Scenario Analysis: This scenario presents a professional challenge due to the critical nature of diagnostic reasoning in precision oncology. Misinterpreting imaging or selecting inappropriate diagnostic modalities can lead to delayed or incorrect treatment, directly impacting patient outcomes and potentially violating ethical obligations of care. The complexity arises from balancing the need for timely diagnosis with the imperative to adhere to best practices and regulatory guidelines for diagnostic procedures, ensuring patient safety and data integrity. Correct Approach Analysis: The best approach involves a systematic, multi-disciplinary review of the patient’s clinical presentation, molecular profiling data, and relevant imaging findings. This integrated analysis, ideally conducted by a tumor board or a designated multidisciplinary team, ensures that imaging selection and interpretation are informed by the most comprehensive patient data. This aligns with best practices in precision oncology, emphasizing a holistic view of the patient rather than isolated diagnostic steps. Regulatory frameworks, while not explicitly dictating this exact process, implicitly support it through requirements for evidence-based medicine and patient-centered care, ensuring that diagnostic decisions are robust and justifiable. Incorrect Approaches Analysis: One incorrect approach is to rely solely on a single imaging modality without considering the clinical context or molecular profile. This fails to leverage the full spectrum of diagnostic information available and may lead to an incomplete or misleading diagnosis, potentially violating the principle of providing the most accurate and comprehensive care. Another incorrect approach is to proceed with advanced imaging or invasive procedures without a clear diagnostic rationale derived from initial clinical assessment and molecular data. This can lead to unnecessary patient burden, increased costs, and potential risks without a commensurate benefit, contravening ethical considerations of beneficence and non-maleficence. A further incorrect approach is to interpret imaging findings in isolation, without consulting with other specialists or considering the patient’s unique genetic and clinical profile. This siloed approach increases the risk of misinterpretation and can result in treatment decisions that are not truly precision-based, undermining the core tenets of precision oncology. Professional Reasoning: Professionals should adopt a structured diagnostic reasoning process that begins with a thorough review of the patient’s clinical history and molecular data. This initial assessment should guide the selection of appropriate imaging modalities, prioritizing those that will yield the most relevant information for treatment planning. Imaging interpretation should then be integrated with all available data, ideally through multidisciplinary consultation, to arrive at a comprehensive and accurate diagnosis. Continuous learning and adherence to evolving best practices in diagnostic imaging and precision medicine are paramount.

Scenario Analysis: This scenario presents a professional challenge rooted in the inherent tension between advancing medical knowledge and ensuring equitable access to potentially life-saving treatments. The physician faces pressure from a pharmaceutical company, a desire to contribute to a groundbreaking study, and the ethical obligation to act in the best interest of all eligible patients, not just those who might offer the most immediate research benefit. Careful judgment is required to navigate these competing interests while upholding the integrity of the qualification process and patient welfare. Correct Approach Analysis: The best professional practice involves a thorough and objective evaluation of all potential candidates against the established eligibility criteria for the Elite Gulf Cooperative Precision Oncology Medicine Practice Qualification. This approach prioritizes fairness and adherence to the qualification’s stated purpose, which is to identify and recognize practitioners who meet specific standards in precision oncology. The regulatory framework for such qualifications typically emphasizes meritocracy and the avoidance of undue influence or bias. By focusing solely on whether a candidate meets the defined criteria, the physician upholds the integrity of the qualification and ensures that recognition is based on demonstrable competence and adherence to best practices in precision oncology, rather than external pressures or perceived research potential. Incorrect Approaches Analysis: One incorrect approach involves prioritizing candidates who are likely to contribute significantly to ongoing research or who have strong connections with pharmaceutical sponsors. This fails to adhere to the qualification’s purpose, which is to assess individual practitioner capabilities, not their research output or industry affiliations. Such a bias could lead to the exclusion of highly qualified individuals who may not be actively involved in research but possess exceptional clinical skills in precision oncology. This approach also risks compromising the independence and objectivity of the qualification process, potentially violating ethical guidelines against conflicts of interest and undue influence. Another incorrect approach is to fast-track candidates based on their perceived potential to advance the field, even if they do not fully meet all the established eligibility criteria. While innovation is important, qualifications are designed to set a baseline standard. Deviating from these standards based on subjective assessments of future potential undermines the credibility of the qualification and could lead to practitioners being recognized without possessing the foundational knowledge and skills deemed necessary. This approach disregards the established framework and could lead to a dilution of the qualification’s value. A further incorrect approach is to allow the financial incentives or research opportunities offered by a pharmaceutical company to influence the selection process. This introduces a clear conflict of interest. The purpose of the qualification is to assess a practitioner’s expertise in precision oncology, independent of any commercial relationships. Allowing such incentives to sway decisions compromises the integrity of the assessment and could lead to the selection of less qualified individuals who are more amenable to commercial partnerships, rather than those who are demonstrably the most competent. This violates ethical principles of impartiality and could have regulatory implications regarding fair practice. Professional Reasoning: Professionals should approach qualification assessments with a commitment to impartiality and adherence to established criteria. The decision-making process should involve: 1) Clearly understanding the stated purpose and eligibility requirements of the qualification. 2) Objectively evaluating each candidate against these criteria, using verifiable evidence. 3) Identifying and mitigating any potential conflicts of interest, including those arising from industry relationships or personal biases. 4) Documenting the assessment process and the rationale for each decision to ensure transparency and accountability. 5) Prioritizing the integrity of the qualification and the standards it represents over external pressures or perceived benefits.

