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2011 PICU Rotation Goals and Learning Objectives

I.  Medical Knowledge

Goal:  Demonstrate knowledge of established and evolving biomedical, clinical and social sciences and the application of knowledge to patient care and education of others Fellows are expected to develop this knowledge through reading major textbooks in pediatric critical care; attending monthly lectures including core lecture series, morbidity and mortality conference, ethics conference, trauma conference, journal club, professor rounds; and observing and discussing senior fellow and faculty management.

Objectives:

  1. Year One

    1. Recognize need for, state proper indications for, discuss potential complications of, and demonstrate appropriate initial stabilization of patients requiring
      1. Airway management
      2. Cardiopulmonary resuscitation
      3. Transport (intra- and inter-facility)
      4. Invasive procedures
      5. Recognition and initial management of shock
  1. Demonstrate appropriate titration of basic life support including
    1. Conventional mechanical ventilation
    2. Hemodynamic support
  1. Explain indications for, and manage, advanced life support technologies (under close senior fellow and attending supervision) including:
    1. Extracorporeal life support
    2. Renal replacement therapies
    3. Plasmapheresis/plasma exchange 
  1. Explain methods of, indications for, and limitations of, and demonstrate interpretations of resulting data from common ICU monitoring modalities, including
    1. Respiratory
      1. Pulse oximetry
      2. End-tidal CO2 monitoring
      3. Flow-volume loops
      4. Pressure volume curves
  1. Hemodynamic
    1. Invasive hemodynamic monitoring, including arterial, central venous, and pulmonary arterial
    2. ECG
    3. Non-invasive cardiac output determination
    4. Central/mixed venous oxygen saturation
  1. Neurologic
    1. Glasgow Coma Scale
    2. Intracranial pressure monitors
    3. Intracranial oxygenation
    4. Cerebral blood flow
    5. Train-of-four monitoring
    6. EEG (including continuous)
  1. Write orders reflecting understanding of
    1. Principles of antimicrobial therapy
    2. Nutritional requirements of critically ill children
    3. Alterations in drug metabolism during critical illness and organ dysfunction
  1. Explain basic pathophysiologic and pharmacologic principles underlying management of, provide care for patients with, and relate management decisions to classic literature about patients with
    1. Respiratory disease, including
      1. Respiratory physiology and monitoring
      2. Status asthmaticus
      3. Neonatal respiratory failure
      4. Bronchiolitis and pneumonia
      5. Acute Lung Injury and Acute Respiratory Distress Syndrome
      6. Chronic respiratory failure
  1. Cardiac disease, including
    1. Shock of multiple etiologies
    2. Deranged cardiorespiratory Interactions
    3. Pulmonary hypertension
    4. Heart failure in Infants and children
  1. Neurological/neuromuscular disease
    1. Acute neuromuscular disease
    2. Chronic neuromuscular disease
    3. Coma
    4. Neurologic monitoring
    5. Neurologic imaging
    6. Head and spinal cord trauma
    7.  Status epilepticus
    8. Cerebrovascular disease and stroke
    9.  Hypoxic-ischemic encephalopathy
    10.  Metabolic encephalopathies in children
    11.  Brain neoplasms
    12.  Brain death
  1. Immunologic/inflammatory diseases
    1. Multiple organ dysfunction syndrome
    2.  Complications of solid organ transplantation
    3.  White blood cell function in Critical Illness
    4.  Immune system and viral Illness
    5.  Cancer and chemotherapy
    6.  Acquired immunodeficiency
    7.  Congenital immunodeficiency
    8. Immune Modulation and Immunotherapy
  1. Infectious diseases
    1. Bacterial sepsis
    2. Critical viral infections
    3. Central nervous system infections
    4. Nosocomial Infections in the PICU
    5. Toxin-related infectious diseases
    6. Opportunistic infections
    7.  International and emerging infections
  1. Nutritional and gastrointestinal disorders
    1. The acute abdomen
    2. Acute and chronic liver dysfunction
    3. Pancreatitis
    4. Gastrointestinal bleeding
    5. Malabsorption syndromes
    6. Life-threatening complications of inflammatory bowel disease
  1. Renal, endocrine, and metabolic disorders
    1. Adrenal dysfunction
    2. Disorders of glucose homeostasis
    3. Disorders of water, sodium, and potassium homeostasis
    4. Disorders of calcium, magnesium, and phosphate
    5. Acute renal failure and end-stage renal disease
    6. Hypertensive crisis
    7.  Inborn errors of metabolism
  1. Oncologic and hematologic disorders
    1. Oncologic emergencies and complications
    2. Hematologic emergencies
    3. Bone marrow and stem cell transplantation
    4. Coagulation issues in the PICU
    5. Sickle cell disease
  1. Environmental crises
    1. Multiple trauma
    2. Drowning and near drowning: submersion injuries
    3. Burns, electrical injuries, and smoke snhalation
    4. Poisoning
  1. Discuss basic principles underlying Western medical ethics
  1. Year Two

