This scenario is professionally challenging due to the inherent complexities of palliative care, where patient wishes, family dynamics, and the availability of specialized resources intersect. Effective interdisciplinary coordination is paramount to ensure patient-centered care and timely access to appropriate interventions. The need for clear escalation pathways prevents delays in care and potential patient harm. The best approach involves a proactive and structured process for identifying patients who may benefit from palliative care consultation and establishing clear communication channels for escalation. This includes regular multidisciplinary team meetings where potential candidates are discussed, and a defined protocol for initiating palliative care referrals when specific clinical indicators are met or when patient/family requests arise. This aligns with ethical principles of beneficence and non-maleficence, ensuring patients receive timely and appropriate support. Furthermore, it adheres to best practice guidelines for integrated care, emphasizing seamless transitions and coordinated efforts among healthcare professionals. An incorrect approach would be to rely solely on the primary physician’s informal assessment or to wait for a crisis to occur before considering palliative care involvement. This fails to meet the ethical obligation to proactively identify and address patient needs, potentially leading to delayed symptom management and reduced quality of life. It also bypasses established interdisciplinary coordination mechanisms, risking fragmented care. Another incorrect approach would be to have a vague or undocumented escalation pathway, where referrals are made inconsistently or based on personal relationships rather than established criteria. This creates uncertainty and can lead to inequitable access to palliative care services, violating principles of justice and fairness. It also undermines the systematic approach required for effective healthcare delivery. Finally, an approach that prioritizes the availability of palliative care specialists over the patient’s immediate needs or the primary team’s assessment would be professionally unsound. While specialist input is valuable, the decision to escalate care should be driven by patient benefit and clinical necessity, not solely by resource availability, which can lead to delays and suboptimal care. Professionals should employ a decision-making framework that begins with a thorough assessment of the patient’s current condition, symptom burden, and psychosocial needs. This should be followed by open communication with the patient and family to understand their goals of care. The interdisciplinary team should then collaboratively determine the most appropriate next steps, utilizing established protocols for consultation and escalation. Regular review and adaptation of the care plan based on evolving patient needs are crucial.

The investigation demonstrates a common challenge in professional licensure: ensuring that candidates meet the specific eligibility criteria designed to uphold the standards of specialized medical practice. The Critical Pan-Asia Palliative and Supportive Care Medicine Licensure Examination is designed to certify individuals possessing the requisite knowledge, skills, and ethical grounding to provide high-quality palliative and supportive care across diverse Pan-Asian healthcare settings. The challenge lies in accurately assessing whether an applicant’s prior training and experience align with the examination’s stated purpose and the specific competencies it aims to validate. Misinterpreting eligibility can lead to unqualified practitioners gaining licensure, potentially compromising patient care and undermining public trust in the profession. The best approach involves a meticulous review of the applicant’s credentials against the explicit eligibility requirements published by the examination board. This includes verifying the nature and duration of their palliative care training, the clinical settings in which they gained experience, and any specific postgraduate qualifications or certifications mandated by the examination. The justification for this approach rests on the principle of adherence to established regulatory frameworks. The examination board’s published criteria are the definitive guide for determining eligibility. By strictly following these guidelines, the assessment process remains objective, fair, and transparent, ensuring that only those who demonstrably meet the defined standards are permitted to sit for the licensure examination. This upholds the integrity of the licensure process and safeguards the quality of palliative care provision. An incorrect approach would be to assume that any broad medical experience, even if extensive, is automatically equivalent to the specialized training required for palliative care. This fails to acknowledge the unique skill set and knowledge base that palliative care medicine demands, which are specifically targeted by the examination’s eligibility criteria. Another incorrect approach is to prioritize the applicant’s perceived enthusiasm or stated desire to practice palliative care over documented evidence of relevant training and experience. While motivation is important, it cannot substitute for the foundational requirements established by the licensing body. Finally, an incorrect approach would be to grant eligibility based on informal recommendations or anecdotal evidence of competence without verifying against the formal, published eligibility criteria. This introduces subjectivity and bypasses the structured assessment process designed to ensure standardized qualification. Professionals should employ a decision-making framework that begins with a thorough understanding of the examination’s stated purpose and eligibility requirements. This involves consulting the official documentation provided by the licensing authority. Next, they must systematically compare the applicant’s submitted credentials against each specific criterion. If any aspect of the applicant’s qualifications is unclear or appears to fall short, the professional should seek clarification directly from the applicant or the examination board, rather than making assumptions. The decision to grant or deny eligibility should be based solely on objective evidence that either meets or does not meet the established requirements.

