Scenario Analysis: This scenario is professionally challenging because it requires the neurologist to differentiate between a primary neurological disorder and a presentation that may be influenced by psychological factors, all while adhering to the ethical imperative of patient-centered care and avoiding diagnostic bias. The pressure to quickly identify the underlying cause, coupled with the patient’s subjective and potentially vague symptoms, necessitates a structured and hypothesis-driven approach to history taking and examination. Misinterpreting the symptoms could lead to delayed or incorrect treatment, impacting patient outcomes and trust. Correct Approach Analysis: The best professional practice involves a systematic, hypothesis-driven history taking and a targeted, high-yield physical examination. This approach begins with open-ended questions to allow the patient to describe their experience fully, followed by more specific inquiries designed to test initial hypotheses about potential neurological causes (e.g., stroke, seizure, neurodegenerative disease). The physical examination then focuses on specific neurological domains most likely to reveal objective signs related to the leading hypotheses. This method is ethically sound as it prioritizes understanding the patient’s perspective while efficiently gathering objective data to confirm or refute diagnostic possibilities, aligning with principles of beneficence and non-maleficence by ensuring thoroughness and avoiding premature conclusions. It respects patient autonomy by actively listening and incorporating their narrative into the diagnostic process. Incorrect Approaches Analysis: One incorrect approach is to solely focus on ruling out common neurological emergencies without adequately exploring the patient’s subjective experience or considering less common but relevant diagnoses. This can lead to a superficial history and examination, potentially missing crucial clues that point towards a different underlying etiology or a co-occurring condition. It fails to fully explore the patient’s narrative, potentially violating the principle of patient-centered care and leading to a less accurate diagnosis. Another unacceptable approach is to prematurely attribute the symptoms to psychological factors without a comprehensive neurological workup. This demonstrates diagnostic bias and can lead to a failure to identify a treatable neurological condition, violating the duty of care and the principle of non-maleficence. It also risks alienating the patient and eroding trust in the medical professional. A further incorrect approach is to conduct a broad, unfocused physical examination without specific hypotheses guiding the selection of tests. While appearing comprehensive, this can be inefficient, time-consuming, and may still miss subtle but critical findings if the examiner is not actively testing specific neurological functions relevant to the suspected conditions. This lacks the efficiency and precision required for effective clinical reasoning. Professional Reasoning: Professionals should employ a structured, iterative process. Begin with broad, open-ended questions to gather the patient’s story. Formulate initial differential diagnoses based on this narrative. Then, use targeted, hypothesis-driven questions to gather more specific information to support or refute these hypotheses. Concurrently, plan and execute a high-yield physical examination that directly assesses the neurological systems implicated by the leading hypotheses. Be prepared to revise hypotheses and adjust the examination based on findings. Maintain an open mind to both neurological and non-neurological contributing factors, ensuring a comprehensive and patient-centered evaluation.

The analysis reveals a scenario where a neurologist is considering the Elite North American Behavioral Neurology Competency Assessment for a colleague. This situation is professionally challenging because it requires a nuanced understanding of the assessment’s purpose, eligibility criteria, and the ethical implications of recommending or discouraging participation. Misinterpreting these aspects could lead to professional disservice, wasted resources, or even ethical breaches if the assessment is not appropriate for the individual’s circumstances or career goals. Careful judgment is required to ensure the recommendation aligns with both the assessment’s objectives and the colleague’s best interests. The best professional approach involves a thorough understanding of the Elite North American Behavioral Neurology Competency Assessment’s stated purpose and its specific eligibility requirements. This includes recognizing that the assessment is designed to validate advanced competency in behavioral neurology for those seeking to demonstrate specialized expertise, often for career advancement, board certification, or leadership roles within the field. A professional would consult the official documentation from the assessing body to confirm the target audience, prerequisites (such as years of practice, specific training, or prior certifications), and the assessment’s intended outcomes. Based on this information, they would then engage in a direct, confidential discussion with the colleague to understand their career aspirations, current skill set, and perceived areas for development. This conversation would inform a recommendation that is grounded in factual knowledge of the assessment and tailored to the