Scenario Analysis: This scenario presents a common challenge in specialized medical fields like structural heart disease: efficiently gathering critical information from a patient with potentially complex symptoms and a history that may be difficult to elicit due to their condition. The professional challenge lies in balancing the need for a comprehensive understanding of the patient’s cardiac status with the practical limitations of their current state and the time constraints of clinical practice. A hypothesis-driven approach is essential to avoid getting lost in extraneous details and to focus on the most probable causes of the patient’s presentation, thereby optimizing diagnostic yield. Correct Approach Analysis: The best professional practice involves initiating the history taking by formulating a primary hypothesis based on the patient’s presenting complaint and initial observations. This hypothesis then guides the subsequent questioning, focusing on symptoms, risk factors, and past medical history directly relevant to that hypothesis. For example, if the presenting complaint is exertional dyspnea, the initial hypothesis might center on worsening valvular stenosis or heart failure. The clinician would then systematically explore associated symptoms like chest pain, palpitations, syncope, and edema, while also inquiring about relevant comorbidities such as hypertension, diabetes, and previous cardiac interventions. This structured, yet flexible, approach ensures that high-yield information is gathered efficiently, minimizing patient fatigue and maximizing diagnostic accuracy. This aligns with ethical principles of beneficence and non-maleficence by prioritizing the patient’s well-being and avoiding unnecessary diagnostic detours. Incorrect Approaches Analysis: An approach that begins with a broad, unfocused inquiry without a guiding hypothesis is inefficient and risks overwhelming the patient with irrelevant questions. This can lead to a superficial understanding of the core problem and a failure to identify critical diagnostic clues. It also fails to respect the patient’s time and potential discomfort. Another incorrect approach is to solely rely on a pre-defined checklist of questions without adapting them to the patient’s specific presentation or evolving hypotheses. While checklists can be useful for ensuring completeness, rigid adherence can lead to missing unique aspects of a patient’s condition and can feel impersonal, potentially hindering rapport. Finally, an approach that prioritizes physical examination findings over a targeted history is also suboptimal. While physical examination is crucial, a well-directed history can significantly refine the differential diagnosis and guide the focus of the physical exam, making it more efficient and informative. Without a hypothesis to guide the examination, clinicians may perform a more exhaustive, and potentially less relevant, set of maneuvers. Professional Reasoning: Professionals should adopt a dynamic, hypothesis-driven approach to history taking. This involves: 1) Actively listening to the presenting complaint and observing initial signs. 2) Formulating a preliminary differential diagnosis (hypothesis). 3) Designing targeted questions and physical examination maneuvers to confirm or refute these hypotheses. 4) Being prepared to revise hypotheses as new information emerges. This iterative process ensures efficient and effective patient assessment, leading to more accurate diagnoses and appropriate management plans.

Scenario Analysis: This scenario is professionally challenging because it requires balancing a patient’s expressed wishes with the clinician’s professional judgment regarding the appropriateness and potential benefit of a novel, albeit promising, treatment. The core tension lies in respecting patient autonomy while upholding the principle of beneficence and avoiding potential harm from an unproven intervention. Navigating this requires a deep understanding of informed consent, ethical considerations in experimental treatments, and the regulatory landscape governing such interventions. Correct Approach Analysis: The best professional practice involves a comprehensive, multi-faceted discussion with the patient and their family. This approach prioritizes thorough education about the experimental nature of the therapy, its potential risks and benefits based on available data, and the standard of care alternatives. It also necessitates a collaborative decision-making process, involving the patient’s values and preferences, and ensuring they fully comprehend the uncertainties. Crucially, this approach includes seeking input from the institutional review board (IRB) or ethics committee, and ensuring all regulatory requirements for investigational devices or treatments are met, including appropriate documentation and patient enrollment in a formal trial if applicable. This aligns with ethical principles of informed consent, non-maleficence, and patient-centered care, as well as regulatory mandates for patient safety and research integrity. Incorrect Approaches Analysis: Proceeding with the treatment without further consultation or formal approval, despite the patient’s strong desire, fails to uphold the principle of non-maleficence and potentially violates regulatory requirements for experimental therapies. This approach bypasses essential safety checks and ethical oversight, exposing the patient to unknown risks without adequate safeguards. Agreeing to the treatment solely based on the patient’s request and the physician’s personal enthusiasm, without a rigorous assessment of the evidence, the patient’s suitability, and adherence to regulatory protocols, constitutes a failure of professional responsibility. This prioritizes patient desire over evidence-based practice and ethical due diligence, potentially leading to harm and regulatory non-compliance. Delaying the discussion about the experimental treatment until after the patient’s condition has significantly deteriorated, or solely relying on the patient to initiate further inquiries, represents a passive and potentially harmful approach. It fails to proactively engage the patient in understanding all available options, including potentially beneficial experimental ones, and abdicates the clinician’s role in guiding the patient through complex treatment decisions. Professional Reasoning: Professionals should employ a framework that begins with a thorough understanding of the patient’s condition and preferences. This is followed by a comprehensive review of available evidence for all treatment options, including standard of care and investigational therapies. A critical step is to assess the regulatory landscape and institutional policies governing experimental treatments. Open, honest, and empathetic communication with the patient and their family is paramount, ensuring they are fully informed and empowered to participate in shared decision-making. When dealing with novel or experimental interventions, seeking multidisciplinary input and formal ethical/regulatory review is essential to ensure patient safety and adherence to best practices.

