This scenario presents a professional challenge due to the complex interplay of multiple specialists, potential for communication breakdowns, and the critical need to ensure patient safety and continuity of care in a neuroimmunological context. The patient’s fluctuating neurological status and the involvement of diverse medical disciplines necessitate a robust and clearly defined escalation pathway to prevent delays in critical interventions or misinterpretations of evolving symptoms. Careful judgment is required to navigate these interdisciplinary dynamics effectively. The best approach involves immediate, direct, and documented communication with the primary neurologist, clearly outlining the observed changes and the rationale for concern, while simultaneously initiating the hospital’s established rapid response team protocol. This is correct because it prioritizes direct physician-to-physician communication for critical clinical updates, ensuring the most knowledgeable specialist is immediately informed. The documented initiation of the rapid response team protocol adheres to institutional guidelines for urgent patient deterioration, providing a structured and immediate multidisciplinary response. This aligns with ethical principles of beneficence and non-maleficence by ensuring prompt and appropriate care, and regulatory expectations for clear communication and patient safety protocols. An incorrect approach would be to rely solely on a nurse’s note in the electronic health record without direct verbal communication to the primary neurologist. This fails to ensure timely awareness by the physician responsible for the patient’s overall management and may lead to delays in assessment and intervention, potentially violating the duty of care. Another incorrect approach would be to escalate only to the on-call resident without informing the attending neurologist, as this bypasses the primary physician’s oversight and may not provide the most experienced clinical judgment for a complex neuroimmunological case. Finally, waiting for the next scheduled multidisciplinary team meeting to discuss the patient’s changes would be a significant failure, as the patient’s condition is acutely deteriorating and requires immediate attention, not delayed discussion. This approach neglects the urgency of the situation and the ethical imperative to act swiftly in the face of potential harm. Professionals should employ a decision-making framework that prioritizes patient safety, clear communication, and adherence to established protocols. This involves a continuous assessment of the patient’s status, understanding the roles and responsibilities of each team member, and knowing when and how to escalate concerns through appropriate channels. When faced with significant clinical changes, the first step should always be to inform the most senior and responsible clinician directly, followed by activating relevant institutional emergency response systems if indicated.

Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between a physician’s duty to provide optimal patient care and the potential for financial gain through research participation. The physician must navigate ethical considerations regarding informed consent, potential bias in treatment recommendations, and the responsible use of investigational therapies, all within the framework of neuroimmunology research ethics and patient welfare. The complexity arises from the experimental nature of the treatment and the physician’s dual role as clinician and researcher. Correct Approach Analysis: The best professional practice involves a comprehensive and transparent approach to patient care and research participation. This includes thoroughly evaluating the patient’s condition against established treatment protocols, clearly explaining the investigational nature of the therapy, its potential benefits and risks, and the availability of standard treatments. Crucially, it necessitates obtaining fully informed consent, ensuring the patient understands they can refuse participation without impacting their standard care. The physician must also disclose any potential conflicts of interest related to the research study, such as financial incentives or sponsorship, to the patient and the relevant institutional review board (IRB) or ethics committee. This approach prioritizes patient autonomy, beneficence, and non-maleficence, adhering to ethical guidelines for clinical research and medical practice. Incorrect Approaches Analysis: Recommending the investigational therapy solely based on its inclusion in a research study, without a thorough assessment of its suitability for the individual patient’s current clinical status and comparison to existing standard treatments, violates the principle of beneficence and potentially non-maleficence. This approach risks exposing the patient to unproven risks without a clear clinical indication. Suggesting the investigational therapy as the primary or only option, while downplaying or omitting information about standard treatment alternatives, undermines patient autonomy and the principle of informed consent. This can create undue pressure on the patient to participate in the research, compromising their right to make an uncoerced decision. Accepting financial incentives from the research sponsor to recruit patients, without full disclosure to the patient and the IRB, constitutes a significant ethical breach and a conflict of interest. This can lead to biased decision-making, where recruitment is prioritized over the patient’s best interests, and erodes trust in the research process. Professional Reasoning: Professionals should adopt a patient-centered decision-making framework. This involves prioritizing the patient’s well-being and autonomy above all else. When considering investigational treatments, a systematic approach should be followed: 1) Assess clinical appropriateness: Does the investigational treatment align with the patient’s specific condition and prognosis, considering all available standard therapies? 2) Ensure full transparency: Clearly communicate the experimental nature, potential benefits, risks, and alternatives. 3) Obtain genuine informed consent: Verify the patient’s understanding and voluntary agreement. 4) Manage conflicts of interest: Disclose all relevant financial or personal interests to the patient and relevant oversight bodies. 5) Consult ethical guidelines and institutional policies: Adhere strictly to established research ethics and clinical practice standards.