    1. Explain principles of advanced pediatric critical care support in the following areas including demonstrating familiarity with current literature:
      1. Life suppport technologies
        1. Advanced modes of mechanical ventilation (HFO, APRV, Inverse Ratio)
        2. Management, complications and outcomes of extracorporeal life support
        3. Management, complications and outcomes of renal replacement therapies
  1. Respiratory disease
    1. The molecular biology of acute lung injury
    2. Sleep and breathing
  1. Cardiac disease
    1. Cardiovascular physiology
    2. Cardiorespiratory interactions
  1. Neurological disease
    1. Molecular biology of brain injury
    2. Developmental neurobiology & neurophysiology
  1. Oncology and hematology
    1. Cancer therapy: Mechanisms and toxicity
  1. Infectious diseases
    1. Mechanisms of microbial pathogenesis
  1. Nutritional and gastrointestinal disorders
    1. Fulminant hepatic failure and transplantation
    2. Intestinal and multivisceral transplantation
    3. Intestinal insufficiency and failure
  1. Renal, endocrine, and metabolic disorders
    1. Inborn errors of metabolism
  1. Year 3

    1. Read and be able to explain principles relevant to pediatric critical care medicine of the following:
      1. Advanced concepts of pediatric critical care
        1. Genomic medicine
        2. Innate immunity and inflammation
        3. Cellular adaptations to stress
        4. Shock and reperfusion injury
        5. Neurohormonal control of the immune system
        6. Rehabilitation of children with critical illness
        7. Organ donation concepts and protocols
      2. Environmental crises
        1. Terrorism and Mass Casualty Events

 

 II.  Patient Care

Goal:  Provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention or treatment of disease esp associated with actual or threatened organ system failure, and at the end-of-life

Objectives:

