This scenario is professionally challenging because it requires a fellow to balance personal readiness with the ethical and professional obligations to patient care and the integrity of the fellowship program. The pressure to complete training and enter independent practice can create a conflict of interest, necessitating a rigorous and objective self-assessment process. Careful judgment is required to ensure that personal circumstances do not compromise patient safety or the standards of the fellowship. The best professional practice involves a comprehensive, multi-faceted self-assessment that includes objective feedback from mentors and supervisors, a thorough review of clinical competency metrics, and an honest evaluation of personal well-being and preparedness for independent practice. This approach aligns with the ethical imperative to practice medicine competently and safely, as underscored by professional medical organizations’ guidelines on physician well-being and continuing professional development. It also respects the program’s commitment to graduating well-prepared physicians. An approach that prioritizes personal timelines or external pressures over objective readiness is professionally unacceptable. Focusing solely on completing the required number of cases without considering the complexity, variety, or demonstrated mastery of skills would be a failure to uphold the standards of perioperative care. This neglects the ethical duty to ensure competence before independent practice, potentially jeopardizing patient safety. Similarly, disregarding feedback from supervisors or mentors, or minimizing personal indicators of burnout or stress, represents a failure to acknowledge the holistic requirements of physician readiness. This can lead to impaired judgment and decision-making, which is a direct violation of the ethical principle of beneficence and non-maleficence. An approach that relies on anecdotal evidence or a superficial understanding of program requirements, without engaging in systematic self-evaluation and seeking external validation, also falls short of professional standards. Professionals should employ a decision-making framework that integrates objective data (e.g., case logs, competency assessments, simulation performance) with subjective self-reflection and structured feedback from trusted mentors. This framework should prioritize patient safety and ethical practice above all else, recognizing that successful fellowship completion is a prerequisite for responsible independent practice. Regular, honest communication with program directors and mentors is crucial for navigating personal challenges and ensuring that readiness for exit is assessed comprehensively and ethically.

Scenario Analysis: This scenario presents a professional challenge because it requires balancing the immediate need for patient care with the ethical and regulatory obligations to obtain informed consent. The patient’s emergent condition creates a time-sensitive situation, potentially leading to a temptation to bypass standard consent procedures. However, failing to adhere to consent protocols, even in emergencies, can have significant legal and ethical repercussions, undermining patient autonomy and trust. Careful judgment is required to navigate the nuances of implied consent in emergencies while respecting the patient’s rights as much as possible. Correct Approach Analysis: The best professional practice involves proceeding with life-saving interventions under the doctrine of implied consent when a patient is unable to provide express consent due to their emergent condition. This approach recognizes that a reasonable person in such a situation would consent to necessary medical treatment to preserve life or limb. It prioritizes immediate patient well-being while operating within established ethical and legal frameworks that permit emergency exceptions to informed consent. This aligns with the fundamental ethical principle of beneficence, balanced with the practical necessity of urgent care. Incorrect Approaches Analysis: Proceeding with non-emergent, elective procedures without attempting to obtain consent from a surrogate or waiting for the patient to regain capacity is ethically and legally unacceptable. This approach disregards the patient’s right to autonomy and self-determination, even when incapacitated. It constitutes battery, as treatment is performed without valid consent. Delaying all necessary life-saving interventions until express consent can be obtained from the patient or a surrogate, even when the patient is clearly unable to consent and their condition is deteriorating rapidly, is professionally negligent. This approach prioritizes procedural adherence over the patient’s immediate survival and well-being, violating the principle of beneficence and potentially leading to preventable harm or death. Obtaining consent from a family member who is not legally authorized as a surrogate decision-maker, without a documented advance directive or clear legal standing, is problematic. While family input is valuable, acting solely on the wishes of an unauthorized individual can lead to legal challenges and may not reflect the patient’s true wishes, thus undermining their autonomy. Professional Reasoning: Professionals should employ a decision-making framework that prioritizes patient safety and well-being while adhering to ethical and legal standards. In emergent situations where a patient cannot consent, the framework should first assess the urgency of the intervention. If life-saving or limb-saving treatment is immediately required, implied consent for such necessary interventions should be invoked. Simultaneously, efforts should be made to identify and contact a legally authorized surrogate decision-maker to discuss the patient’s condition and treatment plan, especially for interventions that are not immediately life-threatening but are part of the overall management. Documentation of the patient’s condition, the rationale for proceeding under implied consent, and any attempts to contact surrogates is crucial.