Scenario Analysis: This scenario is professionally challenging because it requires the specialist to integrate complex imaging findings with clinical presentation to arrive at a definitive diagnosis and treatment plan for a structural heart disease. The challenge lies in the potential for subtle imaging abnormalities to be misinterpreted, leading to delayed or incorrect management, and the ethical imperative to select the most appropriate and least invasive diagnostic pathway while ensuring patient safety and optimal outcomes. The rapid evolution of imaging modalities and interventional techniques further complicates this decision-making process. Correct Approach Analysis: The best professional practice involves a systematic, multi-modal imaging approach that begins with non-invasive modalities to characterize the suspected structural abnormality and its functional impact. This typically includes echocardiography (transthoracic and transesophageal) as the primary imaging modality due to its accessibility, safety, and excellent visualization of cardiac structures and function. If initial imaging is inconclusive or requires further detail for procedural planning, advanced non-invasive imaging such as cardiac CT or MRI may be employed. This approach prioritizes patient safety by minimizing exposure to ionizing radiation and invasive procedures until absolutely necessary, aligning with the ethical principle of beneficence and non-maleficence. It also adheres to established clinical guidelines for the diagnosis and management of structural heart disease, which emphasize a stepwise diagnostic strategy. Incorrect Approaches Analysis: One incorrect approach is to immediately proceed to invasive diagnostic angiography without a thorough non-invasive evaluation. This fails to adhere to the principle of least harm, exposing the patient to unnecessary risks associated with an invasive procedure, including bleeding, infection, and vascular complications, without first exhausting safer diagnostic options. It also represents a failure to optimize resource utilization. Another incorrect approach is to rely solely on a single imaging modality, especially if it is not the most appropriate for the suspected pathology, and to disregard the clinical context. This can lead to misdiagnosis or incomplete assessment, potentially resulting in suboptimal treatment. It neglects the ethical duty to provide comprehensive and accurate diagnostic services. A further incorrect approach is to delay definitive diagnosis and management due to uncertainty in imaging interpretation without seeking expert consultation or employing further appropriate imaging. This can lead to patient harm through prolonged symptoms and disease progression, violating the duty of care. Professional Reasoning: Professionals should employ a structured diagnostic reasoning process that begins with a comprehensive clinical assessment, including patient history, physical examination, and initial laboratory investigations. This is followed by the selection of the most appropriate initial imaging modality based on the suspected pathology and clinical question. Interpretation of imaging should be performed systematically, correlating findings with the clinical picture. If uncertainty persists or further detail is required, a stepwise escalation to more advanced or invasive imaging should be considered, always weighing the diagnostic yield against the associated risks and patient preferences. Collaboration with multidisciplinary teams, including imaging specialists and interventional cardiologists, is crucial for complex cases.

