Scenario Analysis: This scenario presents a professional challenge in navigating the eligibility criteria for advanced practice examinations within a pan-regional context. The core difficulty lies in interpreting and applying potentially nuanced requirements to individual qualifications, ensuring both adherence to the examination’s stated purpose and the candidate’s suitability for advanced practice. Misinterpretation can lead to wasted resources, professional disappointment, and potentially undermine the integrity of the certification process. Careful judgment is required to balance the need for standardized assessment with the recognition of diverse training pathways. Correct Approach Analysis: The best approach involves a thorough and direct review of the official examination documentation, specifically focusing on the stated purpose and eligibility criteria. This entails meticulously examining the requirements for advanced respiratory therapy practice as defined by the examining body, cross-referencing them with the candidate’s documented training, experience, and any relevant professional development. This method ensures that decisions are grounded in the explicit guidelines established for the examination, thereby upholding its intended purpose of certifying individuals with a defined level of advanced competency. Adherence to these published standards is ethically imperative and regulatory sound, as it promotes fairness and transparency in the certification process. Incorrect Approaches Analysis: One incorrect approach involves making assumptions about eligibility based on the general understanding of advanced practice without consulting the specific examination guidelines. This fails to acknowledge that each examination sets its own unique standards and may have specific prerequisites that differ from broader professional definitions. Such an approach risks overlooking critical requirements, leading to a candidate being deemed ineligible despite possessing what might be considered advanced skills in a general sense. Another incorrect approach is to rely solely on anecdotal evidence or the experiences of colleagues regarding past eligibility. This is problematic because examination criteria can evolve, and individual interpretations of past successes may not reflect current regulations. Furthermore, it bypasses the official channels for determining eligibility, which are designed to provide definitive guidance. Finally, an approach that prioritizes the candidate’s perceived desire to advance over a strict adherence to documented eligibility criteria is fundamentally flawed. While professional ambition is important, the examination’s purpose is to assess specific competencies against defined standards, not to facilitate career progression irrespective of qualification. This approach undermines the rigor and validity of the certification process. Professional Reasoning: Professionals faced with determining eligibility for advanced practice examinations should adopt a systematic and evidence-based approach. This involves: 1. Identifying the authoritative source of information (official examination guidelines). 2. Carefully reading and understanding the stated purpose of the examination. 3. Meticulously reviewing all stated eligibility criteria. 4. Objectively comparing the candidate’s qualifications against each criterion. 5. Seeking clarification from the examination board if any criteria are ambiguous. 6. Documenting the decision-making process and the rationale for eligibility or ineligibility. This structured approach ensures fairness, transparency, and compliance with the established standards for advanced practice certification.

Scenario Analysis: This scenario presents a professional challenge because it requires balancing the need for accurate assessment of candidate performance with the practicalities of exam administration and resource allocation. Misinterpreting or misapplying the blueprint weighting, scoring, and retake policies can lead to unfair candidate outcomes, damage the credibility of the examination, and potentially violate regulatory guidelines designed to ensure fair and consistent assessment. Careful judgment is required to ensure that policy is applied equitably and transparently. Correct Approach Analysis: The best professional practice involves a thorough review of the official examination blueprint and the documented retake policy. This approach ensures that any decisions regarding scoring discrepancies or retake eligibility are grounded in the established standards and guidelines. Specifically, understanding how the blueprint dictates the relative importance of different content areas and how this translates into scoring, and then applying the retake policy consistently based on defined criteria (e.g., minimum score thresholds, number of attempts), is paramount. This adherence to documented policy ensures fairness, transparency, and defensibility of the examination process, aligning with the ethical obligation to provide a valid and reliable assessment. Incorrect Approaches Analysis: One incorrect approach involves making ad-hoc adjustments to scoring based on perceived candidate difficulty or subjective impressions of performance. This bypasses the established blueprint weighting and scoring methodology, leading to inconsistent and potentially biased results. It fails to uphold the principle of standardized assessment and can be seen as a violation of the examination’s integrity. Another incorrect approach is to grant retake opportunities outside the defined policy parameters without a clear, documented rationale. This could involve waiving retake eligibility criteria based on personal judgment or perceived extenuating circumstances not covered by the policy. Such actions undermine the fairness and consistency of the retake policy, potentially creating an uneven playing field for candidates and violating the principle of equitable treatment. A further incorrect approach is to prioritize administrative convenience or cost-saving over adherence to the established scoring and retake policies. For instance, attempting to quickly resolve a scoring anomaly by simply averaging scores or assigning a passing grade without proper validation against the blueprint and policy would be a failure. This prioritizes expediency over accuracy and fairness, compromising the validity of the examination. Professional Reasoning: Professionals involved in examination administration must adopt a systematic decision-making process. This begins with a comprehensive understanding of all relevant policies, including the examination blueprint, scoring rubrics, and retake guidelines. When faced with a discrepancy or a request that deviates from policy, the first step should be to consult the official documentation. If ambiguity exists, seeking clarification from the relevant examination committee or governing body is essential. Decisions should always be based on objective criteria and documented procedures to ensure fairness, consistency, and accountability. The ultimate goal is to maintain the integrity and validity of the assessment process.