colleague’s individual professional trajectory. This approach is correct because it prioritizes accurate information and personalized guidance, ensuring that any recommendation is well-informed, ethical, and beneficial to the colleague. It upholds professional integrity by acting in the colleague’s best interest, supported by verifiable criteria. An incorrect approach would be to assume the assessment is a general professional development tool applicable to any neurologist seeking to enhance their skills, without verifying specific eligibility. This failure stems from a lack of due diligence regarding the assessment’s defined scope and target demographic. Ethically, recommending participation without confirming eligibility could lead to the colleague investing time and resources into an assessment for which they are not qualified, causing frustration and potentially damaging their professional standing if their lack of eligibility becomes apparent. Another incorrect approach would be to base the recommendation solely on personal opinion or anecdotal evidence about the assessment’s difficulty or perceived prestige, without consulting official guidelines. This is professionally unsound as it relies on subjective and potentially inaccurate information. The ethical failure here lies in providing advice that is not grounded in objective criteria, potentially misleading the colleague and not serving their best interests. A further incorrect approach would be to discourage the colleague from pursuing the assessment based on a generalized perception of its rigor, without understanding the colleague’s specific strengths and weaknesses or the assessment’s actual requirements. This could inadvertently hinder the colleague’s professional growth and prevent them from achieving a recognized validation of their expertise if they are indeed eligible and would benefit from it. The ethical lapse is in imposing personal biases or assumptions that could limit another professional’s opportunities. The professional reasoning process for similar situations should involve a commitment to evidence-based guidance. This means actively seeking out and consulting official documentation for any assessment or certification being considered. It requires engaging in open and honest communication with the individual seeking advice, understanding their goals and current standing. Finally, it necessitates making recommendations that are objective, transparent, and directly aligned with the stated purpose and eligibility criteria of the program in question, always prioritizing the individual’s professional well-being and development.

This scenario is professionally challenging because it requires balancing the immediate need for diagnostic information with the ethical and regulatory obligations to obtain informed consent and protect patient privacy. The neurologist must navigate potential conflicts between the patient’s stated wishes, the family’s concerns, and the established legal and ethical standards governing medical practice in North America. Careful judgment is required to ensure that any diagnostic procedures are conducted with full patient autonomy and in compliance with relevant privacy laws. The correct approach involves obtaining explicit, informed consent from the patient for the proposed diagnostic imaging, even if the patient’s capacity is fluctuating. This means clearly explaining the purpose of the MRI, the procedure itself, potential risks and benefits, and alternative options. If the patient is deemed to have diminished capacity at the time of the scan, the neurologist must follow established protocols for assessing and documenting capacity, and if necessary, involve a surrogate decision-maker in the consent process, always prioritizing the patient’s previously expressed wishes or best interests. This aligns with fundamental ethical principles of autonomy and beneficence, and regulatory requirements for patient consent and data privacy, such as those found in HIPAA in the United States or PIPEDA in Canada, which mandate patient control over their health information and require consent for its use and disclosure. An incorrect approach would be to proceed with the MRI based solely on the family’s insistence without obtaining the patient’s consent or properly assessing their capacity. This violates the principle of patient autonomy and could contravene privacy regulations by using patient data without authorization. Another incorrect approach would be to delay the MRI indefinitely due to the patient’s fluctuating capacity, potentially compromising diagnostic accuracy and timely treatment, without first exhausting all avenues for obtaining consent or making a best-interests decision. Proceeding with the MRI without a clear understanding of the patient’s wishes or a formal capacity assessment, even with the family’s agreement, risks acting outside of established ethical and legal boundaries for patient care and data handling. Professionals should employ a decision-making framework that prioritizes patient autonomy, beneficence, and non-maleficence. This involves a systematic assessment of the patient’s capacity, thorough communication with the patient and their family, and adherence to institutional policies and relevant legal statutes regarding consent and privacy. When capacity is uncertain, a structured approach to capacity assessment and the involvement of appropriate ethical or legal consultation should be considered.