Scenario Analysis: This scenario presents a professional challenge due to the need to balance diagnostic urgency with patient safety and resource optimization, particularly in the context of palliative care where the patient’s quality of life and comfort are paramount. The physician must navigate potential diagnostic pathways while respecting the patient’s wishes and the principles of judicious medical intervention. Careful judgment is required to select the most appropriate imaging modality that will yield clinically relevant information without causing undue distress or burden to the patient. Correct Approach Analysis: The best professional practice involves a systematic approach that prioritizes non-invasive and less burdensome investigations first, especially when the diagnostic yield is likely to be high and the information gained is crucial for immediate management decisions. This approach involves a thorough clinical assessment, including a detailed history and physical examination, to guide the selection of imaging. If initial clinical suspicion warrants imaging, the least invasive and most informative modality for the suspected condition should be chosen. In this case, a chest X-ray is a readily available, low-radiation, and often highly informative initial investigation for suspected pneumonia, which is a common and treatable complication in palliative care patients. It provides a broad overview of the lung fields and can quickly identify significant infiltrates. This aligns with the ethical principle of beneficence (acting in the patient’s best interest) by seeking to diagnose and treat a potentially reversible condition that could significantly impact comfort and quality of life, while minimizing harm. It also respects the principle of non-maleficence by avoiding unnecessary or overly burdensome investigations. Incorrect Approaches Analysis: Pursuing an immediate CT scan of the chest without a prior clinical assessment or chest X-ray represents an escalation of investigation that may be premature and overly burdensome. While a CT scan offers greater detail, it involves higher radiation exposure and can be more time-consuming and uncomfortable for a frail patient. This approach fails to adhere to the principle of proportionality, where the benefit of the investigation must outweigh the potential harm and burden. Ordering an MRI of the chest without a clear indication for soft tissue detail or specific contraindications to CT would also be an inappropriate escalation. MRI is generally not the first-line investigation for suspected pneumonia and can be lengthy and claustrophobic, potentially causing significant distress to a palliative care patient. Relying solely on laboratory markers without considering imaging when there is a strong clinical suspicion of pneumonia overlooks the direct visual evidence that imaging can provide, potentially delaying diagnosis and appropriate treatment. While labs are important, they are often complementary to imaging in diagnosing pneumonia. Professional Reasoning: Professionals should employ a tiered approach to diagnostic reasoning and imaging selection. This begins with a comprehensive clinical assessment to formulate differential diagnoses. Based on this assessment, the least invasive, most cost-effective, and most appropriate imaging modality should be selected to answer the most pressing clinical question. This decision-making process should always consider the patient’s overall condition, prognosis, and wishes, particularly in palliative care. The goal is to obtain necessary information efficiently and with minimal patient burden, aligning with ethical principles and best practice guidelines for diagnostic imaging.