This scenario presents a professional challenge because it requires balancing immediate patient needs with the integrity of data collection and the ethical obligation to report accurately. The advanced practice professional must navigate potential biases in data interpretation and ensure that interventions are based on objective findings, not assumptions influenced by external pressures or incomplete information. Careful judgment is required to uphold patient safety and professional standards. The best approach involves a systematic review of the monitoring system’s data, cross-referencing it with the patient’s clinical presentation and history, and then initiating a targeted investigation based on the discrepancies. This is correct because it adheres to the principles of evidence-based practice and professional accountability. By first validating the data and then investigating anomalies, the professional ensures that any subsequent interventions are well-founded and directly address the patient’s actual physiological state. This aligns with ethical obligations to provide competent care and avoid unnecessary or potentially harmful interventions. Regulatory frameworks emphasize the importance of accurate assessment and data-driven decision-making in patient care. An approach that immediately escalates based on a single, unverified alarm without further assessment is professionally unacceptable. This bypasses the critical step of data validation, potentially leading to unnecessary alarm fatigue for other healthcare providers and diverting resources from genuine issues. It also risks misinterpreting the situation, which could delay appropriate care or lead to inappropriate interventions. Ethically, this demonstrates a failure to exercise due diligence in patient assessment. Another unacceptable approach is to dismiss the discrepancy as a system error without thorough investigation. While system malfunctions can occur, assuming this without evidence is a dereliction of duty. The professional has a responsibility to investigate all potential causes of abnormal readings, including physiological changes in the patient. Ignoring potential patient distress based on an assumption of technical fault is a significant ethical and regulatory failing. Finally, an approach that involves adjusting the monitoring system’s parameters to align with the perceived clinical picture, rather than investigating the cause of the discrepancy, is also professionally unsound. This constitutes data manipulation and compromises the integrity of the monitoring process. It is a direct violation of ethical principles related to honesty and accuracy in patient care and would likely contravene regulatory guidelines on data integrity and patient monitoring. Professionals should employ a decision-making framework that prioritizes data verification, clinical correlation, and systematic investigation. When faced with conflicting data, the process should involve: 1) acknowledging the discrepancy, 2) gathering all relevant patient information, 3) systematically evaluating the reliability of the monitoring data, 4) investigating potential causes for the discrepancy (both patient-related and system-related), and 5) intervening based on a comprehensive and validated assessment.

