trust essential in the therapeutic relationship. Ethically, this approach prioritizes the wishes of others over the individual receiving care, which is a violation of patient rights. Another incorrect approach would be to avoid direct discussion with the patient about their end-of-life preferences, instead relying solely on family input. This is ethically problematic as it bypasses the primary stakeholder in the care decisions and can lead to care that is misaligned with the patient’s true desires. It also fails to provide the patient with the opportunity to express their values and fears, which is crucial for providing meaningful palliative care. Finally, an incorrect approach would be to impose a care plan based on the healthcare team’s subjective assessment of the patient’s “quality of life” without thorough, collaborative discussion and explicit patient consent. This can be paternalistic and may not reflect the patient’s own definition of a good quality of life, especially in the context of chronic or terminal illness. It disregards the patient’s lived experience and their right to self-determination. Professional decision-making in such situations requires a structured process: first, ensuring the patient’s capacity to make decisions; second, engaging in open, honest, and empathetic communication with both the patient and their family to understand all perspectives and concerns; third, educating all parties about the patient’s prognosis and available care options, including the benefits and burdens of each; and fourth, facilitating a shared decision-making process that ultimately respects the competent patient’s choices, while providing support to the family.

This scenario presents a professional challenge because it requires navigating the inherent tension between maintaining the integrity of a quality and safety review process and accommodating individual circumstances that may impact a candidate’s performance. The blueprint weighting, scoring, and retake policies are designed to ensure a standardized and equitable assessment of nursing competency across the pan-regional hospice and palliative care network. Deviating from these established policies without clear, objective justification risks undermining the credibility of the review and potentially compromising patient care standards. The best approach involves a thorough review of the existing retake policy and a clear, documented process for evaluating exceptional circumstances. This approach is correct because it upholds the established framework for quality and safety assurance while providing a mechanism for fairness. Specifically, it aligns with the ethical principle of justice by ensuring that all candidates are assessed against the same standards, but also acknowledges the need for due process and consideration of extenuating factors that are beyond an individual’s control. The policy itself, when properly applied, serves as the regulatory guide for such situations, ensuring consistency and preventing arbitrary decisions. This method prioritizes transparency and adherence to established governance structures, which are paramount in healthcare quality assurance. An incorrect approach would be to grant a retake solely based on a candidate’s expressed desire or a vague assertion of personal difficulty without requiring substantiation. This fails to adhere to the established retake policy, which is the governing regulatory framework for such situations. Ethically, this approach risks violating the principle of fairness to other candidates who have met the policy requirements. It also bypasses the established quality assurance mechanisms, potentially allowing individuals to proceed without demonstrating the required competency, which could have implications for patient safety. Another incorrect approach is to dismiss the candidate’s request outright without any consideration of the retake policy or the possibility of extenuating circumstances. This demonstrates a lack of empathy and potentially a failure to follow due process as outlined in the policy. While adherence to policy is crucial, a rigid, unyielding stance without exploring the policy’s provisions for exceptional cases can be professionally detrimental and ethically questionable, particularly in a field focused on compassionate care. A further incorrect approach would be to arbitrarily alter the scoring or weighting of the review for the individual candidate. This directly undermines the blueprint’s purpose, which is to provide a standardized measure of competency. Such an action would violate the principles of equity and validity inherent in any assessment process and would be a clear breach of the established quality and safety review framework. Professionals should approach such situations by first understanding the established blueprint weighting, scoring, and retake policies thoroughly. They should then assess the candidate’s request against these policies, looking for specific provisions that address extenuating circumstances. If such provisions exist, the professional should follow the documented procedure for evaluating the evidence presented by the candidate. This involves objective assessment, clear communication with the candidate, and documentation of the decision-making process. If the policies are unclear or do not adequately address the situation, escalation to a designated review committee or supervisor, following established protocols, is the appropriate next step to ensure consistent and fair application of the review standards.