This scenario presents a common challenge in palliative and supportive care: balancing the patient’s immediate comfort and quality of life with the need for evidence-based interventions that may have longer-term implications or require careful consideration of resource allocation. The professional challenge lies in navigating patient autonomy, family involvement, and the clinician’s duty to provide optimal care within the framework of established medical evidence and ethical guidelines. It requires a nuanced approach that respects individual patient values while adhering to best practices. The best approach involves a comprehensive assessment of the patient’s current symptom burden, functional status, and psychosocial needs, followed by a shared decision-making process with the patient and their family. This process should integrate current evidence on managing acute exacerbations of chronic conditions, the efficacy of palliative interventions for symptom relief, and the potential benefits and burdens of preventive care strategies in the context of a life-limiting illness. This aligns with ethical principles of beneficence, non-maleficence, and respect for autonomy, and is supported by professional guidelines emphasizing patient-centered care and evidence-based practice in palliative medicine. The focus is on tailoring interventions to the individual’s goals of care and prognosis. An approach that prioritizes aggressive, potentially burdensome interventions without a thorough assessment of their alignment with the patient’s goals of care fails to respect patient autonomy and may lead to iatrogenic harm, violating the principle of non-maleficence. Similarly, an approach that solely focuses on symptom management without considering evidence-based preventive strategies that could improve quality of life or prevent future complications, where appropriate and aligned with patient wishes, may not represent the most comprehensive supportive care. Finally, an approach that relies solely on family directives without actively involving the patient in decision-making, where capacity allows, or without a clear understanding of the patient’s previously expressed wishes, can lead to care that is not aligned with the patient’s values and may be ethically problematic. Professionals should employ a systematic decision-making process that begins with a thorough patient assessment, including their values, preferences, and goals. This should be followed by an evidence-based review of available management options, considering both acute symptom control and long-term supportive care. Crucially, this information must be communicated clearly to the patient and their family to facilitate shared decision-making, ensuring that the chosen care plan is both clinically appropriate and ethically sound, respecting the patient’s autonomy and promoting their well-being.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the integrity of the examination process with the compassionate consideration of a candidate facing extenuating circumstances. The examination board must uphold established policies while also acknowledging the human element and potential for bias in decision-making. The core tension lies in ensuring fairness to all candidates while providing reasonable accommodations. Correct Approach Analysis: The best approach involves a thorough, documented review of the candidate’s situation against the established retake policy, seeking objective evidence to support their claim. This approach prioritizes adherence to the established regulatory framework governing licensure examinations, which typically outlines specific criteria for retakes and appeals. By requiring documented evidence and a formal review process, the board ensures consistency, fairness, and transparency, minimizing the risk of arbitrary decisions. This aligns with ethical principles of justice and fairness in professional licensing. Incorrect Approaches Analysis: One incorrect approach involves immediately granting a retake based solely on the candidate’s verbal assertion of distress. This bypasses the established policy and lacks the necessary documentation, potentially creating a precedent that undermines the fairness of the examination for other candidates. It introduces subjectivity and the risk of bias, as the decision is not based on objective criteria. Another incorrect approach is to rigidly enforce the retake policy without any consideration for the candidate’s circumstances, even if compelling evidence is presented. This demonstrates a lack of empathy and may violate ethical considerations regarding professional duty of care and the spirit of the regulations, which often allow for exceptions in documented hardship cases. It fails to acknowledge that policies are frameworks, not absolute barriers, and can lead to a perception of inflexibility and a failure to support aspiring professionals. A third incorrect approach is to suggest the candidate seek alternative pathways or reapply for future examinations without a formal review of their current situation. This prematurely dismisses the candidate’s current attempt and may not be in line with the examination board’s mandate to assess competency for licensure. It also fails to engage with the established appeal or exception process, which is designed to handle such situations. Professional Reasoning: Professionals faced with such situations should first consult the relevant examination regulations and guidelines regarding retakes, appeals, and special circumstances. They should then gather all available information, including objective evidence from the candidate. A structured decision-making process involves: 1) understanding the policy, 2) assessing the evidence against the policy’s criteria, 3) considering any ethical implications, and 4) making a decision that is consistent, fair, and defensible. If the policy allows for discretion, it should be exercised judiciously and with clear justification.