The control framework reveals a common ethical challenge in advanced practice allied health: balancing patient autonomy with the duty of care when a patient’s wishes may lead to suboptimal health outcomes. This scenario is professionally challenging because it requires the advanced practitioner to navigate complex ethical principles, including beneficence, non-maleficence, autonomy, and justice, within the established regulatory and professional guidelines for respiratory therapy. The practitioner must respect the patient’s right to make decisions about their own care while also ensuring they are acting in the patient’s best interest and adhering to professional standards. The approach that represents best professional practice involves a comprehensive and collaborative discussion with the patient, involving their family or designated support persons, and potentially other members of the multidisciplinary team. This approach prioritizes informed consent and shared decision-making. It involves clearly explaining the risks and benefits of all available treatment options, including the potential consequences of refusing recommended therapy, in a manner that the patient can understand. The practitioner should actively listen to the patient’s concerns, values, and goals, and explore the underlying reasons for their refusal. This collaborative process aims to reach a decision that respects the patient’s autonomy while ensuring they are fully informed and that the practitioner has fulfilled their duty of care. This aligns with ethical principles of patient-centered care and professional accountability. An approach that involves unilaterally overriding the patient’s stated wishes and proceeding with treatment without further discussion or exploration of their reasoning is professionally unacceptable. This fails to respect patient autonomy and can lead to a breakdown of trust. It also risks alienating the patient and potentially leading to non-adherence if treatment is imposed. Another professionally unacceptable approach is to simply document the patient’s refusal and disengage from further discussion or support. While respecting autonomy is important, this approach neglects the practitioner’s duty of care to ensure the patient is making an informed decision and to explore alternatives or address barriers to acceptance. It can be seen as a failure to advocate for the patient’s well-being. Finally, an approach that involves pressuring the patient or using coercive language to force them into accepting treatment is unethical and unprofessional. This undermines the patient’s right to self-determination and can create a hostile therapeutic relationship. Professionals should employ a structured decision-making process when faced with such dilemmas. This typically involves: 1) Identifying the ethical issue and relevant principles. 2) Gathering all relevant information about the patient’s condition, preferences, and values. 3) Exploring all available options and their potential consequences. 4) Consulting with colleagues, supervisors, or ethics committees if necessary. 5) Making a decision that is ethically sound, legally compliant, and respects the patient’s rights and dignity. 6) Documenting the decision-making process and the rationale behind the chosen course of action.

Scenario Analysis: This scenario presents a professional challenge because it requires balancing the candidate’s immediate desire for rapid advancement with the ethical obligation to ensure thorough and competent preparation. The pressure to pass an advanced examination quickly can lead to shortcuts that compromise the quality of learning and ultimately patient care. Ethical judgment is required to guide the candidate towards a sustainable and effective preparation strategy that prioritizes genuine understanding over mere expediency. Correct Approach Analysis: The best approach involves a structured, phased preparation that aligns with the complexity of advanced practice and the scope of the Pan-Regional Advanced Respiratory Therapy Advanced Practice Examination. This includes dedicating sufficient time to review foundational knowledge, engaging with advanced clinical concepts, and practicing application through case studies and mock examinations. This method ensures that the candidate not only memorizes information but also develops the critical thinking and problem-solving skills necessary for advanced practice. Regulatory frameworks and professional ethical guidelines for advanced practice emphasize competence and patient safety, which are best achieved through comprehensive preparation rather than rushed cramming. This approach directly supports the professional’s duty to maintain high standards of care. Incorrect Approaches Analysis: Focusing solely on past examination papers without understanding the underlying principles is an ethically unsound approach. This method risks superficial knowledge acquisition, leading to an inability to adapt to novel clinical situations not covered in previous exams. It fails to meet the professional obligation to possess a deep and nuanced understanding of advanced respiratory therapy, potentially jeopardizing patient outcomes. Prioritizing only the most frequently tested topics, while seemingly efficient, neglects the breadth of knowledge required for advanced practice. This selective study can create blind spots in the candidate’s understanding, leaving them unprepared for less common but critical clinical scenarios. This approach is ethically problematic as it prioritizes exam success over comprehensive competence, which is a cornerstone of professional responsibility. Relying exclusively on informal study groups without structured learning resources or expert guidance can lead to the propagation of misinformation or incomplete understanding. While collaboration can be beneficial, it cannot replace a systematic review of established knowledge and best practices. This method lacks the rigor necessary for advanced practice and may not align with the evidence-based standards expected in respiratory therapy, thus posing an ethical risk to patient care. Professional Reasoning: Professionals should approach advanced examination preparation with a mindset of continuous learning and skill development, not just test-taking. This involves creating a personalized study plan that acknowledges individual strengths and weaknesses, allocating adequate time for each topic, and utilizing a variety of reputable resources. Regular self-assessment and seeking feedback from mentors or peers are crucial components of this process. The ultimate goal is to achieve a level of expertise that ensures safe and effective patient care, which inherently requires a thorough and well-planned preparation strategy.