The performance metrics show a candidate for the Critical North American Perioperative Medicine Fellowship has consistently scored below the passing threshold on the simulation-based assessments, despite multiple retake opportunities. This scenario is professionally challenging because it requires balancing the program’s commitment to training competent perioperative physicians with the responsibility to uphold patient safety standards and the integrity of the fellowship’s accreditation. The fellowship director must navigate institutional policies, ethical obligations to the candidate, and the paramount duty to protect future patients from inadequately trained practitioners. The best approach involves a thorough, documented review of the candidate’s performance data, consultation with the fellowship’s assessment committee, and a transparent discussion with the candidate regarding their progress and the implications of their scores. This approach aligns with the principles of fair assessment and due process, ensuring that decisions are based on objective evidence and established program criteria. It also respects the candidate’s right to understand the basis of any adverse outcome. Furthermore, it upholds the ethical imperative to ensure that only those who meet the required standards of competence are certified, thereby safeguarding patient welfare. This process is implicitly supported by the accreditation standards of North American fellowship programs, which emphasize rigorous and fair evaluation. An approach that focuses solely on the number of retakes allowed without considering the underlying reasons for consistent underperformance fails to address the core issue of competence. This overlooks the ethical responsibility to ensure that all fellows achieve a defined level of proficiency before independent practice. Another unacceptable approach would be to pass the candidate despite repeated failures, based on personal sympathy or a desire to avoid difficult conversations. This directly violates the ethical obligation to patient safety and undermines the credibility of the fellowship and the profession. It also fails to adhere to the spirit of the accreditation standards, which are designed to ensure a high standard of care. A further inappropriate response would be to dismiss the candidate without a clear, documented explanation of the performance deficiencies and the rationale for the decision. This lacks transparency and fairness, potentially leaving the candidate without understanding how to improve or address their shortcomings, and failing to meet the ethical requirement for clear communication in professional evaluations. Professionals should employ a structured decision-making process that begins with a clear understanding of the program’s established blueprint, including weighting of assessment components and retake policies. This should be followed by objective data collection and analysis of the candidate’s performance. Consultation with a designated committee or mentors provides diverse perspectives and ensures adherence to institutional guidelines. Finally, transparent and empathetic communication with the candidate is crucial, outlining the findings, the rationale for the decision, and any available recourse or support.

Scenario Analysis: This scenario is professionally challenging because it requires balancing patient autonomy and informed consent with the physician’s duty to provide appropriate care, especially when a patient’s decision-making capacity may be compromised. The perioperative setting adds urgency and complexity, as timely decisions are crucial for patient safety and surgical outcomes. Navigating potential conflicts between patient wishes and medical recommendations demands careful ethical consideration and adherence to established guidelines. Correct Approach Analysis: The best professional practice involves a systematic assessment of the patient’s decision-making capacity. This approach prioritizes understanding the patient’s values and preferences while ensuring they comprehend the risks, benefits, and alternatives of the proposed procedure. It involves a structured conversation where the healthcare team explains the medical rationale, addresses the patient’s concerns, and explores any underlying factors that might influence their decision. If capacity is deemed intact, the patient’s informed refusal must be respected, with appropriate documentation and exploration of alternative management strategies. If capacity is questioned, a formal capacity assessment, potentially involving a multidisciplinary team or ethics consultation, is warranted to determine the appropriate course of action, which may include involving a surrogate decision-maker. This aligns with ethical principles of autonomy, beneficence, and non-maleficence, and is supported by professional guidelines emphasizing shared decision-making and respect for patient rights. Incorrect Approaches Analysis: One incorrect approach involves proceeding with the surgery solely based on the surgeon’s professional judgment without adequately assessing the patient’s understanding or capacity, especially when there are indications of potential compromise. This disregards the fundamental ethical and legal requirement of informed consent and violates the principle of patient autonomy. It can lead to performing a procedure against a patient’s true, albeit perhaps poorly articulated, wishes, or without their full comprehension of the implications. Another incorrect approach is to immediately dismiss the patient’s concerns as irrational or uninformed without a thorough investigation. This paternalistic stance fails to acknowledge the patient’s right to express their fears and preferences. It can alienate the patient, erode trust, and prevent the identification of underlying issues that might be addressed to facilitate a more informed decision. It also bypasses the opportunity to explore less invasive or alternative treatments that might be more acceptable to the patient. A third incorrect approach is to rely solely on a family member’s interpretation of the patient’s wishes without a formal assessment of the patient’s own capacity or a clear understanding of their current preferences. While family input is valuable, it cannot replace the patient’s direct involvement in decision-making when they possess the capacity to participate. This can lead to decisions being made that do not align with the patient’s actual desires or best interests, potentially leading to legal and ethical challenges. Professional Reasoning: Professionals should employ a structured approach to capacity assessment and informed consent. This involves: 1) establishing rapport and ensuring a conducive environment for communication; 2) clearly explaining the medical condition, proposed intervention, alternatives, and risks/benefits in understandable language; 3) actively listening to and addressing patient concerns and questions; 4) assessing the patient’s understanding of the information provided; 5) evaluating the patient’s ability to weigh the information and make a choice; and 6) documenting the entire process thoroughly. If capacity is uncertain, a formal assessment process should be initiated, involving relevant specialists and ethical consultation as needed.