The risk matrix shows a potential for increased patient falls in the palliative care unit, highlighting a critical quality and safety concern. This scenario is professionally challenging because it requires a nuanced understanding of the purpose and eligibility criteria for the Applied Pan-Regional Hospice and Palliative Nursing Quality and Safety Review, balancing immediate patient needs with the broader goals of quality improvement and regulatory compliance. Careful judgment is required to determine the most appropriate course of action that aligns with the review’s objectives and ensures patient safety. The best approach involves proactively engaging with the review process by submitting a comprehensive application that clearly articulates the identified risk, the unit’s current quality improvement initiatives related to fall prevention, and a request for the review to assess the effectiveness of these measures and identify further areas for enhancement. This approach is correct because the Applied Pan-Regional Hospice and Palliative Nursing Quality and Safety Review is designed precisely for situations where a unit identifies specific quality or safety concerns and seeks expert evaluation and guidance to improve patient outcomes. By framing the application around the fall risk, the unit demonstrates a commitment to data-driven quality improvement and leverages the review’s purpose to address a tangible patient safety issue. This aligns with the ethical imperative to provide safe and effective care and the regulatory expectation for continuous quality improvement in palliative settings. An incorrect approach would be to delay the application until a formal incident report is filed, arguing that the risk matrix alone does not constitute a “critical incident” necessitating immediate review. This fails to recognize that the review’s purpose extends beyond responding to adverse events; it is also a proactive tool for identifying and mitigating potential risks before they result in harm. Ethically, delaying action on a known risk is unacceptable. Another incorrect approach would be to submit a generic application for review without specifically mentioning the fall risk, hoping the review team will identify it. This is professionally unacceptable because it misrepresents the unit’s understanding of the review’s purpose and its own quality priorities. The review is most effective when it is targeted and informed by the unit’s specific challenges. Finally, an incorrect approach would be to dismiss the risk matrix as a preliminary indicator and decide to manage the fall risk internally without seeking external review, believing the unit has sufficient expertise. This overlooks the value of the Applied Pan-Regional Hospice and Palliative Nursing Quality and Safety Review as a mechanism for external validation, knowledge sharing, and identifying best practices that might not be apparent from an internal perspective. It also fails to fully utilize a resource designed to enhance quality and safety across the pan-regional network. Professionals should approach such situations by first understanding the stated purpose and eligibility criteria of any quality and safety review. They should then assess internal data and risk assessments to identify specific areas where external expertise or validation would be most beneficial. A proactive, transparent, and targeted application that clearly articulates the identified issue and the desired outcomes from the review process is the most effective strategy for leveraging these valuable resources to improve patient care.

This scenario is professionally challenging because it requires balancing the immediate needs of a patient with the long-term implications of their care, all while navigating the complexities of a pan-regional healthcare system. Ensuring consistent, high-quality assessment and monitoring across diverse patient populations and care settings demands a robust understanding of both clinical best practices and the ethical imperative to provide equitable care. The challenge lies in translating broad quality and safety principles into actionable, individualized care plans that respect the lifespan needs of hospice and palliative care patients. The best approach involves a systematic, individualized assessment that integrates patient and family goals with evidence-based diagnostic and monitoring strategies across the lifespan. This includes recognizing that a child’s developmental stage, an adult’s life experiences, and an elder’s physiological changes all necessitate tailored approaches to pain management, symptom control, and psychosocial support. Regulatory frameworks, such as those guiding palliative care standards and patient rights, emphasize the importance of comprehensive, ongoing assessment that respects patient autonomy and dignity. Ethical principles of beneficence and non-maleficence demand that care be adapted to the unique needs of each patient at every stage of life, ensuring that interventions are appropriate and beneficial. An approach that relies solely on standardized protocols without considering individual lifespan needs fails to acknowledge the unique physiological, psychological, and social factors that influence symptom presentation and response to treatment at different ages. This can lead to suboptimal care, potentially causing unnecessary suffering or failing to address critical issues. For example, a protocol designed for adults might overlook the specific communication challenges or developmental needs of a pediatric patient, or it might not adequately address the complex comorbidities often seen in older adults. Another incorrect approach is to prioritize diagnostic testing over symptom assessment and patient-reported outcomes. While diagnostics are important, in palliative and hospice care, the primary focus is on symptom relief and quality of life. Over-reliance on diagnostic procedures without considering the patient’s experience and goals can be burdensome, invasive, and may not directly contribute to improved comfort or function. This can also lead to a misallocation of resources and a deviation from the core principles of palliative care. Finally, an approach that neglects to involve the patient and their family in the assessment and monitoring process is ethically and professionally unsound. Patient and family preferences, values, and goals are central to developing an effective care plan. Failing to solicit this input can result in care that is misaligned with the patient’s wishes, leading to dissatisfaction and potentially compromising the therapeutic relationship. Professional decision-making in these situations requires a commitment to patient-centered care, continuous learning, and adherence to ethical guidelines that prioritize patient well-being and dignity across all stages of life.