The control framework reveals a complex ethical dilemma arising from conflicting professional responsibilities and patient autonomy within the context of advanced respiratory therapy. The scenario is professionally challenging because it requires the advanced practitioner to balance the immediate physiological needs of a critically ill patient with the patient’s previously expressed wishes, which may now be influenced by their current diminished capacity. The core conflict lies in interpreting and acting upon a patient’s advance directive when their current state of understanding and communication is compromised, necessitating careful ethical deliberation and adherence to established professional guidelines. The best professional approach involves a thorough and documented assessment of the patient’s current capacity to understand their situation and make informed decisions, alongside a diligent effort to ascertain the most current and relevant interpretation of their advance directive. This approach is correct because it prioritizes patient autonomy while acknowledging the potential for changes in a patient’s wishes or understanding due to their medical condition. It aligns with ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm), as well as the legal and professional obligation to respect patient autonomy and ensure informed consent or its surrogate. Documenting the capacity assessment and the process of interpreting the advance directive provides a transparent record of the decision-making process, safeguarding both the patient and the practitioner. An approach that prioritizes immediate intervention based solely on the advance directive without a current capacity assessment fails to acknowledge the dynamic nature of a patient’s condition and their potential to regain or alter their decision-making capacity. This is ethically problematic as it may override a patient’s current, albeit unexpressed, wishes or understanding, potentially leading to interventions they would not desire in their present state. It also risks misinterpreting the spirit of the advance directive in light of new clinical realities. Another incorrect approach is to proceed with aggressive treatment without consulting the patient’s designated healthcare proxy or family, particularly if the advance directive is ambiguous or the patient’s capacity is questionable. This neglects the crucial role of surrogate decision-makers who are often best positioned to interpret the patient’s values and preferences, and it bypasses established protocols for managing complex end-of-life care decisions. Ethically, this can be seen as a failure to involve all relevant parties in a decision that profoundly impacts the patient. Finally, an approach that delays necessary care while solely focusing on obtaining a definitive legal interpretation of the advance directive, without considering the patient’s immediate physiological stability and the potential for irreversible harm from delay, is also professionally unsound. While legal clarity is important, the immediate clinical needs of the patient must be addressed in a timely manner, especially when life-sustaining interventions are involved, and this must be balanced with the ethical imperative to act in the patient’s best interest. Professionals should employ a structured decision-making process that begins with a comprehensive assessment of the patient’s current clinical status and decision-making capacity. This should be followed by a thorough review of any existing advance directives, seeking clarification from the patient if possible, or from their designated healthcare proxy or family if capacity is compromised. Consultation with ethics committees or legal counsel may be warranted in complex cases. Throughout this process, clear and consistent documentation of all assessments, discussions, and decisions is paramount.

The control framework reveals a situation where a respiratory therapist is faced with a critical decision regarding equipment calibration that directly impacts patient safety and the integrity of therapeutic interventions. This scenario is professionally challenging because it pits the immediate need for patient care against the established protocols for equipment validation, potentially leading to adverse patient outcomes if not handled correctly. The therapist must balance their duty of care to the patient with their professional and regulatory obligations. The best approach involves prioritizing patient safety through adherence to established protocols. This means immediately ceasing the use of the potentially miscalibrated device and initiating the documented procedure for recalibration or replacement. This approach is correct because it aligns with fundamental ethical principles of beneficence and non-maleficence, ensuring that patient care is not compromised by unreliable equipment. Furthermore, it adheres to regulatory guidelines that mandate the use of properly functioning and calibrated medical devices to ensure accurate diagnosis and treatment, thereby preventing potential harm and maintaining professional accountability. An incorrect approach involves proceeding with the therapy using the device despite the calibration alert, perhaps with the rationale that the alert might be a false positive or that the patient’s condition is too critical to delay treatment. This is professionally unacceptable as it knowingly exposes the patient to the risk of receiving incorrect dosages or therapeutic pressures, which could lead to significant harm or even death. It violates the principle of non-maleficence and disregards established safety protocols designed to prevent such occurrences. Another incorrect approach is to attempt a quick, ad-hoc recalibration without following the manufacturer’s specified procedures or involving qualified biomedical engineering personnel. This is flawed because it bypasses the rigorous validation process required to ensure the device is functioning within acceptable parameters. Such an action could result in an improperly calibrated device that still delivers inaccurate therapy, creating a false sense of security while continuing to endanger the patient. It also undermines the established quality control mechanisms within the healthcare setting. Finally, an incorrect approach would be to ignore the calibration alert entirely and continue therapy without any attempt to address the issue, perhaps due to time pressure or a lack of perceived urgency. This is the most egregious failure, as it demonstrates a complete disregard for patient safety and professional responsibility. It directly contravenes regulatory requirements for equipment maintenance and patient care standards, exposing both the patient and the therapist to significant risks and potential legal ramifications. The professional reasoning process for similar situations should involve a systematic evaluation of the situation. First, recognize and acknowledge the alert or anomaly. Second, consult established protocols and manufacturer guidelines for the specific equipment. Third, assess the immediate risk to the patient if therapy is continued or delayed. Fourth, take appropriate action to mitigate risk, which may involve discontinuing use, initiating recalibration, or seeking assistance from biomedical engineering. Fifth, document all actions taken and any communication with relevant parties. This structured approach ensures that patient safety remains paramount while adhering to professional and regulatory standards.