This scenario presents a professionally challenging situation due to the inherent complexity of managing structural heart disease in a patient with multiple comorbidities and a history of non-adherence. The challenge lies in balancing the immediate need for effective treatment with the long-term goal of sustainable patient management, requiring careful consideration of evidence-based guidelines, patient autonomy, and the practicalities of care delivery. The physician must navigate potential conflicts between aggressive medical intervention and the patient’s capacity or willingness to adhere to complex regimens. The correct approach involves a comprehensive, multidisciplinary assessment that prioritizes shared decision-making and addresses the root causes of non-adherence. This includes a thorough evaluation of the patient’s understanding of their condition, the rationale for treatment, and the potential consequences of non-compliance. Engaging specialists in cardiology, geriatrics, and potentially social work or behavioral health is crucial to develop a tailored, evidence-based management plan that is both clinically effective and practically achievable for the patient. This approach aligns with ethical principles of beneficence and autonomy, ensuring the patient’s values and preferences are central to care planning, and adheres to best practices in chronic disease management which emphasize patient education and support. An incorrect approach would be to solely focus on aggressive pharmacological or interventional treatment without adequately addressing the patient’s adherence issues. This fails to acknowledge the evidence that optimal outcomes in chronic disease management are contingent on patient engagement and adherence. Such an approach risks exacerbating the patient’s condition due to continued non-compliance, leading to preventable hospitalizations and poorer long-term prognosis, and may be seen as a failure to provide holistic care. Another incorrect approach would be to dismiss the patient’s concerns or perceived barriers to adherence and proceed with a standard treatment protocol without modification. This disregards the patient’s lived experience and can lead to further disengagement and mistrust, undermining the therapeutic relationship. It also fails to apply evidence-based principles that advocate for individualized care plans, especially in complex cases with comorbidities and adherence challenges. A further incorrect approach would be to unilaterally decide on a treatment plan that the patient is unlikely to follow, without a clear strategy for support or follow-up. This demonstrates a lack of respect for patient autonomy and can lead to a cycle of treatment failure and frustration for both the patient and the healthcare team. It neglects the crucial element of ensuring the patient has the necessary resources and understanding to manage their condition effectively. Professionals should adopt a structured decision-making process that begins with a thorough assessment of the patient’s clinical status and their individual circumstances, including their understanding, beliefs, and barriers to care. This should be followed by a collaborative discussion with the patient and, where appropriate, their family or caregivers, to establish shared goals. Evidence-based guidelines should then be applied to develop a range of treatment options, considering the patient’s capacity to adhere to each. Finally, a plan for ongoing monitoring, support, and adjustment based on the patient’s progress and evolving needs should be established.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the need for accurate and fair assessment of candidate performance with the potential for subjective interpretation of blueprint weighting and scoring. Misinterpreting or misapplying retake policies can lead to unfairness, erode confidence in the certification process, and potentially impact patient safety if unqualified individuals are certified. Careful judgment is required to ensure adherence to established guidelines and ethical principles. Correct Approach Analysis: The best professional practice involves a thorough review of the official certification blueprint and associated scoring guidelines. This includes understanding the stated weighting of different content domains, the established passing score, and the explicit retake policy, including any limitations on the number of attempts or required remediation between attempts. Adherence to these documented policies ensures consistency, fairness, and transparency in the certification process, aligning with the ethical obligation to maintain high standards for specialists. This approach directly addresses the audit findings by demonstrating a commitment to following established procedures. Incorrect Approaches Analysis: One incorrect approach involves relying on anecdotal evidence or informal discussions with colleagues regarding blueprint weighting and retake policies. This is professionally unacceptable because it bypasses the official documentation, leading to potential misinterpretations and inconsistent application of rules. It fails to uphold the principle of transparency and fairness inherent in a standardized certification process. Another incorrect approach is to assume that the retake policy is flexible and can be adjusted based on individual candidate circumstances or perceived effort. This is ethically problematic as it undermines the integrity of the certification program. Retake policies are established to ensure a consistent standard for all candidates and deviating from them introduces bias and erodes the credibility of the certification. A further incorrect approach is to prioritize the candidate’s desire for immediate re-certification over the established remediation requirements outlined in the retake policy. This demonstrates a lack of professional integrity and a failure to uphold the standards set by the certifying body. The remediation steps are designed to ensure that candidates address identified knowledge gaps, thereby improving future performance and ultimately protecting patient welfare. Professional Reasoning: Professionals faced with such situations should adopt a systematic decision-making process. First, they must identify and consult the definitive source of information – the official certification blueprint, scoring rubrics, and retake policy documents. Second, they should seek clarification from the certifying body’s administrative or examination committee if any aspect of the policies is unclear. Third, they must apply the policies consistently and impartially to all candidates, avoiding any personal biases or external pressures. Finally, they should maintain thorough documentation of all decisions and communications related to candidate assessments and retake eligibility.