Scenario Analysis: This scenario presents a common challenge in neuroimmunology: differentiating between inflammatory demyelinating diseases and other neurological conditions that can mimic them. The professional challenge lies in selecting the most appropriate and cost-effective diagnostic imaging strategy while adhering to evidence-based guidelines and ensuring patient safety and optimal resource utilization. Misinterpretation or premature reliance on less specific imaging can lead to delayed diagnosis, inappropriate treatment, and unnecessary patient anxiety or harm. Correct Approach Analysis: The best professional practice involves a systematic, stepwise approach to diagnostic imaging, beginning with the most sensitive and specific initial imaging modality for suspected inflammatory demyelination, followed by more advanced techniques if initial findings are equivocal or require further characterization. This approach aligns with the principles of efficient healthcare delivery and evidence-based medicine, aiming to confirm or refute the suspected diagnosis with the least invasive and most informative initial steps. Specifically, commencing with a comprehensive Magnetic Resonance Imaging (MRI) protocol of the brain and spinal cord, including contrast enhancement, is crucial. This allows for the detection of characteristic lesions, their distribution, and enhancement patterns indicative of active inflammation, which are key diagnostic features. This initial step is supported by numerous neuroimaging guidelines for suspected demyelinating diseases, emphasizing its role in early and accurate diagnosis. Incorrect Approaches Analysis: One incorrect approach would be to immediately proceed to advanced imaging techniques like Diffusion Tensor Imaging (DTI) or functional MRI without first establishing a baseline with conventional MRI. This is professionally unacceptable as it bypasses the foundational diagnostic information provided by standard MRI sequences, potentially leading to misinterpretation of subtle findings or unnecessary exposure to longer scan times and increased costs without clear diagnostic benefit at this initial stage. It fails to adhere to the principle of starting with the most appropriate and least resource-intensive diagnostic tool. Another incorrect approach would be to rely solely on non-imaging diagnostic methods, such as extensive blood work or lumbar puncture, without obtaining appropriate neuroimaging. While these investigations are important adjuncts, they are often not sufficient on their own to definitively diagnose or exclude inflammatory demyelinating diseases, especially in the early stages. Neuroimaging provides critical anatomical and pathological information that these other tests cannot, and delaying imaging can significantly impede timely diagnosis and management. This approach neglects the primary role of imaging in visualizing the central nervous system lesions characteristic of these conditions. A third incorrect approach would be to select a limited or incomplete MRI protocol, such as only imaging the brain without the spinal cord, or omitting contrast enhancement. This is professionally flawed because inflammatory demyelinating lesions can occur in either the brain or spinal cord, and their distribution is a key diagnostic criterion. The absence of contrast enhancement can mask active inflammation, leading to missed diagnoses or underestimation of disease activity. This incomplete imaging strategy fails to provide the comprehensive data required for accurate diagnostic reasoning. Professional Reasoning: Professionals should employ a diagnostic reasoning framework that prioritizes a thorough clinical assessment, followed by a stepwise, evidence-based approach to investigations. This involves formulating a differential diagnosis, identifying the most likely diagnoses, and then selecting imaging modalities that are most sensitive and specific for those conditions. The process should be iterative, with the interpretation of initial findings guiding the need for further investigations. Cost-effectiveness, patient safety, and adherence to established clinical guidelines are paramount considerations throughout the diagnostic workflow.