The control framework reveals a scenario where a respiratory therapist, Ms. Anya Sharma, is faced with a diagnostic imaging request that appears to deviate from standard protocol for a patient with a known, stable chronic condition. The professional challenge lies in balancing the physician’s directive with the therapist’s responsibility to ensure appropriate and necessary diagnostic procedures, particularly when potential for over-utilization or unnecessary radiation exposure exists. This requires careful judgment to uphold patient safety and resource stewardship. The best professional approach involves Ms. Sharma seeking clarification from the ordering physician regarding the rationale for the advanced imaging modality. This approach is correct because it upholds the principles of evidence-based practice and patient-centered care. By engaging in open communication, Ms. Sharma ensures that the diagnostic decision is informed by the most current clinical information and aligns with the patient’s specific needs and the diagnostic goals. This proactive step prevents potential misdiagnosis, unnecessary patient exposure to radiation, and inefficient use of healthcare resources, all of which are implicitly guided by professional ethical codes and regulatory expectations for quality patient care. An incorrect approach would be to proceed with the advanced imaging without seeking further information. This fails to critically evaluate the appropriateness of the diagnostic test in the context of the patient’s stable condition and the physician’s request. It bypasses the therapist’s professional responsibility to question and confirm the necessity of procedures, potentially leading to unnecessary radiation exposure for the patient and increased healthcare costs without a clear clinical benefit. Another incorrect approach would be to refuse to perform the imaging outright without any attempt at communication or understanding the physician’s intent. This demonstrates a lack of collaborative spirit and could impede necessary diagnostic workups if there is, in fact, a subtle but clinically significant change in the patient’s condition that warrants the advanced imaging. It also fails to acknowledge the physician’s role in directing patient care. Finally, an incorrect approach would be to consult a colleague for advice on whether to proceed without first attempting to clarify the situation with the ordering physician. While peer consultation can be valuable, it should not be the primary step when direct communication with the source of the directive is feasible and appropriate. This delays resolution and may lead to decisions based on incomplete information. Professionals should employ a decision-making framework that prioritizes clear communication, critical evaluation of diagnostic requests, and adherence to evidence-based practice. When faced with a potentially questionable order, the first step should always be to seek clarification from the ordering clinician. If the clarification is unsatisfactory or raises further concerns, then escalation to a supervisor or relevant clinical pathway should be considered. This process ensures that patient care is both effective and ethically sound.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate need for patient care with the long-term imperative of preventing healthcare-associated infections (HAIs) and ensuring the highest quality of respiratory therapy services. The rapid escalation of patient needs can create pressure to bypass established protocols, making adherence to safety and infection prevention measures paramount. Failure to do so can lead to patient harm, increased healthcare costs, and regulatory sanctions. Correct Approach Analysis: The best professional practice involves a systematic, evidence-based approach to process optimization for infection prevention and quality control in respiratory therapy. This entails a continuous cycle of identifying potential risks, implementing standardized protocols based on current guidelines (e.g., from national health bodies and professional respiratory therapy organizations), providing comprehensive staff education and competency validation, and establishing robust monitoring and feedback mechanisms. This approach ensures that all interventions are aligned with best practices for patient safety and regulatory compliance, minimizing the risk of HAIs and maintaining high standards of care. It directly addresses the core principles of quality improvement and patient safety mandated by regulatory bodies focused on healthcare standards. Incorrect Approaches Analysis: Relying solely on anecdotal evidence or individual practitioner experience to guide infection prevention protocols is professionally unacceptable. This approach lacks the rigor of evidence-based practice and can perpetuate outdated or ineffective methods, increasing the risk of HAIs. It fails to meet the regulatory requirement for standardized, evidence-based care. Implementing new equipment or techniques without a thorough risk assessment, staff training, and integration into existing quality control frameworks is also professionally unsound. This can lead to improper use, equipment