The efficiency study reveals a common challenge in neurological practice: balancing diagnostic thoroughness with resource optimization. This scenario is professionally challenging because it requires the neurologist to make critical decisions about imaging selection and interpretation under pressure to be efficient, potentially impacting patient care if not handled judiciously. Careful judgment is required to ensure that efficiency does not compromise diagnostic accuracy or patient safety. The best professional approach involves a systematic, evidence-based workflow that prioritizes diagnostic yield and patient safety. This begins with a thorough clinical assessment to formulate a differential diagnosis. Based on this, the neurologist selects the most appropriate imaging modality that directly addresses the most likely or most critical diagnostic possibilities. For instance, if a vascular etiology is suspected, a CTA or MRA might be prioritized over a standard MRI. Interpretation then follows a structured protocol, comparing findings against the clinical presentation and relevant literature. This approach is correct because it aligns with established clinical practice guidelines and ethical principles of patient care, emphasizing a patient-centered, evidence-based diagnostic process. It ensures that investigations are targeted and that interpretations are clinically relevant, minimizing unnecessary radiation exposure or cost while maximizing diagnostic accuracy. An incorrect approach would be to routinely order the most advanced or comprehensive imaging study available for all patients presenting with neurological symptoms, regardless of the clinical suspicion. This fails to consider the principle of judicious resource utilization and may expose patients to unnecessary risks associated with certain imaging techniques. It also overlooks the importance of tailoring investigations to the specific clinical question, potentially leading to incidental findings that cause patient anxiety and further unnecessary investigations. Another incorrect approach is to rely solely on automated interpretation software without critical clinical review. While AI tools can be valuable aids, they are not substitutes for expert clinical judgment. Over-reliance on automated interpretations can lead to missed diagnoses or misinterpretations, particularly in complex or atypical cases, violating the neurologist’s responsibility for accurate diagnosis and patient care. A further incorrect approach involves delaying interpretation or follow-up of imaging results due to workload pressures, without a clear system for prioritizing urgent findings. This can lead to significant delays in diagnosis and treatment, potentially worsening patient outcomes and constituting a breach of professional duty of care. Professionals should employ a decision-making framework that integrates clinical expertise, patient history, physical examination findings, and an understanding of the diagnostic utility and limitations of various imaging modalities. This framework should include a systematic approach to differential diagnosis, evidence-based selection of investigations, and rigorous interpretation, with clear protocols for managing urgent findings and communicating results.

Scenario Analysis: This scenario presents a common challenge in behavioral neurology: managing a patient with a complex, chronic condition exhibiting fluctuating symptoms and requiring a multi-faceted treatment plan. The professional challenge lies in balancing the immediate need for symptom control with long-term functional improvement and patient autonomy, all within the framework of evidence-based practice and ethical considerations. The clinician must navigate potential diagnostic uncertainty, patient adherence issues, and the need for interdisciplinary collaboration. Careful judgment is required to select the most appropriate management strategy that is both clinically effective and ethically sound. Correct Approach Analysis: The best approach involves a comprehensive, individualized assessment that integrates current evidence-based guidelines for the specific neurological condition with the patient’s unique presentation, functional goals, and preferences. This includes a thorough review of the patient’s medication regimen for efficacy and side effects, exploration of non-pharmacological interventions (e.g., physical therapy, occupational therapy, cognitive rehabilitation), and consideration of psychosocial factors impacting well-being and adherence. The clinician should then collaboratively develop a treatment plan with the patient, clearly outlining realistic goals, expected outcomes, and potential risks and benefits of each intervention. This approach aligns with the ethical principles of beneficence, non-maleficence, and respect for patient autonomy, and adheres to the professional obligation to provide care based on the best available scientific evidence. Incorrect Approaches Analysis: One incorrect approach would be to solely focus on adjusting the current pharmacological regimen without a broader assessment. This fails to acknowledge that many behavioral neurological conditions require a multimodal approach and may not be adequately managed by medication alone. It risks overlooking non-pharmacological interventions that could significantly improve function and quality of life, and may lead to polypharmacy or unnecessary side effect burden without addressing the root causes of functional decline. Another incorrect approach would be to dismiss the patient’s subjective reports of functional decline and attribute them solely to non-compliance or psychological factors without objective investigation. This demonstrates a lack of empathy and a failure to conduct a thorough differential diagnosis. It can lead to misdiagnosis, inadequate treatment, and erosion of the patient-clinician trust, violating the principle of thoroughness in patient care. A third incorrect approach would be to implement a rigid, one-size-fits-all treatment protocol without considering the patient’s individual circumstances, preferences, or the specific nuances of their condition’s progression. This disregards the principle of individualized care and the importance of shared decision-making, potentially leading to a treatment plan that is not well-tolerated or effective for the specific patient, and may not align with their personal values or goals. Professional Reasoning: Professionals should employ a systematic decision-making process that begins with a comprehensive patient assessment, including a detailed history, neurological examination, and review of relevant investigations. This should be followed by an evidence-based literature review to identify current best practices for the patient’s condition. The clinician must then synthesize this information with the patient’s individual needs and preferences to formulate a differential diagnosis and a range of potential management strategies. Collaborative goal setting and shared decision-making are paramount in developing an individualized, evidence-based treatment plan that prioritizes patient well-being and functional outcomes. Regular reassessment and adaptation of the plan based on patient response and evolving evidence are also critical components of effective management.