Scenario Analysis: This scenario presents a professional challenge rooted in the inherent tension between patient autonomy, the physician’s duty of care, and the evolving landscape of precision oncology. The physician must navigate the ethical imperative to provide the best possible care while respecting the patient’s informed decisions, even when those decisions diverge from the physician’s expert recommendation. The complexity is amplified by the potential for significant patient benefit from a novel treatment, balanced against the uncertainties inherent in cutting-edge medicine and the patient’s right to refuse. Careful judgment is required to ensure the patient’s well-being is paramount while upholding ethical and professional standards. Correct Approach Analysis: The best professional approach involves a comprehensive and empathetic discussion with the patient, focusing on understanding the root of their refusal. This includes reiterating the potential benefits and risks of the recommended precision oncology treatment in clear, understandable terms, addressing any specific fears or misconceptions they may have. Crucially, it involves exploring alternative treatment options that might align better with the patient’s values or concerns, even if they are less optimal from a purely clinical perspective. The physician should document this thorough discussion, including the patient’s expressed reasons for refusal and the exploration of alternatives, ensuring the patient feels heard and respected. This approach aligns with the ethical principles of beneficence (acting in the patient’s best interest by exploring all avenues), non-maleficence (avoiding harm by not coercing the patient), and respect for autonomy (honoring the patient’s right to make informed decisions about their own healthcare). It also adheres to professional guidelines that emphasize shared decision-making and patient-centered care. Incorrect Approaches Analysis: One incorrect approach is to dismiss the patient’s concerns and insist on the recommended treatment, citing its superior efficacy. This fails to respect patient autonomy and can erode trust, potentially leading to the patient disengaging from care altogether. It also overlooks the possibility that the patient’s refusal may stem from valid, albeit perhaps unarticulated, ethical, religious, or personal beliefs that the physician has not adequately explored. Another incorrect approach is to immediately withdraw all treatment recommendations and offer only palliative care without a thorough exploration of the patient’s reasoning or alternative therapeutic avenues. This can be perceived as abandonment and may prematurely limit the patient’s options for potentially life-extending or quality-of-life-improving treatments, failing the duty of beneficence. A further incorrect approach is to proceed with the recommended treatment against the patient’s explicit wishes, perhaps by seeking a second opinion without the patient’s full consent or by subtly pressuring the patient. This constitutes a serious breach of patient autonomy and can have significant legal and ethical repercussions, undermining the fundamental doctor-patient relationship. Professional Reasoning: Professionals should adopt a decision-making framework that prioritizes open communication, empathy, and a thorough understanding of the patient’s perspective. This involves active listening to identify the underlying reasons for the patient’s decision, providing clear and balanced information about all available options, and collaboratively developing a care plan that respects the patient’s values and autonomy while striving to achieve the best possible health outcomes. Documentation of these discussions is essential for accountability and continuity of care.