Scenario Analysis: This scenario presents a common challenge in neuroimmunology: managing a patient with a complex autoimmune neurological condition where treatment efficacy can vary significantly and potential side effects require careful monitoring. The professional challenge lies in balancing the need for aggressive treatment to control disease activity with the imperative to minimize iatrogenic harm, all while adhering to evolving evidence and patient-specific factors. Careful judgment is required to select the most appropriate evidence-based strategy that aligns with the patient’s clinical status, preferences, and the current understanding of the disease. Correct Approach Analysis: The best professional practice involves a comprehensive, evidence-based approach that integrates current clinical trial data, expert consensus guidelines, and a thorough assessment of the individual patient’s disease severity, comorbidities, and treatment history. This approach prioritizes shared decision-making, ensuring the patient understands the risks, benefits, and alternatives of proposed treatments. It also necessitates a robust plan for monitoring treatment efficacy and potential adverse events, with clear criteria for escalation, de-escalation, or switching therapies. 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 practice according to the highest standards of care informed by the latest scientific evidence. Incorrect Approaches Analysis: One incorrect approach involves relying solely on historical treatment protocols without critically evaluating newer evidence or the patient’s specific circumstances. This fails to uphold the principle of practicing evidence-based medicine and may lead to suboptimal outcomes or unnecessary exposure to ineffective or harmful treatments. It disregards the dynamic nature of medical knowledge and the importance of personalized care. Another incorrect approach is to initiate a novel or off-label treatment without a clear rationale supported by emerging research or compassionate use protocols, especially if established, evidence-based options have not been adequately explored or failed. This deviates from the standard of care and carries a higher risk of unforeseen adverse events, potentially violating the principle of non-maleficence. It also bypasses the crucial step of informed consent regarding the experimental nature of such a treatment. A third incorrect approach is to delay or withhold treatment due to uncertainty or fear of side effects, without a clear plan for managing the underlying disease. While caution is warranted, prolonged inaction in the face of active autoimmune neurological disease can lead to irreversible neurological damage and significant disability, contravening the duty to provide timely and effective care. Professional Reasoning: Professionals should employ a systematic decision-making process that begins with a thorough diagnostic workup and risk stratification. This is followed by a comprehensive review of the latest evidence, including randomized controlled trials, meta-analyses, and consensus guidelines relevant to the specific neuroimmunological condition. Patient preferences, values, and goals of care must be actively solicited and integrated into the decision-making process. Treatment plans should be individualized, incorporating monitoring strategies for both efficacy and safety, with pre-defined thresholds for intervention or modification. Regular re-evaluation of the treatment plan in light of new evidence and the patient’s evolving clinical status is paramount.

The scenario presents a common challenge for candidates preparing for a high-stakes fellowship exit examination: balancing comprehensive preparation with time constraints and the need for effective resource utilization. The professional challenge lies in navigating a vast landscape of potential study materials and strategies, ensuring that the chosen approach is both efficient and compliant with the implicit ethical obligation to demonstrate mastery of the subject matter through diligent and appropriate preparation. Failure to do so can lead to inadequate knowledge, potentially impacting future patient care and professional standing. The best approach involves a structured, evidence-based strategy that prioritizes official examination guidelines and reputable academic resources, coupled with a realistic timeline. This method is correct because it directly addresses the examination’s stated objectives and content domains, minimizing the risk of studying irrelevant material. It aligns with the ethical imperative to prepare thoroughly and competently for professional practice, ensuring that the knowledge acquired is directly applicable to the field of neuroimmunology. Furthermore, it respects the candidate’s time by focusing on high-yield areas and proven learning techniques, fostering a deep understanding rather than superficial memorization. An approach that relies solely on anecdotal advice from peers or outdated study guides is professionally unacceptable. This fails to acknowledge the dynamic nature of medical knowledge and examination content, potentially leading to the acquisition of misinformation or an incomplete understanding of current best practices. It also disregards the official guidance provided by the examination board, which is the definitive source for understanding the scope and expectations of the fellowship. Another professionally unacceptable approach is to defer preparation until the final weeks before the examination. This strategy is inherently flawed as it does not allow for the deep cognitive processing and retention required for complex neuroimmunological concepts. It increases the likelihood of superficial learning and stress, which can impair performance. Ethically, it suggests a lack of commitment to mastering the subject matter to the standard expected of a fellowship graduate. Finally, an approach that exclusively focuses on memorizing facts without understanding underlying mechanisms or clinical applications is also professionally deficient. While factual recall is important, neuroimmunology requires a nuanced understanding of pathophysiology, diagnostic interpretation, and therapeutic strategies. This method risks producing a candidate who can recite information but cannot apply it effectively in a clinical context, which is a failure of professional responsibility. Professionals should adopt a decision-making framework that begins with thoroughly reviewing the official examination syllabus and recommended reading lists. This should be followed by an assessment of personal strengths and weaknesses, allowing for targeted study. A realistic timeline should be constructed, incorporating regular review and practice assessments. Seeking guidance from mentors or recent graduates who have successfully navigated the examination can provide valuable insights, but this should supplement, not replace, a structured, self-directed preparation plan based on official resources.