malfunction, and an increased likelihood of introducing infections or compromising patient safety, violating principles of safe practice and quality assurance. Focusing exclusively on patient comfort and symptom relief without concurrently addressing infection prevention and quality control measures is a significant ethical and regulatory failure. While patient comfort is crucial, it cannot supersede the fundamental responsibility to prevent harm, including infections, and maintain the quality of care delivered. This approach neglects critical aspects of patient safety and regulatory compliance. Professional Reasoning: Professionals should employ a structured decision-making process that prioritizes patient safety and regulatory adherence. This involves: 1) identifying the problem or area for improvement; 2) consulting current evidence-based guidelines and regulatory requirements; 3) developing and implementing standardized protocols; 4) ensuring adequate staff training and competency; 5) establishing a system for ongoing monitoring, data collection, and performance evaluation; and 6) using this data for continuous quality improvement. This systematic approach ensures that all decisions are informed, evidence-based, and aligned with the highest standards of patient care and safety.

Scenario Analysis: This scenario is professionally challenging because it requires balancing patient autonomy and best clinical practice within the evolving landscape of advanced respiratory therapies. The core tension lies in respecting a patient’s informed refusal of a potentially beneficial intervention while ensuring their safety and adherence to established protocols. Advanced practice professionals must navigate complex ethical considerations, including beneficence, non-maleficence, and respect for autonomy, all within the framework of their professional scope and institutional guidelines. Correct Approach Analysis: The best professional approach involves a thorough, documented discussion with the patient regarding the proposed therapeutic intervention, its benefits, risks, and alternatives, ensuring their understanding of the consequences of refusal. This approach prioritizes informed consent and patient autonomy. It requires the advanced practice professional to clearly articulate the rationale behind the recommended therapy, address all patient concerns, and document the patient’s decision-making process and the rationale for their refusal. This aligns with ethical principles of respect for autonomy and beneficence, as it empowers the patient to make decisions about their care while ensuring they are fully informed. It also adheres to professional guidelines that mandate comprehensive patient education and shared decision-making. Incorrect Approaches Analysis: One incorrect approach involves proceeding with the therapeutic intervention without obtaining explicit, informed consent, especially after the patient has expressed reservations or refused. This constitutes a violation of patient autonomy and potentially battery, as it disregards the patient’s right to self-determination regarding their medical care. It fails to uphold the ethical principle of respect for autonomy and can lead to significant legal and ethical repercussions. Another incorrect approach is to dismiss the patient’s concerns and simply document their refusal without further exploration or attempts to understand the underlying reasons. This demonstrates a lack of empathy and a failure to engage in a collaborative decision-making process. It neglects the professional responsibility to ensure the patient’s understanding and may overlook reversible factors contributing to their refusal, such as fear, misinformation, or cultural beliefs. This approach undermines the therapeutic relationship and fails to uphold the principle of beneficence by not fully exploring all avenues to achieve the best possible outcome for the patient. A further incorrect approach is to unilaterally alter the therapeutic protocol to accommodate the patient’s refusal without a clear clinical justification or consultation with the multidisciplinary team. While flexibility is sometimes necessary, arbitrary changes to established protocols without a sound clinical basis can compromise patient safety and the integrity of evidence-based practice. This can lead to suboptimal outcomes and may not align with institutional policies or best practice guidelines for respiratory therapy. Professional Reasoning: Professionals should employ a shared decision-making model. This involves: 1) Eliciting the patient’s values and preferences. 2) Presenting evidence-based treatment options, including the risks, benefits, and alternatives. 3) Assessing the patient’s understanding of the information provided. 4) Collaboratively deciding on a course of action that aligns with the patient’s values and the clinical evidence. In cases of refusal, it is crucial to explore the reasons for refusal, provide further education, and document the entire process meticulously. If the refusal poses an immediate and significant threat to life or limb, escalation to a multidisciplinary team and ethical consultation may be warranted.