Scenario Analysis: This scenario is professionally challenging because it requires navigating the tension between an individual’s desire to advance their career and the established policies designed to ensure competency and fairness. The neurologist’s anxiety and the potential impact on their professional standing create a high-stakes situation where adherence to policy must be balanced with empathy and clear communication. The core challenge lies in upholding the integrity of the assessment process while supporting the individual. Correct Approach Analysis: The best professional approach involves a direct, transparent, and policy-aligned response. This entails clearly communicating the established retake policy, including any limitations or specific procedures, and outlining the next steps the neurologist must take if they wish to retake the assessment. This approach is correct because it upholds the regulatory framework governing the assessment, ensuring fairness and consistency for all candidates. It respects the blueprint weighting and scoring mechanisms by not allowing exceptions that could undermine their validity. Ethically, it promotes honesty and transparency, preventing the appearance of favoritism or undue influence. Incorrect Approaches Analysis: One incorrect approach involves immediately agreeing to a special arrangement without consulting the official policy or relevant governing body. This is professionally unacceptable because it bypasses established procedures, potentially creating a precedent that compromises the integrity of the assessment. It violates the principle of fairness by offering a potentially unequal opportunity compared to other candidates and could lead to accusations of bias. Another incorrect approach is to dismiss the neurologist’s concerns without providing clear information about the retake policy. This is ethically problematic as it lacks empathy and fails to offer constructive guidance. It also risks alienating a colleague and could lead to misunderstandings about the assessment process, potentially damaging professional relationships and the reputation of the assessment program. A further incorrect approach is to suggest that the blueprint weighting and scoring can be arbitrarily adjusted for this specific case. This is a direct violation of the assessment’s foundational principles. The blueprint weighting and scoring are designed to ensure a standardized and objective evaluation of competency. Deviating from these established metrics undermines the validity and reliability of the assessment, rendering the results meaningless and potentially leading to unqualified individuals being certified. This also breaches regulatory requirements that mandate adherence to standardized assessment protocols. Professional Reasoning: Professionals facing such situations should first consult the official documentation for the assessment, including the blueprint, scoring guidelines, and retake policies. They should then communicate these policies clearly and empathetically to the individual. If there are any ambiguities or the need for an exception, the appropriate governing committee or administrative body should be consulted for guidance, ensuring that any decision is made in accordance with established regulations and ethical principles. The focus should always be on maintaining the integrity and fairness of the assessment process.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the candidate’s desire for efficient preparation with the ethical obligation to provide accurate and comprehensive guidance. Misleading a candidate about preparation resources or timelines can lead to inadequate preparation, potential failure on the assessment, and damage to the candidate’s career prospects and the reputation of the assessment body. The neurologist must exercise sound professional judgment to offer advice that is both helpful and responsible, adhering to professional standards and best practices for candidate support. Correct Approach Analysis: The best professional practice involves recommending a multi-faceted preparation strategy that acknowledges the breadth of the Elite North American Behavioral Neurology Competency Assessment. This approach correctly emphasizes utilizing a combination of foundational academic resources (e.g., established textbooks in behavioral neurology, relevant review articles), practice questions that simulate the assessment format and difficulty, and engaging with study groups or mentors. This is correct because it aligns with the principles of comprehensive professional development and assessment preparation. It ensures the candidate is exposed to diverse learning materials and assessment styles, fostering a deeper understanding rather than superficial memorization. This approach implicitly adheres to ethical guidelines that promote competence and professional integrity by encouraging thorough and evidence-based preparation. Incorrect Approaches Analysis: Recommending solely relying on a single, recently published review article, even if it appears comprehensive, is professionally unacceptable. This approach fails to account for the depth