The performance metrics show a candidate, Dr. Anya Sharma, has narrowly failed the Global Pacific Rim Neuroimmunology Fellowship Exit Examination twice. This scenario is professionally challenging because it requires balancing the need to uphold rigorous standards for patient safety and the integrity of the fellowship program with compassion and support for a promising but struggling candidate. The fellowship’s blueprint weighting, scoring, and retake policies are the governing framework for such decisions, demanding a careful, evidence-based approach that avoids arbitrary or emotionally driven outcomes. The best professional approach involves a thorough review of Dr. Sharma’s performance data against the established blueprint weighting and scoring criteria, coupled with an objective assessment of her progress and potential for future success. This includes examining the specific areas of weakness identified in her previous attempts, evaluating the fellowship’s defined retake policy, and considering any documented remediation efforts. This approach is correct because it adheres strictly to the program’s established policies, ensuring fairness and consistency in evaluation. It prioritizes patient safety by ensuring that only candidates who meet the defined competency standards are certified. Furthermore, it aligns with ethical principles of due process and transparency by relying on objective data and pre-defined criteria. An incorrect approach would be to immediately grant Dr. Sharma a third attempt without a formal review process, even if she expresses strong commitment. This fails to uphold the integrity of the examination process and the established blueprint weighting and scoring policies. It bypasses the structured evaluation designed to ensure competency and could set a precedent for leniency that undermines the program’s standards. Another incorrect approach would be to dismiss Dr. Sharma from the program solely based on two failed attempts without considering the nuances of her performance or the program’s specific retake policy. This might be overly punitive and fail to acknowledge potential for improvement, especially if the policy allows for further remediation or a structured third attempt under specific conditions. It also risks overlooking the possibility that the examination itself might have unforeseen biases or that external factors could have impacted her performance. A further incorrect approach would be to offer Dr. Sharma a modified or less rigorous examination for her next attempt. This directly violates the principle of standardized assessment and the blueprint weighting and scoring policies. It compromises the validity and reliability of the fellowship’s certification process, as it would mean her qualification would not be comparable to that of other fellows who completed the standard examination. Professionals should employ a decision-making framework that begins with a clear understanding of the relevant policies and guidelines (blueprint weighting, scoring, retake policies). This framework involves objective data collection and analysis, consultation with relevant stakeholders (e.g., examination committee), and a commitment to fairness and consistency. When faced with a candidate who has not met initial benchmarks, the process should involve identifying specific areas for improvement, offering structured remediation, and then making a decision regarding further attempts based on a comprehensive review of performance against established criteria, rather than on subjective impressions or external pressures.

This scenario is professionally challenging because it requires balancing the immediate need for a potentially life-saving treatment with the ethical and regulatory obligations to ensure informed consent and patient autonomy, especially when dealing with a vulnerable population and novel therapeutic approaches. The rapid progression of the disease and the limited availability of established treatments create pressure to act quickly, but this must not override fundamental patient rights and safety protocols. The best approach involves a comprehensive and transparent discussion with the patient and their legal guardian regarding the experimental nature of the therapy, its potential benefits and risks, and available alternative treatments, even if those alternatives are palliative. This approach is correct because it upholds the principles of informed consent, which are paramount in medical ethics and are enshrined in regulatory frameworks governing clinical research and novel treatments. Specifically, it aligns with the ethical imperative to respect patient autonomy and the legal requirement for a thorough explanation of risks, benefits, and alternatives before any medical intervention, particularly an experimental one. This ensures that the decision to proceed is voluntary and based on a clear understanding of the situation. An incorrect approach would be to proceed with the experimental therapy without a detailed discussion of its investigational status and potential uncertainties, even if the guardian expresses urgency. This fails to meet the ethical standard of informed consent and violates regulatory requirements for patient protection in research settings, potentially exposing the patient to unacknowledged risks and undermining their right to make informed decisions about their own care. Another incorrect approach involves prioritizing the potential for a breakthrough treatment over the patient’s right to understand the experimental nature of the intervention. While the desire to offer hope is understandable, it cannot justify withholding critical information about the uncertainties and risks associated with an unproven therapy. This approach disregards the ethical principle of non-maleficence and the regulatory obligation to ensure that participants in experimental treatments are fully aware of what they are agreeing to. A further incorrect approach would be to rely solely on the guardian’s consent without ensuring the patient, to the extent of their capacity, understands the situation. While guardians have a crucial role, the patient’s own assent, where possible, is an important ethical consideration, and regulatory guidelines often emphasize involving the patient in decision-making to the greatest extent feasible. The professional decision-making process for similar situations should involve a structured approach: first, thoroughly assess the patient’s condition and prognosis. Second, identify all available treatment options, including standard care, palliative care, and any relevant experimental therapies. Third, engage in a detailed, empathetic, and transparent discussion with the patient and their legal guardian, clearly outlining the nature of each option, including the experimental status, potential benefits, known risks, and uncertainties of the proposed therapy. Fourth, document the informed consent process meticulously. Finally, consult with ethics committees or senior colleagues if there are any ambiguities or complex ethical considerations.