Scenario Analysis: This scenario presents a professional challenge stemming from the inherent tension between advancing patient care through novel treatments and adhering to the stringent regulatory requirements governing the use of investigational devices. The core difficulty lies in balancing the potential benefits for a patient with limited options against the imperative to follow established protocols designed to ensure patient safety and the integrity of clinical research. Missteps in this area can lead to regulatory non-compliance, ethical breaches, and compromised patient outcomes. Careful judgment is required to navigate the ethical considerations of patient autonomy, beneficence, and non-maleficence, all within the framework of regulatory oversight. Correct Approach Analysis: The best professional practice involves a comprehensive and documented discussion with the patient regarding the investigational nature of the device, its potential risks and benefits, and available alternatives. This discussion must be followed by obtaining informed consent that explicitly acknowledges the experimental status of the treatment. Crucially, the physician must ensure that the use of the investigational device aligns with the approved protocol of a relevant clinical trial or an authorized compassionate use program. This approach is correct because it prioritizes patient autonomy and safety by ensuring the patient is fully informed and has voluntarily agreed to participate in an experimental treatment. It also upholds regulatory compliance by ensuring the investigational device is used within a sanctioned framework, such as a clinical trial or compassionate use program, which are overseen by regulatory bodies like the FDA in the US. This adherence to protocol is fundamental to the ethical and legal use of investigational medical products. Incorrect Approaches Analysis: Proceeding with the investigational device without explicit informed consent that details its experimental nature and potential risks is a significant ethical and regulatory failure. This violates the principle of patient autonomy and exposes the physician and institution to legal and regulatory repercussions. Administering the device under the guise of standard care, even if the patient has a serious condition, misrepresents the treatment’s status and undermines the integrity of the regulatory process. Using the investigational device without enrolling the patient in an approved clinical trial or obtaining specific authorization for compassionate use, even with a patient’s general agreement to try “new treatments,” is a direct contravention of regulatory requirements. Investigational devices are not approved for general clinical use until they have undergone rigorous testing and regulatory review. Circumventing these established pathways, regardless of the patient’s perceived benefit, constitutes a serious breach of regulatory compliance and can jeopardize the validity of future research and patient safety. Professional Reasoning: Professionals facing such situations should employ a structured decision-making process. First, thoroughly understand the regulatory landscape governing investigational devices within the relevant jurisdiction. Second, assess the patient’s clinical condition and the potential benefits and risks of the investigational device compared to established treatments. Third, engage in transparent and comprehensive communication with the patient, ensuring they understand the experimental nature of the proposed treatment, its potential outcomes, and their right to refuse. Fourth, meticulously document all discussions, assessments, and the informed consent process. Finally, always ensure that the use of any investigational device strictly adheres to approved clinical trial protocols or authorized compassionate use pathways, seeking guidance from institutional review boards (IRBs) and regulatory affairs departments when necessary.

Scenario Analysis: This scenario presents a professional challenge due to the inherent tension between advancing medical knowledge and ensuring patient safety and data integrity. The clinician must navigate the complex ethical landscape of using patient data for research while adhering to strict privacy regulations and maintaining the trust of patients and the medical community. The rapid evolution of structural heart disease treatments necessitates robust research, but this must be balanced against the imperative to protect sensitive health information. Correct Approach Analysis: The best professional practice involves obtaining explicit, informed consent from patients for the use of their de-identified structural heart disease data in research. This approach directly addresses the core principles of patient autonomy and data privacy. By clearly explaining the research purpose, potential risks and benefits, and the measures taken to de-identify data, the clinician ensures patients understand how their information will be used and can make an autonomous decision. This aligns with the ethical imperative to respect patient rights and the regulatory requirement for data protection, ensuring that research is conducted with transparency and patient approval. Incorrect Approaches Analysis: Using de-identified data without explicit consent, even if the data is anonymized, fails to uphold the principle of patient autonomy. While de-identification reduces direct privacy risks, it does not negate the ethical obligation to inform patients about the secondary use of their health information. This approach risks eroding patient trust and may violate specific data protection regulations that require consent for research purposes, even for anonymized datasets. Sharing aggregated, anonymized structural heart disease outcome data with a research consortium without individual patient consent, even for the purpose of improving treatment protocols, is ethically problematic. While aggregation and anonymization reduce individual identifiability, the fundamental principle of informed consent for the use of personal health information in research is bypassed. This approach may contravene regulations that mandate patient authorization for any research utilization of their data, regardless of the level of anonymization. Presenting structural heart disease patient cases, including detailed clinical histories and procedural outcomes, at an international medical conference without obtaining specific consent for such a presentation, even if patient names are omitted, is a significant ethical and regulatory breach. While omitting names is a step towards privacy, the richness of clinical detail can still lead to indirect identification, especially within a specialized field. This approach violates the expectation of confidentiality and the right to privacy concerning one’s medical information, potentially leading to reputational harm and legal repercussions. Professional Reasoning: Professionals in this field should adopt a decision-making framework that prioritizes patient rights and regulatory compliance. This involves a proactive approach to informed consent, ensuring that all research activities involving patient data are transparent and authorized. When in doubt about the appropriate use of patient information, clinicians should consult institutional review boards (IRBs) or ethics committees and adhere strictly to applicable data protection laws and professional guidelines. The foundation of ethical medical practice lies in respecting patient autonomy and safeguarding their sensitive health information.