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate needs and preferences of a patient with complex palliative care requirements against the established evidence-based protocols designed to ensure optimal quality and safety. The family’s strong emotional investment and potential misunderstanding of palliative care principles can create friction, necessitating sensitive communication and a commitment to shared decision-making while upholding professional standards. Correct Approach Analysis: The best professional approach involves a collaborative discussion with the patient and their family, clearly articulating the evidence-based rationale for the proposed nursing interventions and care plan. This approach prioritizes patient autonomy and informed consent, ensuring that all parties understand the goals of palliative care, which are focused on symptom management, comfort, and quality of life. By explaining how specific interventions, such as regular repositioning for pressure ulcer prevention or scheduled pain medication administration, are supported by robust clinical evidence and directly contribute to the patient’s well-being and dignity, the care team builds trust and facilitates shared decision-making. This aligns with ethical principles of beneficence, non-maleficence, and respect for autonomy, and implicitly adheres to professional nursing standards that mandate evidence-based practice and patient-centered care. Incorrect Approaches Analysis: One incorrect approach involves overriding the family’s concerns without thorough explanation or exploration of their underlying fears. This can lead to a breakdown in trust, patient dissatisfaction, and potential non-adherence to the care plan, undermining the goals of palliative care and potentially violating the patient’s right to participate in their care decisions. It fails to acknowledge the family’s role and emotional distress. Another incorrect approach is to proceed with interventions solely based on the family’s stated preferences, even if these preferences contradict established evidence-based practices for palliative care. This risks providing suboptimal care, potentially leading to preventable suffering or complications, and deviates from the professional obligation to provide care that is known to be effective and safe. It prioritizes perceived family satisfaction over evidence-based quality and safety. A further incorrect approach is to dismiss the family’s input as uninformed and proceed with the care plan without attempting to educate or engage them. This demonstrates a lack of empathy and poor communication skills, which are crucial in palliative care. It can alienate the family, create a hostile care environment, and prevent the formation of a therapeutic alliance necessary for effective care delivery. Professional Reasoning: Professionals should employ a structured approach to address such situations. First, actively listen to and acknowledge the family’s concerns and perspectives. Second, clearly and compassionately explain the evidence-based rationale behind the proposed care plan, linking interventions directly to the patient’s comfort, symptom management, and quality of life goals. Third, engage in shared decision-making, exploring any discrepancies between the evidence-based plan and the family’s wishes, and seeking mutually agreeable solutions that uphold the patient’s best interests and professional standards. Finally, document all discussions, decisions, and the rationale for the care plan.

This scenario is professionally challenging because it requires balancing the need for efficient candidate preparation with the ethical imperative of providing accurate and comprehensive information. Misleading candidates about the scope or availability of resources can lead to inadequate preparation, negatively impacting their performance and potentially compromising patient care standards if they are not fully equipped. Careful judgment is required to ensure transparency and support without creating false expectations. The best approach involves proactively identifying and communicating a realistic timeline for accessing comprehensive study materials, including official guidelines, practice assessments, and recommended reading lists. This approach is correct because it aligns with the ethical duty of care towards candidates, ensuring they have a fair opportunity to prepare. It also reflects best practice in professional development, where clear communication about expectations and resources is paramount. Providing this information well in advance allows candidates to plan their study schedules effectively, manage their time, and seek clarification on any ambiguities, thereby fostering a more equitable and effective learning environment. This proactive communication also supports the integrity of the certification process by ensuring all candidates are working with the same foundational understanding of what is required. An incorrect approach involves suggesting that candidates can rely solely on informal study groups and anecdotal advice from past participants. This fails to acknowledge the importance of official, vetted preparation resources and can lead to candidates being misinformed about the current standards and expectations. It risks overlooking critical updates or nuances in the applied pan-regional hospice and palliative nursing quality and safety review that may not be captured in informal discussions. Another incorrect approach is to recommend that candidates focus only on the most recent examination content without providing access to the full range of preparatory materials. This can create a narrow focus that might miss foundational knowledge or broader quality and safety principles essential for comprehensive understanding. It also fails to equip candidates with the tools to assess their own knowledge gaps effectively. A further incorrect approach is to imply that the examination is largely intuitive and requires minimal formal preparation, suggesting that on-the-job experience is sufficient. This understates the rigor of a formal review process and the specific knowledge and skills it aims to assess. It can lead to candidates underestimating the effort required, resulting in inadequate preparation and potentially a failure to meet the established quality and safety benchmarks. The professional reasoning process for making decisions in similar situations should involve prioritizing transparency, accuracy, and fairness. Professionals should always refer to official guidelines and recommendations when advising on preparation. They should consider the potential impact of their advice on candidate outcomes and the overall integrity of the certification process. A framework that emphasizes clear communication of expectations, provision of reliable resources, and encouragement of proactive engagement with official materials will best serve both the candidates and the profession.