Scenario Analysis: This scenario presents a professional challenge for a candidate preparing for the Critical Pan-Asia Palliative and Supportive Care Medicine Licensure Examination. The core difficulty lies in effectively and efficiently utilizing limited preparation time while ensuring comprehensive coverage of the vast and nuanced subject matter. The pressure to pass a high-stakes examination, coupled with the inherent complexity of palliative and supportive care, necessitates a strategic and well-informed approach to resource selection and time management. Failure to do so can lead to inadequate preparation, increased anxiety, and ultimately, examination failure. Careful judgment is required to balance breadth and depth of study, prioritize key areas, and adopt learning strategies that promote retention and application of knowledge. Correct Approach Analysis: The best professional practice involves a structured, multi-modal preparation strategy that prioritizes official examination syllabi and guidelines, supplemented by reputable, peer-reviewed resources and practice assessments. This approach begins with a thorough review of the examination’s official syllabus to identify core competencies and knowledge domains. Subsequently, candidates should allocate study time proportionally to the weightage of each topic, focusing on understanding underlying principles and clinical applications rather than rote memorization. Integrating diverse learning materials, such as textbooks, clinical guidelines, and case studies, alongside regular self-assessment through practice questions and mock examinations, allows for identification of knowledge gaps and reinforcement of learning. This method ensures that preparation is targeted, comprehensive, and aligned with the examination’s objectives, maximizing the likelihood of success. Incorrect Approaches Analysis: Relying solely on a single, popular review book without consulting the official syllabus or other authoritative sources is professionally unacceptable. This approach risks overlooking critical topics or dedicating excessive time to less important areas, as review books may not perfectly align with the examination’s specific content or emphasis. Furthermore, it fails to incorporate diverse learning modalities that cater to different learning styles and reinforce knowledge through varied contexts. Focusing exclusively on memorizing facts and figures from various online forums and unofficial study guides, without understanding the underlying clinical reasoning or application, is also professionally unsound. This method promotes superficial learning and is unlikely to equip candidates with the ability to critically analyze clinical scenarios, a key requirement for a licensure examination. It also exposes candidates to potentially inaccurate or outdated information, which can be detrimental. Devoting the majority of preparation time to a single, highly specialized sub-area of palliative care, even if it is a personal area of interest, without adequately covering the broader scope of the examination, is a flawed strategy. This approach neglects the comprehensive nature of the licensure examination, which assesses a wide range of competencies. It can lead to significant knowledge deficits in other essential areas, jeopardizing overall examination performance. Professional Reasoning: Professionals preparing for high-stakes examinations should adopt a systematic and evidence-based approach. This involves: 1. Understanding the Examination Blueprint: Thoroughly reviewing the official syllabus, learning objectives, and examination format provided by the examining body. 2. Strategic Resource Selection: Identifying and utilizing a combination of authoritative resources, including official guidelines, peer-reviewed literature, reputable textbooks, and validated practice assessments. 3. Time Management and Prioritization: Developing a realistic study schedule that allocates time based on the weightage and complexity of each topic, with regular review and consolidation. 4. Active Learning Techniques: Employing active recall, spaced repetition, concept mapping, and case-based learning to promote deep understanding and retention. 5. Regular Self-Assessment: Consistently using practice questions and mock examinations to gauge progress, identify weaknesses, and refine study strategies. 6. Seeking Feedback: If possible, engaging with study groups or mentors to discuss challenging concepts and receive constructive feedback.

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, compounded by the sensitive nature of palliative care where communication and shared decision-making are paramount. Navigating cultural nuances and ensuring patient autonomy while respecting family involvement requires careful judgment and adherence to ethical principles. The best approach involves a structured, multi-disciplinary discussion that prioritizes open communication with the patient and their family, facilitated by the palliative care team. This approach acknowledges the patient’s right to self-determination, as enshrined in ethical guidelines for patient care, which emphasize informed consent and respect for patient autonomy. By involving the patient directly in understanding their goals of care and exploring their values, and then facilitating a conversation with the family to ensure their understanding and address their concerns, this method upholds the principle of beneficence by acting in the patient’s best interest while respecting their wishes. It also promotes transparency and trust, crucial elements in palliative care. An incorrect approach would be to unilaterally decide to withhold information from the patient based on the family’s request. This fails to respect the patient’s fundamental right to be informed about their own health status and treatment options, a core tenet of patient autonomy and informed consent principles. It also risks undermining the patient-physician relationship and can lead to significant distress for the patient if they later discover information was withheld. Another incorrect approach would be to proceed with aggressive interventions that contradict the patient’s stated wishes, even if the family believes these are in the patient’s best interest. This disregards the patient’s expressed values and preferences, violating the principle of respect for autonomy. Palliative care specifically aims to align medical interventions with the patient’s goals, which may include comfort and quality of life over aggressive curative treatments. Finally, an incorrect approach would be to avoid direct communication with the patient and solely engage with the family to determine the course of care. This abdicates the professional responsibility to the patient and fails to uphold the ethical obligation to ensure the patient’s voice is heard and respected in their own care decisions. While family input is valuable, it should not supersede the informed decisions of a competent patient. Professionals should employ a decision-making framework that begins with assessing the patient’s capacity to make decisions. If the patient has capacity, their wishes are paramount. The framework should then involve open, honest, and empathetic communication with both the patient and their family, ideally as a joint discussion. This communication should aim to understand everyone’s perspectives, values, and concerns. A multi-disciplinary team approach, including physicians, nurses, social workers, and potentially spiritual care providers, can offer comprehensive support and facilitate complex discussions. When conflicts arise, the focus should remain on the patient’s best interests as defined by the patient themselves, while striving to achieve consensus and understanding among all parties.