This scenario presents a significant professional challenge due to the inherent conflict between a patient’s stated wishes and the perceived best medical interest by the healthcare team, particularly in the context of a complex and potentially life-altering procedure like structural heart disease intervention. Navigating this requires a delicate balance of respecting patient autonomy, upholding the principle of beneficence, and adhering to ethical and legal standards of informed consent. The pressure to proceed with a treatment deemed beneficial by experts, coupled with the patient’s expressed desire to avoid certain interventions, creates a high-stakes ethical dilemma. The correct approach involves a comprehensive and iterative process of ensuring the patient’s understanding and voluntary agreement. This entails clearly and thoroughly explaining the risks, benefits, and alternatives to the proposed intervention, using language the patient can comprehend. It requires actively listening to the patient’s concerns, values, and reasons for their preferences, and addressing them empathetically. Crucially, it involves assessing the patient’s capacity to make such decisions. If capacity is confirmed, and the patient, after being fully informed, continues to refuse the intervention, their decision must be respected, even if it differs from the medical team’s recommendation. This aligns with the fundamental ethical principle of patient autonomy and the legal requirement for informed consent, which mandates that treatment decisions are made by a competent patient. An incorrect approach would be to proceed with the intervention against the patient’s explicit refusal, even if the medical team believes it is in their best interest. This directly violates the principle of patient autonomy and the legal requirement for consent. Such an action constitutes battery. Another incorrect approach would be to subtly pressure or coerce the patient into agreeing to the intervention by downplaying their concerns or emphasizing the negative consequences of refusal without fully exploring their reasoning. This undermines the voluntariness aspect of informed consent and can be considered a form of undue influence. Finally, assuming the patient lacks capacity without a formal assessment and then proceeding with treatment based on the presumed best interest of a surrogate decision-maker, without exhausting all avenues to confirm the patient’s own wishes and capacity, is also ethically and legally problematic. Professional decision-making in such situations should follow a structured process: 1) Assess patient capacity. 2) Provide clear, comprehensive, and understandable information about the proposed treatment, including risks, benefits, and alternatives. 3) Elicit and understand the patient’s values, preferences, and reasons for their decisions. 4) Engage in shared decision-making, allowing the patient to actively participate in the choice. 5) Respect the competent patient’s informed refusal of treatment, even if it contradicts medical recommendations. If capacity is in doubt, involve ethics committees and follow established protocols for surrogate decision-making.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the imperative to improve structural heart disease outcomes across a diverse population with the ethical and regulatory obligations to ensure equitable access to care and avoid exacerbating existing health disparities. The specialist must navigate complex data, understand the social determinants of health, and implement interventions that are both clinically effective and socially responsible, all within the framework of public health policy and ethical medical practice. Correct Approach Analysis: The best professional approach involves a comprehensive, data-driven strategy that explicitly addresses health equity. This entails identifying specific populations within the broader region experiencing disproportionately worse outcomes or facing barriers to accessing structural heart disease care. This identification should be informed by epidemiological data, socioeconomic indicators, and qualitative insights into patient experiences. Once disparities are identified, interventions should be tailored to address the root causes, which may include improving access to screening, enhancing culturally competent patient education, reducing financial barriers to treatment, and advocating for policy changes that promote equitable resource allocation. This approach aligns with the principles of public health, which emphasize prevention, population-level interventions, and the reduction of health inequalities, and is ethically mandated by the principle of justice, requiring fair distribution of healthcare resources and opportunities. Incorrect Approaches Analysis: One incorrect approach would be to focus solely on implementing the latest structural heart disease technologies and treatments across the entire region without first assessing differential access or outcomes. This could inadvertently widen existing