Scenario Analysis: This scenario is professionally challenging because it requires a candidate to balance the demands of rigorous fellowship preparation with the ethical imperative of maintaining patient safety and professional well-being. Over-reliance on a single, intensive study method without adequate breaks or diverse resource utilization can lead to burnout, diminished learning, and potentially compromise patient care due to fatigue or incomplete knowledge acquisition. The pressure to perform well on a high-stakes exit examination necessitates strategic planning that prioritizes sustainable learning and comprehensive understanding. Correct Approach Analysis: The best approach involves a structured, multi-modal preparation strategy that integrates diverse learning resources with a realistic timeline and built-in self-care. This includes allocating dedicated time for reviewing core perioperative medicine principles, engaging with practice questions from reputable sources, attending relevant review courses or webinars, and actively participating in case discussions. Crucially, this approach incorporates regular breaks, adequate sleep, and stress management techniques to prevent burnout and optimize cognitive function. This aligns with ethical guidelines emphasizing physician well-being and the professional responsibility to maintain competence through continuous, well-rounded learning. The use of varied resources ensures exposure to different perspectives and reinforces learning through multiple modalities, which is a hallmark of effective adult learning and professional development. Incorrect Approaches Analysis: One incorrect approach involves dedicating the majority of preparation time to solely memorizing facts from a single textbook, neglecting practice questions and real-world application. This fails to develop critical thinking and problem-solving skills essential for perioperative decision-making and may not align with the examination’s focus on applying knowledge. It also overlooks the importance of diverse learning modalities. Another incorrect approach is to cram extensively in the weeks immediately preceding the exam, sacrificing sleep and personal well-being. This strategy is counterproductive, leading to cognitive fatigue, reduced information retention, and an increased risk of errors in judgment, which directly contravenes the ethical obligation to practice safely and competently. A further incorrect approach is to rely exclusively on passive learning methods, such as simply re-reading notes or watching lectures without active engagement. This passive consumption of information is less effective for long-term retention and the development of analytical skills compared to active recall and problem-solving, which are vital for a comprehensive exit examination. Professional Reasoning: Professionals facing high-stakes examinations should adopt a proactive and balanced preparation strategy. This involves early planning, identifying key knowledge domains, and selecting a variety of high-quality learning resources. A structured schedule that incorporates active learning techniques, regular self-assessment through practice questions, and consistent self-care is paramount. Professionals should regularly evaluate their progress and adjust their study plan as needed, recognizing that sustained, effective learning is more beneficial than short-term, intense cramming. Prioritizing well-being is not a luxury but a professional necessity that underpins the ability to perform competently and ethically.