The control framework reveals a complex ethical and professional challenge in managing a patient with a chronic condition requiring precision oncology medicine, where new evidence suggests a potentially more effective preventive strategy. The challenge lies in balancing the established treatment plan, patient autonomy, physician expertise, and the imperative to provide the best available evidence-based care, especially when that evidence might necessitate a significant shift in management. The physician must navigate potential patient anxiety, the financial implications of a new treatment, and the responsibility to inform the patient comprehensively. The correct approach involves a thorough, evidence-based discussion with the patient about the newly published research. This approach prioritizes patient autonomy and informed consent by presenting all relevant information, including the benefits, risks, and uncertainties of the new preventive strategy, alongside the current management plan. It acknowledges the physician’s duty of care to stay abreast of medical advancements and to offer the most effective treatments supported by robust evidence. This aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as the professional obligation to provide evidence-based care, which is a cornerstone of modern medical practice and regulatory expectations for quality patient management. An incorrect approach would be to dismiss the new evidence without thorough consideration, perhaps due to inertia or a perceived burden of changing the current plan. This fails to uphold the physician’s duty to provide the best available care and deprives the patient of the opportunity to make an informed decision about a potentially superior preventive measure. Ethically, this could be seen as a breach of beneficence and a failure to adhere to the principles of evidence-based medicine. Another incorrect approach would be to unilaterally alter the treatment plan without adequate patient consultation and informed consent. This disregards patient autonomy and the right to make decisions about their own healthcare. While the physician may believe they are acting in the patient’s best interest, imposing a new treatment without discussion is paternalistic and ethically unsound, potentially leading to patient distrust and non-adherence. Finally, an approach that involves presenting the new evidence but downplaying its significance or potential benefits, or conversely, overstating its certainty without acknowledging limitations, would also be professionally unacceptable. This constitutes a failure in transparent communication and can lead to a misinformed patient decision, undermining the principle of informed consent and the physician’s ethical obligation to provide accurate and balanced information. Professional decision-making in such situations requires a systematic process: first, critically appraise the new evidence for its validity and applicability to the individual patient; second, consult relevant professional guidelines and expert opinions; third, engage in open and honest communication with the patient, explaining the evidence, potential implications, and treatment options; and fourth, collaboratively develop a revised care plan that respects the patient’s values and preferences while adhering to best medical practice.

The scenario presents a professional challenge due to the inherent tension between a candidate’s desire to achieve a passing score and the integrity of the assessment process. The practice qualification is designed to ensure a high standard of competence in a specialized field, and the blueprint weighting and retake policies are crucial mechanisms for maintaining this standard. A candidate’s personal circumstances, while understandable, should not compromise the fairness and validity of the examination. Careful judgment is required to balance empathy with adherence to established policies. The best professional approach involves a thorough understanding and strict adherence to the published blueprint weighting and retake policies. This means acknowledging the candidate’s situation but firmly explaining that the examination’s structure and retake conditions are non-negotiable and designed to ensure standardized evaluation for all candidates. The focus should be on guiding the candidate towards understanding these policies and their implications for their next attempt, rather than making exceptions. This approach upholds the integrity of the qualification, ensures fairness to all candidates, and reinforces the importance of preparation aligned with the official blueprint. An incorrect approach would be to unilaterally alter the scoring or retake conditions based on the candidate’s personal circumstances. This undermines the established policies and creates an unfair advantage for this candidate over others who have prepared under the same rules. It also sets a dangerous precedent, potentially leading to future requests for exceptions and eroding the credibility of the qualification. Another incorrect approach would be to dismiss the candidate’s concerns without providing clear explanations of the existing policies. While not making exceptions, a lack of clear communication can lead to frustration and a perception of unfairness. Professionals have an ethical obligation to ensure candidates understand the rules governing their assessment. A further incorrect approach would be to suggest that the candidate might have a valid appeal based on their personal situation, without a clear basis in the established appeal procedures. This could lead to false hope and unnecessary administrative burden, while still failing to address the core issue of policy adherence. The professional reasoning process for such situations should involve: first, understanding the established policies and their rationale; second, empathetically listening to the candidate’s concerns; third, clearly and respectfully communicating the relevant policies and their implications; and fourth, guiding the candidate on how to proceed within the established framework, focusing on future preparation and adherence to the rules.

Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between a candidate’s perceived urgency to prepare for a qualification and the ethical obligation to provide accurate and reliable guidance. The pressure to pass an exam, especially one related to a specialized field like precision oncology medicine, can lead candidates to seek shortcuts or rely on unverified information. Professionals must balance supporting candidates with upholding the integrity of the qualification and ensuring candidates are adequately prepared through legitimate means. Correct Approach Analysis: The best professional approach involves guiding the candidate towards officially sanctioned and validated preparation resources, emphasizing the importance of a structured timeline aligned with the qualification’s syllabus. This approach is correct because it directly addresses the candidate’s need for preparation while adhering to the principles of professional integrity and the guidelines set by the Elite Gulf Cooperative. Relying on official study guides, recommended reading lists, and accredited training providers ensures that the candidate is engaging with material that is directly relevant and has been vetted for accuracy and completeness, thereby maximizing their chances of success and demonstrating a commitment to genuine learning. This aligns with the ethical duty to provide accurate and responsible advice. Incorrect Approaches Analysis: One incorrect approach involves recommending unofficial online forums or unverified study notes shared by previous candidates. This is professionally unacceptable because such resources are not vetted for accuracy, may contain outdated information, or could even be misleading. Relying on these sources risks the candidate internalizing incorrect knowledge, which is detrimental to their learning and could lead to failure. It also bypasses the established channels for qualification preparation, undermining the credibility of the Elite Gulf Cooperative’s standards. Another incorrect approach is to suggest that the candidate can “cram” the material in the final weeks before the exam, implying that a superficial understanding is sufficient. This is ethically problematic as it promotes a superficial engagement with a complex and critical field. Precision oncology medicine requires a deep and nuanced understanding, not rote memorization. This approach fails to equip the candidate with the necessary knowledge and skills for actual practice, potentially endangering future patients and devaluing the qualification. A third incorrect approach is to provide the candidate with direct answers or summaries of likely exam questions. This is a severe ethical breach and a direct violation of professional conduct. It constitutes aiding and abetting academic dishonesty, completely undermining the purpose of the qualification, which is to assess a candidate’s genuine knowledge and competence. This action would not only disqualify the candidate but also bring severe reputational damage to the professional providing such assistance. Professional Reasoning: Professionals should adopt a decision-making framework that prioritizes integrity, accuracy, and adherence to established guidelines. When faced with a candidate seeking preparation advice, the first step is to understand their current level of knowledge and their specific needs. The next step is to direct them to the official resources provided by the Elite Gulf Cooperative, such as the syllabus, recommended reading lists, and any officially endorsed training programs. It is crucial to emphasize the importance of a structured study plan that allows for thorough comprehension and retention of the material. If a candidate expresses concerns about time constraints, the professional should help them create a realistic study schedule that aligns with the official timeline and the depth of knowledge required, rather than suggesting shortcuts. Transparency about the importance of genuine learning and the ethical implications of seeking or providing unverified information is paramount.

This scenario presents a professional challenge due to the inherent complexity of integrating cutting-edge genomic data with established clinical practice in precision oncology. The pressure to rapidly adopt novel diagnostic and therapeutic strategies, while ensuring patient safety, data integrity, and adherence to evolving regulatory landscapes, requires meticulous process optimization. Professionals must navigate the ethical considerations of patient consent for advanced molecular profiling, the interpretation of complex genetic findings, and the responsible application of targeted therapies, all within a framework that prioritizes patient well-being and evidence-based medicine. The best approach involves a systematic, multi-disciplinary process that prioritizes robust validation and ethical oversight. This includes establishing clear protocols for sample handling, genomic data analysis, and the interpretation of results by a qualified team of oncologists, geneticists, and bioinformaticians. Crucially, this approach mandates obtaining comprehensive informed consent from patients, detailing the nature of the genomic testing, potential findings, and the implications for treatment decisions. Furthermore, it requires ongoing monitoring of treatment efficacy and adverse events, feeding this data back into clinical practice and research to refine protocols. This aligns with the principles of good clinical practice and the ethical imperative to provide the highest standard of care, ensuring that all decisions are grounded in scientific evidence and patient autonomy. An incorrect approach would be to bypass rigorous validation of novel genomic assays before widespread clinical implementation. This failure to ensure the accuracy and reliability of diagnostic tools can lead to misdiagnosis, inappropriate treatment selection, and potential harm to patients. Ethically, it violates the principle of non-maleficence and the duty to provide competent care. Another unacceptable approach is to proceed with treatment recommendations based solely on raw genomic data without expert clinical interpretation and correlation with the patient’s specific disease presentation and history. This overlooks the nuanced interplay between genetic alterations and clinical phenotype, potentially leading to the selection of ineffective or even detrimental therapies. It also fails to adequately inform the patient about the uncertainties and limitations of such an approach. A further flawed strategy is to implement genomic profiling without a clear framework for data security and patient privacy. The sensitive nature of genomic information necessitates stringent measures to protect it from unauthorized access or misuse, adhering to data protection regulations and ethical standards. Failure to do so erodes patient trust and can have severe legal and ethical repercussions. Professionals should employ a decision-making framework that emphasizes a phased, evidence-based integration of new technologies. This involves initial pilot studies and validation, followed by gradual implementation with continuous quality improvement and ethical review. A commitment to ongoing education and collaboration among all stakeholders is paramount to navigating the dynamic field of precision oncology.