and breadth of knowledge typically assessed in a competency examination. It risks overlooking foundational concepts or specialized areas not covered in that single article, potentially leading to a candidate being underprepared. This is ethically problematic as it provides incomplete guidance. Suggesting that a candidate can adequately prepare by only reviewing lecture notes from a single graduate course is also professionally unacceptable. While lecture notes can be valuable, they are often supplementary to core texts and may not cover all necessary material or provide the level of detail required for a high-stakes competency assessment. This approach risks creating blind spots in the candidate’s knowledge base and is ethically questionable due to its limited scope. Advising a candidate to focus exclusively on memorizing a list of common neurological conditions without understanding their underlying pathophysiology, diagnostic approaches, and treatment nuances is professionally unacceptable. Competency assessments, especially in specialized fields like behavioral neurology, require a deep conceptual understanding and the ability to apply knowledge, not just rote memorization. This approach would lead to superficial knowledge and an inability to handle complex clinical scenarios, failing to meet the ethical standard of promoting genuine competence. Professional Reasoning: Professionals should adopt a decision-making framework that prioritizes accuracy, completeness, and ethical responsibility when advising candidates. This involves: 1) Understanding the scope and nature of the assessment: Researching the assessment’s objectives, format, and typical content areas. 2) Identifying evidence-based preparation strategies: Drawing upon established best practices for professional development and assessment preparation. 3) Considering the candidate’s individual needs and learning style: While providing general guidance, acknowledging that some personalization might be beneficial, but never at the expense of core preparation principles. 4) Maintaining professional integrity: Ensuring advice is honest, realistic, and promotes genuine competence, avoiding shortcuts or misleading information.

This scenario is professionally challenging because it requires balancing the immediate need for information to assess a patient’s condition with the ethical and regulatory obligations to protect patient privacy and obtain informed consent. The neurologist must navigate potential diagnostic urgency against established protocols for data handling and patient rights. Careful judgment is required to ensure that any information gathered is both necessary for immediate care and obtained through appropriate means. The best professional approach involves immediately initiating a clinical assessment based on the presenting symptoms and the information provided by the emergency contact, while simultaneously initiating the process for obtaining formal consent for further investigation and data access. This approach prioritizes patient well-being by allowing for prompt clinical evaluation and intervention, which is critical in neurological emergencies. It also respects patient autonomy and privacy by ensuring that any access to protected health information or more extensive diagnostic procedures is subsequently authorized. This aligns with ethical principles of beneficence and non-maleficence, as well as regulatory frameworks that mandate informed consent and data protection. An incorrect approach would be to immediately access the patient’s full electronic health record without any form of consent or documented emergency justification. This violates patient privacy rights and regulatory requirements concerning protected health information. Another incorrect approach would be to delay any clinical assessment until formal written consent is obtained, even if the patient is incapacitated and the information is urgently needed for diagnosis and treatment. This could lead to a delay in care, potentially harming the patient, and fails to recognize the exceptions to consent requirements in emergency situations. Finally, relying solely on the emergency contact’s verbal permission to access all medical records without any attempt to document the emergency situation or initiate the consent process for further steps is insufficient. While emergency contacts can provide critical information, their authorization for broad data access is typically limited and requires subsequent formalization. Professionals should employ a decision-making framework that first assesses the urgency of the clinical situation. If immediate intervention is required, they should proceed with necessary life-saving or stabilizing measures, documenting the rationale for any deviation from standard consent procedures. Concurrently, they must initiate the process for obtaining informed consent for further diagnostic steps and data access as soon as the patient’s condition or a legally authorized representative permits. This framework emphasizes a tiered approach: immediate clinical necessity, followed by diligent adherence to privacy and consent regulations.