Scenario Analysis: This scenario presents a common challenge in perioperative medicine: balancing the imperative to provide optimal patient care with the realities of resource allocation and cost-effectiveness. The professional challenge lies in making decisions that are not only clinically sound but also ethically justifiable and compliant with healthcare system guidelines, which often implicitly or explicitly require consideration of economic factors. Careful judgment is required to avoid both overtreatment driven by fear of litigation or patient dissatisfaction and undertreatment driven by cost-cutting measures that compromise patient safety or outcomes. Correct Approach Analysis: The best professional practice involves a comprehensive, evidence-based approach that prioritizes patient safety and clinical efficacy while considering resource utilization. This means carefully evaluating the incremental benefit of a proposed intervention against its associated costs and potential harms. It requires a thorough understanding of the patient’s specific condition, comorbidities, and preferences, alongside an awareness of established clinical guidelines and the availability of less resource-intensive alternatives that offer comparable outcomes. This approach aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), while also acknowledging the professional responsibility to be a good steward of healthcare resources, a principle often embedded in professional codes of conduct and institutional policies. Incorrect Approaches Analysis: One incorrect approach is to automatically adopt the most technologically advanced or resource-intensive option simply because it is available or perceived as the “gold standard” without a clear demonstration of superior patient benefit in the specific context. This can lead to unnecessary expenditure, potential for iatrogenic harm from more invasive procedures, and diversion of resources from other patients who might benefit more. This approach fails to adhere to principles of proportionality and cost-effectiveness, potentially violating ethical obligations to use resources wisely and avoid waste. Another unacceptable approach is to dismiss a potentially beneficial intervention solely based on its initial cost, without a thorough evaluation of its long-term value, including potential reductions in complications, hospital stays, or readmissions. This can lead to suboptimal patient outcomes and may ultimately be more costly to the healthcare system in the long run. This approach neglects the principle of beneficence and can be seen as a failure to provide appropriate care due to an incomplete understanding of the total cost of care and patient well-being. A third flawed approach is to defer decision-making entirely to patient preference, irrespective of clinical evidence or resource implications. While patient autonomy is paramount, it must be exercised within a framework of informed consent, where the patient understands the risks, benefits, and alternatives, including the resource implications of their choices. Unfettered patient preference without clinical guidance can lead to the selection of treatments that are not medically indicated, potentially causing harm and misallocating resources. This approach fails to uphold the professional’s role as a clinical expert and ethical guide. Professional Reasoning: Professionals should employ a structured decision-making process that begins with a thorough clinical assessment of the patient’s condition and needs. This should be followed by a review of current evidence-based guidelines and literature to identify appropriate treatment options. For each potential intervention, a nuanced evaluation of its efficacy, safety profile, potential harms, and resource implications (including direct costs, indirect costs, and potential for long-term savings) should be conducted. Patient values and preferences must then be integrated into this assessment, facilitating a shared decision-making process where the patient is fully informed about all aspects of the proposed treatments. This iterative process ensures that decisions are clinically sound, ethically defensible, and aligned with the responsible use of healthcare resources.

Scenario Analysis: This scenario presents a common challenge in perioperative medicine: balancing the need for timely and accurate diagnosis with resource utilization and patient safety. The physician must navigate the complexities of selecting appropriate imaging modalities, interpreting results within the context of the patient’s clinical presentation, and ensuring that diagnostic decisions align with established best practices and ethical considerations, all while being mindful of potential downstream impacts on patient care and healthcare costs. The pressure to make swift decisions in a perioperative setting, coupled with the potential for diagnostic uncertainty, heightens the need for a systematic and evidence-based approach. Correct Approach Analysis: The best professional practice involves a systematic, stepwise approach to diagnostic imaging, beginning with the least invasive and most readily available modalities that can adequately address the clinical question. This approach prioritizes obtaining essential information efficiently while minimizing patient risk and unnecessary expense. In this case, initiating with a focused ultrasound to assess for gross abnormalities like pneumothorax or significant pleural effusion is the most appropriate first step. Ultrasound is non-ionizing, portable, and can provide rapid, real-time information at the bedside. If the ultrasound is inconclusive or reveals findings requiring further characterization, then proceeding to a chest X-ray would be the logical next step, offering a broader overview of the thoracic structures. This tiered strategy aligns with principles of judicious resource utilization and patient safety, as advocated by professional medical guidelines that emphasize starting with lower-risk, higher-yield investigations. Incorrect Approaches Analysis: Proceeding directly to a CT scan without initial ultrasound or chest X-ray is an