gaps, as populations with fewer resources or greater systemic barriers might be less likely to benefit from these advancements. Another incorrect approach would be to rely solely on general public awareness campaigns about structural heart disease without considering the specific needs and communication preferences of diverse sub-populations. This might fail to reach or resonate with those most in need, particularly marginalized communities. Finally, an approach that prioritizes interventions based on ease of implementation or perceived patient demand without a rigorous assessment of actual health needs and disparities risks misallocating resources and failing to address the most critical equity issues. Professional Reasoning: Professionals should adopt a systematic, evidence-based approach that integrates population health principles with a strong commitment to health equity. This involves: 1) Data Collection and Analysis: Gathering comprehensive epidemiological data, disaggregated by relevant demographic and socioeconomic factors, to identify disparities. 2) Needs Assessment: Understanding the specific barriers to care faced by different populations. 3) Targeted Intervention Design: Developing and implementing interventions that are culturally appropriate, accessible, and address the identified disparities. 4) Continuous Monitoring and Evaluation: Regularly assessing the impact of interventions on health equity and making necessary adjustments. 5) Advocacy: Championing policies and resource allocation that promote equitable access and outcomes.

Scenario Analysis: This scenario presents a significant professional challenge due to the inherent conflict between a patient’s expressed wishes and the perceived best medical interest as determined by the treating physician. Navigating this requires a delicate balance of respecting patient autonomy, upholding professional ethical obligations, and adhering to regulatory frameworks governing informed consent and patient care. The complexity is amplified by the potential for differing interpretations of “best interest” and the need to ensure the patient’s decision-making capacity is robust. Correct Approach Analysis: The best professional practice involves a thorough and documented assessment of the patient’s decision-making capacity. This entails ensuring the patient understands the proposed treatment (transcatheter aortic valve implantation – TAVI), its benefits, risks, and alternatives, including the risks of no treatment. It requires confirming the patient can retain and weigh this information and communicate a choice. If capacity is confirmed, the physician must respect the patient’s autonomous decision, even if it differs from the physician’s recommendation, provided the decision is not based on undue influence or a misunderstanding of critical information. This aligns with the fundamental ethical principles of autonomy and beneficence, as well as regulatory requirements for informed consent, which mandate that patients have the right to refuse treatment after being adequately informed. Incorrect Approaches Analysis: Proceeding with TAVI against the patient’s explicit refusal, even with the belief it is in their best interest, constitutes a violation of patient autonomy and potentially battery. This disregards the legal and ethical requirement for informed consent. Seeking a second opinion solely to override the patient’s decision, without a genuine concern for the patient’s capacity or a desire for collaborative decision-making, is ethically questionable. While second opinions are valuable, their purpose should be to enhance understanding and shared decision-making, not to circumvent a patient’s informed refusal. This approach risks undermining trust and disrespecting the patient’s agency. Focusing solely on the patient’s age as a reason to disregard their wishes, without a comprehensive assessment of their capacity, is discriminatory and ethically unsound. Age alone does not determine decision-making capacity. This approach fails to uphold the principle of equal respect for all patients and contravenes regulatory guidelines that prohibit age-based discrimination in healthcare decisions. Professional Reasoning: Professionals should employ a structured approach to capacity assessment. This involves: 1) establishing rapport and ensuring a conducive environment for discussion; 2) clearly explaining the medical condition, proposed treatment, alternatives, and risks/benefits in understandable language; 3) actively probing the patient’s understanding through open-ended questions and observing their responses; 4) assessing their ability to weigh information and make a choice; and 5) documenting the entire process meticulously. If capacity is confirmed, the patient’s decision must be respected. If capacity is questioned, a formal capacity assessment by a qualified professional should be pursued, and if capacity is found to be lacking, a surrogate decision-maker should be involved according to established legal and ethical protocols.