Scenario Analysis: This scenario presents a professional challenge due to the inherent complexity of integrating foundational biomedical sciences with clinical decision-making in palliative care. The patient’s declining renal function, coupled with potential drug interactions and the need for effective pain management, requires a nuanced understanding of pharmacokinetics, pharmacodynamics, and the specific physiological changes associated with end-stage illness. Misjudging these factors can lead to suboptimal pain control, increased risk of adverse drug events, and a diminished quality of life for the patient, directly impacting the core principles of palliative care. Correct Approach Analysis: The best approach involves a comprehensive review of the patient’s current medication regimen, considering the impact of reduced renal clearance on drug accumulation and potential toxicity. This includes evaluating the analgesic efficacy of the current opioid regimen in light of the patient’s pain assessment and exploring alternative or adjunctive pharmacological strategies that are renally safe or require dose adjustments. Simultaneously, it necessitates a thorough understanding of the underlying pathophysiology of the patient’s declining renal function and how it might influence drug metabolism and excretion. This integrated approach, grounded in both biomedical principles and clinical assessment, ensures patient safety and optimizes symptom management. Incorrect Approaches Analysis: One incorrect approach would be to solely focus on increasing the opioid dose without considering the renal impairment. This fails to acknowledge the pharmacokinetic changes that can lead to increased drug levels and a higher risk of opioid-induced neurotoxicity, respiratory depression, and other adverse effects, violating the ethical principle of non-maleficence and potentially contravening guidelines on safe opioid prescribing in renal insufficiency. Another incorrect approach would be to discontinue all potentially renally cleared medications without a thorough assessment of their necessity for symptom control or the availability of safer alternatives. This could lead to uncontrolled pain or other distressing symptoms, compromising the patient’s comfort and quality of life, which is contrary to the fundamental goals of palliative care. A further incorrect approach would be to rely solely on non-pharmacological interventions without adequately addressing the patient’s severe pain, especially when pharmacological options are available and can be safely managed with appropriate adjustments. While non-pharmacological methods are valuable adjuncts, they may not be sufficient for severe pain, and neglecting their role in conjunction with adjusted pharmacotherapy represents a failure to provide comprehensive care. Professional Reasoning: Professionals should adopt a systematic, evidence-based approach. This involves a thorough patient assessment, including a detailed medication review and understanding of the patient’s underlying pathophysiology. Decision-making should prioritize patient safety and comfort, utilizing knowledge of drug interactions, pharmacokinetics, and pharmacodynamics, particularly in the context of organ dysfunction. When faced with complex cases, consultation with specialists (e.g., palliative care pharmacists, nephrologists) is a crucial component of professional practice to ensure the highest standard of care.

This scenario is professionally challenging due to the inherent conflict between a patient’s expressed wishes, which may be influenced by their current suffering and the desire for rapid relief, and the clinician’s ethical and professional obligation to provide comprehensive palliative care, which includes symptom management, psychosocial support, and ensuring the patient’s autonomy is respected within the bounds of their capacity. The clinician must navigate the complexities of assessing capacity, understanding the nuances of a patient’s request for hastened death versus a request for effective symptom relief, and adhering to the strict legal and ethical frameworks governing end-of-life care in the specified jurisdiction. The correct approach involves a thorough assessment of the patient’s capacity to make decisions about their care, a comprehensive evaluation of their symptoms and suffering, and an open, empathetic discussion about all available palliative care options. This approach prioritizes understanding the underlying reasons for the patient’s request, which may stem from uncontrolled pain, existential distress, or a feeling of being a burden. By exploring these factors, the clinician can address the root causes of the patient’s suffering and offer appropriate interventions, including advanced pain management, psychological support, and spiritual care, thereby upholding the principles of beneficence and non-maleficence. This aligns with the ethical imperative to relieve suffering and respect patient autonomy while operating within the legal framework that prohibits active euthanasia or assisted suicide, focusing instead on maximizing comfort and quality of life. An incorrect approach would be to immediately interpret the patient’s statement as a direct request for hastened death and proceed with discussions about such options without a thorough assessment. This fails to explore the possibility that the patient’s distress is treatable through aggressive symptom management and psychosocial support, thereby potentially causing harm by overlooking effective palliative interventions. It