inefficient and potentially harmful approach. This bypasses less invasive and less costly diagnostic tools that could have provided sufficient information. CT scans involve significant radiation exposure and are more expensive than ultrasound or X-rays, representing a failure in judicious resource management and potentially exposing the patient to unnecessary risks without a clear indication of superior diagnostic yield at this initial stage. Ordering both a chest X-ray and a CT scan simultaneously without first attempting a focused ultrasound is also suboptimal. While a chest X-ray provides a broader view than ultrasound, it may not offer the same real-time detail for specific concerns like pneumothorax. Ordering both upfront without a clear clinical rationale for the immediate need for both modalities represents a failure in systematic diagnostic reasoning and efficient resource allocation. Relying solely on the patient’s subjective report of discomfort without any objective imaging to guide further investigation is professionally inadequate. While patient history is crucial, in a perioperative setting where objective findings are paramount for guiding management, ignoring the potential for occult pathology that imaging can reveal is a significant oversight. This approach neglects the physician’s responsibility to utilize available diagnostic tools to ensure patient safety and optimize perioperative management. Professional Reasoning: Professionals should employ a diagnostic reasoning framework that prioritizes clinical correlation, stepwise investigation, and evidence-based practice. This involves formulating a differential diagnosis based on the patient’s history and physical examination, then selecting the most appropriate diagnostic test based on its ability to confirm or refute specific diagnoses, its safety profile, cost-effectiveness, and availability. The process should be iterative, with subsequent investigations guided by the results of prior ones. In perioperative medicine, this framework is critical for ensuring timely and accurate diagnoses that directly impact patient management and outcomes.

This scenario presents a significant professional challenge due to the inherent conflict between a patient’s autonomy, the physician’s duty of care, and the complexities of resource allocation within a health system. The physician must navigate these competing interests while upholding ethical principles and regulatory requirements. Careful judgment is required to ensure patient well-being is prioritized without compromising professional integrity or legal obligations. The best professional approach involves a thorough and documented discussion with the patient and their family regarding the proposed surgical intervention, its risks, benefits, and alternatives, including the option of non-operative management. This discussion must be conducted in a manner that respects the patient’s values and understanding, ensuring they can make an informed decision. Documenting this process meticulously is crucial for demonstrating adherence to informed consent principles and for providing a clear record of the patient’s wishes and the physician’s recommendations. This aligns with the fundamental ethical principle of patient autonomy and the legal requirement for informed consent, as mandated by professional medical bodies and relevant healthcare legislation, which emphasizes the patient’s right to self-determination in medical decision-making. Failing to adequately inform the patient about all reasonable treatment options, including the risks and benefits of non-operative management, constitutes a failure to obtain truly informed consent. This approach undermines patient autonomy and could lead to a patient undergoing a procedure they might not have chosen if fully apprised of all alternatives, potentially violating their right to make decisions about their own body. Another unacceptable approach involves proceeding with surgery based solely on the physician’s judgment of what is “best” without ensuring the patient fully understands and agrees to the proposed intervention and its implications. This paternalistic approach disregards the patient’s right to participate in their healthcare decisions and fails to meet the standard of informed consent, which requires shared decision-making. Finally, deferring the decision-making process to the patient’s family without direct, comprehensive engagement with the patient themselves, assuming the patient lacks capacity, without a formal assessment of capacity, is ethically problematic. While family involvement is important, the primary responsibility for informed consent rests with the patient, provided they have the capacity to make decisions. Circumventing direct patient engagement, especially without a clear and documented assessment of incapacity, infringes upon the patient’s rights. Professionals should employ a decision-making framework that begins with assessing the patient’s capacity to make decisions. If capacity is present, the focus must be on comprehensive, clear, and documented communication regarding all viable treatment options, risks, benefits, and alternatives. This process should be collaborative, respecting the patient’s values and preferences. If capacity is questionable, a formal assessment should be conducted, and appropriate legal and ethical protocols for surrogate decision-making should be followed, always prioritizing the patient’s best interests as understood through their previously expressed wishes or values.