This scenario presents a professional challenge because it requires a candidate to navigate the specific eligibility criteria and stated purpose of a specialized fellowship examination without overstepping the boundaries of their current qualifications or misrepresenting their intent. Careful judgment is required to ensure alignment with the examination’s objectives and the fellowship’s intended scope. The correct approach involves a thorough understanding of the Global Pacific Rim Neuroimmunology Fellowship Exit Examination’s stated purpose, which is to assess advanced competency in neuroimmunology for individuals who have successfully completed a recognized fellowship program in the region. Eligibility is typically tied to the completion of such a program and the recommendation of a supervising faculty member. Therefore, a candidate who has completed a relevant fellowship and meets the formal requirements, even if their immediate post-fellowship role is in a related but not identical subspecialty, is appropriately positioned to apply. This approach is correct because it adheres strictly to the established criteria for the examination, demonstrating respect for the fellowship’s standards and the assessment process. It aligns with the ethical principle of honesty and integrity in professional assessments. An incorrect approach would be to apply for the examination based solely on a general interest in neuroimmunology and a desire to gain exposure, without having completed the prerequisite fellowship training. This is professionally unacceptable because it disregards the fundamental eligibility requirements, undermining the integrity of the examination and potentially taking a spot from a more qualified candidate. It also demonstrates a lack of understanding of the examination’s purpose, which is to certify advanced skills, not to provide introductory learning opportunities. Another incorrect approach would be to apply by claiming to have completed a fellowship when the training was in a significantly different field, such as general neurology or immunology without a specific neuroimmunology focus, and without the required regional fellowship completion. This is professionally unacceptable as it constitutes misrepresentation of qualifications, a serious ethical breach. It violates the principle of truthfulness and can lead to the inappropriate certification of an individual, potentially endangering patient care. Finally, an incorrect approach would be to seek admission to the examination by leveraging personal connections or attempting to bypass the formal application process due to perceived familiarity with the examination committee. This is professionally unacceptable as it undermines the fairness and meritocratic nature of the examination. It violates principles of equity and impartiality, suggesting that personal influence can supersede established criteria, which is detrimental to the credibility of the fellowship and the examination. Professionals should approach such situations by meticulously reviewing the official examination guidelines, understanding the stated purpose and eligibility criteria, and honestly assessing their own qualifications against these requirements. If there is any ambiguity, seeking clarification from the examination administrators is the appropriate step before submitting an application.