This scenario presents a professional challenge due to the inherent conflict between a patient’s expressed wishes, their perceived capacity, and the clinician’s ethical and professional duty to act in the patient’s best interest, particularly within the context of precision oncology where complex treatment decisions carry significant implications. Navigating this requires a delicate balance of respecting patient autonomy while ensuring they are adequately informed and capable of making such decisions. The health system’s role in supporting these processes, through clear communication channels and access to multidisciplinary teams, is also paramount. The best approach involves a comprehensive assessment of the patient’s capacity to understand the proposed precision oncology treatment, its benefits, risks, and alternatives, and to communicate their decision. This assessment should be conducted by the treating physician, potentially with input from a multidisciplinary team including genetic counselors, ethicists, or geriatric psychiatrists if capacity is in doubt. The focus must be on ensuring the patient has received all necessary information in an understandable format and has had their questions thoroughly addressed. This aligns with the fundamental ethical principle of informed consent, which requires voluntariness, disclosure, comprehension, and competence. In the context of precision oncology, where treatments can be experimental or have profound impacts on quality of life, this rigorous assessment is non-negotiable. It upholds patient autonomy while fulfilling the clinician’s duty of care. An approach that prioritizes immediate treatment initiation based solely on the patient’s stated desire, without a thorough capacity assessment, fails to uphold the principle of informed consent. It risks proceeding with a treatment that the patient may not fully comprehend or truly desire upon deeper reflection, potentially leading to regret or harm. This bypasses the crucial step of ensuring the patient is a willing and informed participant in their care. Another incorrect approach would be to dismiss the patient’s wishes entirely and proceed with a standard treatment protocol without further discussion or exploration of the patient’s rationale for preferring the precision oncology option. This disregards patient autonomy and the potential for the precision oncology approach to be genuinely in the patient’s best interest, even if initially perceived as less conventional. It fails to engage the patient in shared decision-making. Finally, deferring the decision solely to the patient’s family without a formal capacity assessment of the patient themselves is ethically unsound. While family input is valuable, the legal and ethical right to make healthcare decisions rests with the competent patient. This approach undermines the patient’s agency and could lead to decisions being made that do not reflect the patient’s true wishes or best interests. Professionals should employ a structured decision-making process that begins with understanding the patient’s perspective and the clinical context. This is followed by a systematic evaluation of the patient’s capacity, ensuring all relevant information is disclosed and understood, and facilitating open dialogue. When capacity is uncertain, seeking multidisciplinary input and utilizing established assessment tools are crucial. The ultimate goal is to arrive at a decision that respects patient autonomy while ensuring safety and promoting well-being, within the established ethical and regulatory frameworks.