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate needs of individual patients with the broader imperative of improving health outcomes for specific populations, particularly those experiencing health inequities. Perioperative clinicians often face time constraints and resource limitations, making it difficult to systematically address population-level concerns. The ethical imperative to provide equitable care necessitates proactive strategies that go beyond treating individual illness to addressing the social determinants of health that disproportionately affect certain groups. Correct Approach Analysis: The best professional practice involves proactively identifying and stratifying patients based on known social determinants of health and perioperative risk factors that are exacerbated by these determinants. This approach requires integrating population health data and epidemiological insights into routine perioperative risk assessment. By understanding which patient subgroups are at higher risk due to factors like socioeconomic status, access to care, or chronic disease prevalence within their community, clinicians can tailor pre-operative optimization strategies, post-operative care plans, and resource allocation to mitigate these risks. This aligns with the ethical principles of justice and beneficence, ensuring that care is distributed fairly and that all patients receive the support needed to achieve optimal outcomes, thereby addressing health equity. Incorrect Approaches Analysis: One incorrect approach involves solely relying on standard perioperative risk scores without considering the underlying social and demographic factors that may influence their accuracy or impact. This fails to acknowledge that standard scores may not adequately capture the unique vulnerabilities of certain populations, leading to potential underestimation of risk and inadequate resource allocation for those most in need. This approach neglects the principles of equity and justice by not actively seeking to identify and address disparities. Another incorrect approach is to address health equity concerns only reactively, by intervening when complications arise that are clearly linked to social determinants. This reactive stance is inefficient and often less effective than proactive measures. It fails to leverage population health data to anticipate and prevent adverse outcomes, thereby failing to uphold the ethical duty of beneficence in a systematic and population-focused manner. A third incorrect approach is to delegate all population health and health equity considerations to administrative or public health departments without direct perioperative clinician engagement. While these departments play a crucial role, perioperative clinicians are on the front lines and possess critical insights into patient needs and barriers to care within the perioperative context. Without their active involvement in identifying and addressing these issues, interventions may be misaligned with clinical realities, and opportunities to improve care at the point of service will be missed, undermining the ethical commitment to providing comprehensive and equitable care. Professional Reasoning: Professionals should adopt a proactive, data-informed approach to perioperative care that integrates population health and health equity considerations. This involves: 1) systematically collecting and analyzing data on social determinants of health and their impact on perioperative outcomes within their patient population; 2) using this data to identify high-risk subgroups; 3) developing and implementing tailored interventions for these subgroups; and 4) continuously evaluating the effectiveness of these interventions to ensure equitable outcomes. This requires interdisciplinary collaboration and a commitment to ongoing learning and adaptation.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate need for a potentially life-saving intervention with the ethical imperative of informed consent and patient autonomy, especially when the patient’s capacity to consent is compromised. The perioperative physician must navigate complex clinical judgment, potential legal ramifications, and the patient’s best interests while adhering to established ethical and regulatory standards. Correct Approach Analysis: The best professional practice involves a systematic approach to assessing and managing the patient’s decision-making capacity. This includes a thorough clinical evaluation by the perioperative physician to determine if the patient can understand the information, appreciate the consequences of their decisions, reason through the options, and communicate their choice. If capacity is found to be lacking, the physician must then identify and consult with the appropriate surrogate decision-maker, typically a legally authorized representative or next of kin, to obtain consent for the necessary intervention, ensuring that the surrogate acts in accordance with the patient’s known wishes or best interests. This aligns with the ethical principles of beneficence and non-maleficence, while respecting patient autonomy to the greatest extent possible and adhering to legal requirements for consent in incapacitated individuals. Incorrect Approaches Analysis: Proceeding with the surgery without a formal assessment of the patient’s capacity and without attempting to identify or consult with a surrogate decision-maker is ethically and legally unacceptable. This approach disregards the fundamental right to informed consent and patient autonomy, potentially leading to battery and violating professional standards. Assuming the patient lacks capacity solely based on their medical condition or the urgency of the situation, without a proper clinical assessment, is a violation of ethical principles and potentially discriminatory. Capacity is a functional assessment, not a diagnosis. Seeking consent from a family member who is not the legally authorized surrogate decision-maker, or who has a conflict of interest, is also professionally unacceptable. This bypasses the established legal and ethical framework for surrogate consent, potentially leading to decisions that do not align with the patient’s wishes or best interests. Professional Reasoning: Professionals should employ a structured decision-making process that prioritizes patient autonomy and safety. This involves: 1) assessing the patient’s capacity to consent; 2) if capacity is present, obtaining informed consent; 3) if capacity is lacking, identifying the appropriate surrogate decision-maker; 4) ensuring the surrogate is adequately informed and acting in the patient’s best interest or according to their known wishes; and 5) documenting all assessments, discussions, and decisions thoroughly.