The evaluation methodology shows a scenario that is professionally challenging due to the inherent conflict between a physician’s duty of care to their patient and the potential for financial gain or professional advancement. The need for careful judgment arises from the ethical imperative to prioritize patient well-being and avoid conflicts of interest, especially when dealing with novel or investigational treatments. The best professional approach involves transparently disclosing the potential conflict of interest to the patient and obtaining informed consent for participation in the clinical trial, while also ensuring the patient understands that their standard care will not be compromised. This aligns with fundamental ethical principles of patient autonomy and beneficence, as well as regulatory requirements for clinical trial conduct, which mandate full disclosure and voluntary participation. The physician must also ensure that the trial protocol is followed rigorously and that the patient’s best interests remain paramount, independent of any personal or institutional benefits derived from the trial. An incorrect approach would be to proceed with enrolling the patient in the clinical trial without full disclosure of the physician’s financial interest in the investigational drug or the potential for publication that could enhance their career. This failure to disclose constitutes a breach of ethical trust and potentially violates regulations governing conflicts of interest in research and clinical practice, undermining the principle of informed consent. Another incorrect approach involves prioritizing the potential benefits of the investigational drug for the patient over the need for full transparency about the physician’s vested interest. While the physician may genuinely believe in the drug’s efficacy, this paternalistic stance disregards the patient’s right to make an autonomous decision based on complete information. This can lead to a perception of coercion and a violation of ethical guidelines that emphasize patient self-determination. Finally, an incorrect approach would be to exclude the patient from the clinical trial solely due to the physician’s conflict of interest, without first assessing the patient’s suitability and willingness to participate. While managing conflicts is crucial, a blanket exclusion without proper evaluation may deprive a potentially eligible patient of access to a promising treatment and is not the most ethically sound resolution. Professionals should employ a decision-making framework that begins with identifying potential conflicts of interest. This should be followed by a thorough assessment of the ethical and regulatory implications, consultation with institutional review boards or ethics committees if necessary, and open, honest communication with the patient. The ultimate goal is to ensure that patient welfare and autonomy are protected while adhering to all professional and regulatory standards.

Scenario Analysis: This scenario presents a significant professional challenge due to the inherent conflict between a patient’s expressed wishes, their perceived capacity, and the clinician’s ethical obligation to ensure patient well-being and safety. The neuroimmunology fellow is faced with a situation where a patient’s decision, while seemingly autonomous, may be influenced by their underlying condition, raising questions about true informed consent. Navigating this requires a delicate balance of respecting patient autonomy, upholding beneficence, and adhering to professional standards of care. The pressure to expedite treatment for a potentially life-altering condition adds further complexity. Correct Approach Analysis: The best professional approach involves a comprehensive assessment of the patient’s capacity to make decisions regarding the proposed treatment. This entails a thorough evaluation of their understanding of the condition, the proposed treatment’s benefits, risks, alternatives, and the consequences of refusal. It requires engaging in open and empathetic communication, addressing any fears or misconceptions, and ensuring the patient has sufficient time and support to deliberate. If capacity is confirmed, the patient’s decision, even if it differs from the clinician’s recommendation, must be respected. This aligns with the fundamental ethical principles of autonomy and informed consent, as well as professional guidelines emphasizing patient-centered care and shared decision-making. The focus is on empowering the patient to make a choice that is truly their own, based on adequate information and understanding. Incorrect Approaches Analysis: One incorrect approach involves proceeding with the treatment solely based on the patient’s initial verbal agreement without a formal capacity assessment. This fails to uphold the principle of informed consent, as the agreement may not be truly informed if the patient lacks the capacity to understand the complex medical information. It also risks violating the patient’s autonomy if their consent is not genuine. Another incorrect approach is to override the patient’s expressed wishes and proceed with treatment against their will, even if the clinician believes it is in their best interest. While beneficence is a core ethical principle, it does not grant clinicians the right to unilaterally disregard a patient’s autonomous decision, especially if they possess decision-making capacity. This action undermines patient autonomy and can erode trust in the healthcare system. A third incorrect approach is to delay treatment indefinitely due to concerns about capacity without actively working to clarify or support the patient’s decision-making process. While caution is warranted, prolonged inaction can be detrimental to the patient’s health, potentially violating the principle of non-maleficence by allowing their condition to worsen unnecessarily. Professional Reasoning: Professionals should adopt a structured decision-making process when faced with potential capacity issues. This begins with recognizing the signs that may indicate a need for a capacity assessment. The next step is to engage in a dialogue with the patient, explaining the condition and treatment options clearly and simply, and observing their responses. If there is doubt about capacity, a formal assessment should be conducted, often involving a multidisciplinary team. Throughout this process, maintaining open communication, demonstrating empathy, and respecting the patient’s dignity are paramount. The ultimate goal is to ensure that any medical decision is made in accordance with the patient’s values and best interests, while upholding their fundamental right to autonomy.