This scenario presents a professional challenge due to the inherent complexity of diagnosing and managing neurodegenerative conditions, which often involve subtle early signs and a significant impact on a patient’s quality of life and autonomy. The integration of foundational biomedical sciences with clinical medicine requires a nuanced understanding of disease mechanisms, genetic predispositions, and the potential for novel therapeutic interventions, all while navigating ethical considerations related to patient consent, disclosure of genetic risks, and the management of progressive cognitive decline. Careful judgment is required to balance diagnostic certainty with the psychological impact of potential diagnoses and to ensure patient-centered care. The best approach involves a comprehensive risk assessment that prioritizes a thorough clinical evaluation, including detailed neurological examination, cognitive testing, and appropriate neuroimaging, to establish a baseline and identify potential contributing factors. This is followed by a discussion with the patient and, with their consent, their family about the diagnostic process, potential differential diagnoses, and the implications of further investigations, including genetic testing if indicated by the clinical presentation and family history. This approach aligns with ethical principles of informed consent, patient autonomy, and beneficence by ensuring the patient is an active participant in their care and that investigations are tailored to their specific needs and concerns. It also adheres to professional guidelines that emphasize a systematic and evidence-based approach to neurological diagnosis. An incorrect approach would be to immediately proceed with extensive genetic testing without a clear clinical indication or prior discussion with the patient about the rationale, potential findings, and implications. This fails to respect patient autonomy and informed consent, potentially causing undue anxiety and distress from unexpected or uninterpretable genetic results. It also represents a failure in clinical reasoning by not establishing a sufficient clinical foundation to guide the selection of appropriate genetic tests. Another incorrect approach would be to rely solely on subjective patient reports of cognitive changes without objective clinical assessment and diagnostic workup. This risks misdiagnosis, delaying appropriate treatment or leading to unnecessary interventions. It neglects the foundational biomedical sciences that underpin neurological diagnosis and fails to meet professional standards for thoroughness and evidence-based practice. A further incorrect approach would be to prematurely disclose a potential diagnosis based on preliminary findings without confirming it through a comprehensive diagnostic process. This can lead to significant psychological distress for the patient and their family, potentially impacting their decision-making and quality of life prematurely. It demonstrates a lack of adherence to the principle of diagnostic certainty before significant disclosures are made. Professionals should employ a decision-making framework that begins with a thorough understanding of the patient’s presenting symptoms and medical history. This should be followed by a systematic diagnostic process that integrates knowledge of neuroanatomy, neurophysiology, neuropathology, and genetics with clinical observations. Throughout this process, open communication with the patient and their family, respecting their values and preferences, is paramount. Ethical considerations, particularly informed consent and the management of uncertainty, should guide every step of the diagnostic and management plan.

Scenario Analysis: This scenario presents a significant professional challenge due to the inherent conflict between a patient’s expressed wishes, potentially influenced by their neurological condition, and the clinician’s ethical obligation to ensure patient safety and well-being. The progressive nature of behavioral neurology conditions can impair judgment and decision-making capacity, creating a complex ethical landscape where respecting autonomy must be balanced with beneficence and non-maleficence. The clinician must navigate the nuances of capacity assessment, the potential for undue influence, and the legal and ethical frameworks governing medical decision-making for individuals with diminished capacity. Correct Approach Analysis: The best professional approach involves a comprehensive and documented assessment of the patient’s decision-making capacity. This entails evaluating the patient’s ability to understand the relevant information about their condition and proposed treatment, appreciate the consequences of their choices, reason through the options, and communicate a choice. If capacity is found to be lacking, the clinician must then follow established legal and ethical protocols for surrogate decision-making, which typically involves identifying and consulting with the legally authorized surrogate (e.g., a healthcare power of attorney or next of kin) while continuing to advocate for the patient’s best interests. This approach upholds the principles of patient autonomy to the greatest extent possible while ensuring safety and adherence to legal and ethical standards. Incorrect Approaches Analysis: One incorrect approach involves overriding the patient’s stated preference solely based on the clinician’s belief that it is not in the patient’s best interest, without a formal capacity assessment or consultation with a surrogate. This fails to respect the principle of autonomy and may violate legal requirements for capacity determination and surrogate involvement. Another incorrect approach is to proceed with the patient’s stated preference without thoroughly investigating potential undue influence or coercion, especially given the patient’s neurological condition. This neglects the ethical duty to protect vulnerable patients and could lead to harmful outcomes. A further incorrect approach is to delay or refuse to engage with the patient’s stated preferences or the surrogate decision-maker due to discomfort with the situation or a lack of clarity on the process. This can lead to a breakdown in the therapeutic relationship and potentially compromise the patient’s care. Professional Reasoning: Professionals should employ a structured decision-making process that prioritizes patient autonomy within the bounds of safety and legal/ethical compliance. This involves: 1) Initial assessment of the patient’s stated wishes and understanding. 2) A formal, documented capacity assessment if any doubt exists. 3) If capacity is lacking, identification and engagement with the legally authorized surrogate. 4) Continuous communication and collaboration with the patient (to the extent possible) and the surrogate. 5) Documentation of all assessments, discussions, and decisions. 6) Consultation with ethics committees or legal counsel when complex ethical or legal issues arise.