The evaluation methodology shows that ensuring accurate and compliant clinical documentation is paramount in hospice and palliative care, especially when dealing with the complexities of interdisciplinary team communication and regulatory oversight. This scenario is professionally challenging because it requires balancing the immediate need for patient care with the long-term implications of documentation for quality assessment, reimbursement, and legal defensibility. Missteps in documentation can lead to significant compliance issues, impacting patient safety and organizational reputation. The best approach involves a systematic review of all available documentation, including electronic health records (EHRs), physician orders, nursing notes, therapy evaluations, and social work assessments, to identify any discrepancies or omissions that could affect the accuracy of the patient’s care plan or billing. This approach prioritizes a comprehensive understanding of the patient’s status and the services provided, ensuring that all documentation aligns with established clinical standards and regulatory requirements. Specifically, it addresses the need to reconcile information across different disciplines, a common challenge in pan-regional care settings. This thoroughness is crucial for demonstrating adherence to quality indicators and for supporting accurate claims submission, thereby meeting the requirements of regulatory bodies and payers. An approach that focuses solely on the physician’s progress notes without cross-referencing other disciplines’ contributions is professionally unacceptable. This failure neglects the interdisciplinary nature of hospice and palliative care, where input from nurses, therapists, and social workers is vital for a holistic patient assessment and care plan. Such a narrow focus risks overlooking critical patient needs or services rendered, leading to incomplete documentation that does not accurately reflect the care provided. This can result in non-compliance with documentation standards, potentially jeopardizing quality reporting and reimbursement. Another professionally unacceptable approach is to assume that the EHR automatically captures all necessary information without manual verification. While EHRs are powerful tools, they are susceptible to data entry errors, system glitches, or incomplete charting by individual team members. Relying on the system without independent review can perpetuate inaccuracies and omissions, leading to a false sense of compliance. This oversight fails to acknowledge the human element in documentation and the need for diligent quality control. Finally, an approach that prioritizes the speed of documentation over its accuracy and completeness is also professionally unacceptable. In a fast-paced environment, there can be pressure to complete notes quickly. However, rushing the process can lead to vague entries, missing critical details, or even factual errors. This haste undermines the integrity of the clinical record, which is essential for continuity of care, legal protection, and regulatory compliance. It demonstrates a lack of commitment to the fundamental principles of good clinical documentation. Professionals should adopt a decision-making process that begins with understanding the specific regulatory requirements for clinical documentation in their jurisdiction. This involves regularly reviewing relevant guidelines from governing bodies and accreditation organizations. When faced with documentation challenges, professionals should systematically cross-reference information from all members of the interdisciplinary team, ensuring consistency and completeness. They should also implement a quality assurance process for documentation, which may include peer review or audits, to identify and correct errors proactively. Prioritizing accuracy, thoroughness, and compliance over speed is essential for maintaining high standards of patient care and organizational integrity.

This scenario is professionally challenging because it requires balancing a patient’s deeply held cultural beliefs with established medical protocols, while also ensuring the patient’s autonomy and dignity are respected. Navigating these competing demands necessitates a nuanced understanding of patient advocacy, ethical principles, and the practice of cultural humility. Careful judgment is required to avoid imposing personal biases or medical paternalism, and to foster a trusting relationship that supports optimal care. The best approach involves actively listening to the patient and their family to understand the specific cultural beliefs and their implications for care decisions. This includes inquiring about the meaning and significance of their practices and collaboratively developing a care plan that respects these beliefs as much as medically feasible, while clearly communicating any limitations or risks. This approach aligns with the ethical principles of respect for autonomy, beneficence, and non-maleficence. It also embodies cultural humility by acknowledging the limits of one’s own knowledge and approaching the patient’s cultural background with a desire to learn and understand, rather than to judge or dismiss. Patient advocacy is central here, as the healthcare professional acts as a liaison and champion for the patient’s values and preferences within the healthcare system. An approach that dismisses the family’s concerns as mere superstition or resistance to medical advice fails to acknowledge the profound impact of cultural beliefs on health decisions and patient well-being. This demonstrates a lack of cultural humility and can lead to a breakdown in trust, patient non-adherence, and potentially harmful outcomes. It violates the principle of respect for autonomy by not adequately considering the patient’s values. Another unacceptable approach is to proceed with medical interventions without fully understanding or attempting to accommodate the cultural practices, assuming that the patient will eventually comply or that medical necessity overrides cultural considerations. This approach is ethically problematic as it disregards the patient’s right to make informed decisions based on their own cultural framework and can be perceived as coercive. It also fails in patient advocacy by not actively seeking solutions that integrate patient values with medical care. Finally, an approach that involves imposing the healthcare team’s preferred course of action without genuine engagement or exploration of alternatives, based on the belief that they possess superior knowledge, represents medical paternalism. This undermines patient autonomy and fails to recognize the patient as an active participant in their care. It also lacks cultural humility by assuming a universal standard of care that may not be culturally congruent or acceptable. Professionals should employ a decision-making framework that prioritizes open communication, active listening, and a genuine desire to understand the patient’s cultural context. This involves asking open-ended questions, seeking clarification, and validating the patient’s experiences and beliefs. When conflicts arise, the focus should be on collaborative problem-solving, exploring potential compromises, and clearly articulating the rationale behind medical recommendations while respecting the patient’s ultimate right to decide.