This scenario is professionally challenging because it requires balancing the advancement of precision oncology medicine with the ethical imperative of ensuring equitable access and addressing potential health disparities within the cooperative’s patient population. The rapid evolution of genomic technologies and targeted therapies can inadvertently exacerbate existing inequalities if not managed proactively. Careful judgment is required to ensure that the benefits of precision oncology are distributed fairly and that vulnerable subgroups are not left behind. The best professional approach involves proactively identifying and mitigating potential health inequities from the outset of the precision oncology program. This includes conducting a thorough population health assessment to understand the demographic, socioeconomic, and genetic diversity of the cooperative’s patient base. It necessitates engaging with diverse patient advocacy groups and community leaders to understand their specific needs and concerns. Furthermore, it requires developing strategies to ensure equitable access to diagnostic testing, genomic sequencing, and targeted therapies, potentially through partnerships with public health organizations, exploring financial assistance programs, and implementing culturally sensitive patient education initiatives. This approach aligns with the ethical principles of justice and beneficence, ensuring that the cooperative’s precision oncology efforts serve the entire population it aims to benefit, and adheres to the spirit of promoting health equity in medical practice. An incorrect approach would be to focus solely on the scientific and clinical aspects of precision oncology without considering the broader population health implications. This might involve prioritizing the implementation of the most cutting-edge genomic technologies without a concurrent plan to address potential barriers to access for certain patient groups, such as those with limited financial resources, lower health literacy, or belonging to underrepresented ethnic or racial backgrounds. Such an approach risks widening existing health disparities, failing to uphold the principle of justice, and potentially leading to a situation where only a privileged segment of the patient population benefits from these advanced treatments. Another incorrect approach would be to assume that existing healthcare access mechanisms are sufficient to ensure equitable participation in precision oncology. This overlooks the specific challenges that may arise with advanced genomic medicine, such as the cost of testing and targeted therapies, the need for specialized genetic counseling, and potential biases in data interpretation that could disadvantage certain populations. Relying on the status quo without targeted interventions for precision oncology would be a failure to proactively address potential inequities and would not meet the ethical obligation to strive for fair distribution of healthcare benefits. Finally, an approach that delays addressing health equity concerns until after the program is established would be professionally unsound. This reactive stance would likely lead to the entrenchment of disparities, making them more difficult and costly to rectify. It would also represent a missed opportunity to integrate equity considerations into the foundational design of the precision oncology practice, which is crucial for its long-term success and ethical integrity. Professionals should adopt a proactive, integrated approach to health equity in precision oncology. This involves a continuous cycle of assessment, planning, implementation, and evaluation, with a constant focus on inclusivity and fairness. Key decision-making steps include: 1) conducting comprehensive population health and epidemiological analyses to identify potential disparities; 2) engaging diverse stakeholders to inform program design; 3) developing targeted strategies to overcome access barriers; 4) establishing robust monitoring systems to track equity outcomes; and 5) fostering a culture of continuous improvement and adaptation to address emerging challenges.

This scenario presents a professional challenge due to the inherent tension between patient autonomy, the physician’s duty of care, and the evolving nature of precision oncology. The physician must navigate complex ethical considerations and adhere to established professional guidelines while respecting the patient’s right to make informed decisions about their treatment, even when those decisions diverge from the physician’s recommendation. The rapid advancements in precision oncology mean that evidence bases can be dynamic, requiring continuous professional development and careful consideration of the latest research and clinical trial data. The best approach involves a thorough and empathetic discussion with the patient, clearly outlining the rationale for the recommended treatment, including its potential benefits, risks, and the supporting evidence. This approach prioritizes shared decision-making, ensuring the patient fully understands the implications of their choices. It involves actively listening to the patient’s concerns, values, and preferences, and then collaboratively developing a treatment plan that aligns with these factors, even if it means exploring alternative options or acknowledging the limitations of current knowledge. This aligns with ethical principles of beneficence, non-maleficence, and respect for autonomy, and is supported by professional guidelines emphasizing patient-centered care and informed consent. An incorrect approach would be to dismiss the patient’s concerns or to proceed with a treatment the patient does not fully understand or consent to, solely based on the physician’s perceived best interest. This would violate the principle of patient autonomy and informed consent, potentially leading to a breakdown in the therapeutic relationship and ethical breaches. Another incorrect approach would be to withhold information about alternative treatments or clinical trials, even if they are less established, as this limits the patient’s ability to make a fully informed choice and could be seen as paternalistic. Finally, pressuring the patient into a specific treatment without adequate time for reflection or addressing their specific anxieties would also be professionally unacceptable, as it undermines the collaborative nature of medical decision-making. Professionals should employ a decision-making framework that begins with understanding the patient’s perspective and values. This should be followed by a clear and transparent presentation of medical information, including uncertainties and alternatives. The process should be iterative, allowing for questions, clarification, and shared deliberation to arrive at a mutually agreed-upon plan that respects both clinical evidence and patient preferences.