also risks misinterpreting a cry for help or relief from suffering as a definitive request for ending life, which is ethically problematic and may violate the clinician’s duty of care. Another incorrect approach would be to dismiss the patient’s statement outright, attributing it solely to depression or temporary distress, without engaging in a meaningful dialogue about their concerns and exploring all available palliative care options. This paternalistic stance disrespects the patient’s autonomy and can lead to a breakdown in trust, leaving the patient feeling unheard and unsupported in their suffering. It fails to acknowledge the patient’s lived experience and the validity of their feelings, even if their expressed desire is not directly actionable. A further incorrect approach would be to focus solely on the physical symptoms and neglect the significant psychosocial and existential dimensions of the patient’s suffering. While symptom management is crucial, palliative care is holistic. Ignoring the emotional, spiritual, and social aspects of the patient’s distress can lead to incomplete care, leaving the patient feeling isolated and their suffering unaddressed in its entirety. The professional decision-making process for similar situations should involve a structured approach: first, assess the patient’s capacity and understanding; second, conduct a comprehensive symptom assessment, including physical, psychological, social, and spiritual domains; third, engage in open and empathetic communication to understand the patient’s values, fears, and goals of care; fourth, explore all available palliative care interventions and support systems; and fifth, document all assessments, discussions, and care plans meticulously, consulting with a multidisciplinary team and ethics committees when necessary.

Scenario Analysis: This scenario presents a significant professional challenge due to the conflict between a patient’s expressed wishes, their perceived capacity to make decisions, and the family’s strong advocacy for a different course of action. Navigating this requires a delicate balance of respecting patient autonomy, ensuring patient well-being, and managing family dynamics within the ethical and legal framework of palliative care. The core tension lies in determining the appropriate level of intervention when a patient’s wishes might be perceived by others as detrimental to their comfort or dignity, and the potential for undue influence or misunderstanding. Correct Approach Analysis: The best professional approach involves a comprehensive assessment of the patient’s capacity to understand their condition, the proposed treatment options (including no treatment), and the consequences of their decisions. This assessment should be conducted by the treating physician, potentially with input from other healthcare professionals experienced in capacity assessment. If capacity is confirmed, the physician must then engage in a thorough discussion with the patient, reiterating the benefits and burdens of all options, and ensuring their decision is free from coercion. This aligns with the fundamental ethical principle of patient autonomy and the legal requirement for informed consent. The physician should also, with the patient’s permission, communicate with the family to explain the patient’s decision and the rationale behind it, fostering understanding and support for the patient’s wishes. This approach prioritizes the patient’s right to self-determination, which is paramount in palliative care. Incorrect Approaches Analysis: One incorrect approach involves overriding the patient’s wishes based solely on the family’s concerns, even if the patient is deemed to have capacity. This violates the principle of patient autonomy and the legal requirement for informed consent, as it disregards the patient’s right to make decisions about their own care. It also risks alienating the patient and undermining the trust essential in the therapeutic relationship. Another incorrect approach is to dismiss the family’s concerns entirely without adequate communication or exploration of their perspective. While patient autonomy is primary, ignoring the family can lead to increased conflict, distress for the patient, and potential legal challenges. A failure to engage with the family, even after the patient’s wishes are confirmed, can be seen as a lapse in holistic care and communication. A third incorrect approach is to proceed with a treatment that the patient has explicitly refused, based on a subjective interpretation of what is “best” for the patient by the healthcare team or family. This constitutes a direct violation of informed consent and patient autonomy, and could be considered battery. It fails to recognize that in palliative care, the patient’s definition of quality of life and comfort is the ultimate determinant of care. Professional Reasoning: Professionals should employ a structured decision-making process that begins with a thorough assessment of the patient’s capacity. If capacity is present, the focus shifts to ensuring informed consent through clear, empathetic communication about all available options, including the option of no further intervention. Simultaneously, professionals should engage in sensitive communication with the family, explaining the patient’s decision and the ethical/legal underpinnings, while seeking their support for the patient’s wishes. This process emphasizes shared decision-making where appropriate, but ultimately respects the autonomous choices of a capacitous patient.