  1. Year One

    1. Provide direct titrated bedside care for patients at risk for or with organ-system failure consistent with evidence from the medical literature
    2. Supervise residents in the care of patients in the PICU
    3. Interpret laboratory and physiologic data, synthesize it to recognize patient deterioration or improvement, and make fundamentally sound decisions regarding patient support
    4. Demonstrate appropriate management for a child following major surgery, including solid organ transplantation
    5. Demonstrate appropriate management for trauma patients including those with multi-system trauma, airway management in patients with cervical spine fracture, head trauma patients with increased intracranial pressure, and patients with spinal cord injuries
    6. Demonstrate appropriate airway management for Level I trauma patients in the CHP trauma bay
    7. Plan an approach for sedation and analgesia in the PICU and titrate the medications as needed
    8. Develop basic proficiency performing PICU procedures
    9. Perform patient consultations to emergency room and pediatric floors and make triage decisions based on patient condition, hospital policies, and needs of the institution as a whole
    10. Initiate appropriate invasive monitoring; evaluate data, and implement appropriate treatment plans
    11. Initiate appropriate pharmacologic support for hypertension, hypotension, and arrhythmias, and evaluate the effectiveness of the intervention
    12. Identify indications for extra-corporeal membrane oxygenation (ECMO) and provide basic management for ECMO patients
    13. Order appropriate and timely laboratory tests for ICU patients
    14. Recognize and provide treatment under close supervision by senior fellows and faculty of acute, life-threatening illnesses in children ranging from newborn to adolescents. Specifically, this includes understanding the management of pediatric patients with:
      1. Cardiovascular instability including arrhythmias, congestive heart failure, cardiomyopathy, and vascular abnormalities
      2. Respiratory failure including acute respiratory distress syndrome, status asthmaticus, upper airway obstruction, pneumonia, and bronchiolitis
      3. Airway management issues including the difficult airway
      4. Renal insufficiency; acute or chronic
      5. CNS pathology including meningitis, encephalopathy, head injury with or without increased ICP, post-operative tumor removal, and status epilepticus
      6. Metabolic, endocrine and electrolyte abnormalities including hypo- or hypernatremic dehydration, diabetic ketoacidosis, and urea cycle defects
      7. Infectious diseases including differentiation of immunocompetent versus immunodeficient patients
      8. Shock including neurogenic, cardiogenic, septic, and hypovolemic shock
      9. Hematologic disorders including anemia, neutropenia, thrombocytopenia, and coagulation disorders
      10. Gastrointestinal diseases including acute and chronic liver failure, pancreatitis, upper and lower GI hemorrhage, chronic malabsorptive syndromes
      11. Solid Organ Transplantation including liver, small bowel, and kidney 
      12. Oncology complications including the treatment of shock, fever, and neutropenia as well as the life-threatening complications from chemotherapy and bone marrow transplantation
      13. Toxic ingestions, including their presenting symptoms, complications, and treatment strategies 
  1. Year Two

    1. Demonstrate and titrate bedside care for patients in the PICU with greater autonomy
    2. Supervise residents and first year fellows in the care of patients in the PICU
    3. Interpret laboratory and physiologic data with increased recognition of exceptions to usual presentations, synthesize it to recognize patient deterioration or improvement, and make fundamentally sound decisions regarding patient support
    4. Demonstrate appropriate management of a child following major surgery, including solid organ transplantation and recognize complications.
    5. Demonstrate appropriate management of trauma patients including those with multi-system trauma, airway management in patients with cervical spine fracture, head trauma patients with increased intracranial pressure, and patients with spinal cord injuries
    6. Demonstrate appropriate airway management for Level I trauma patients in the CHP trauma bay and supervise first year fellows in trauma bay
    7. Plan an approach for sedation and analgesia in the PICU and titrate the medications as needed
    8. Demonstrate proficiency performing PICU procedures and begin to supervise first year fellows performing procedures
    9. Perform patient consultations to emergency room and pediatric floors and supervise first year fellows as they learn to consult outside of the PICU
    10. Initiate appropriate invasive monitoring; evaluate data and implement appropriate treatment plans
    11. Initiate and titrate appropriate pharmacologic support for hypertension, hypotension, and arrhythmias, and evaluate the effectiveness of the intervention
    12. Demonstrate competence in the management of patients on ECMO and ability to troubleshoot common circuit problems
    13. Order appropriate laboratory tests for ICU patients
    14. Demonstrate ability to initiate advanced levels of support for acute, life-threatening illnesses in children ranging from newborn to adolescents who do not respond adequately to basic support. Specifically, this includes understanding the etiology and pathophysiology as well as the management of pediatric patients with:
      1. Cardiovascular instability including arrhythmias, congestive heart failure, cardiomyopathy, and vascular abnormalities
      2. Respiratory failure including acute respiratory distress syndrome, status asthmaticus, upper airway obstruction, pneumonia, and bronchiolitis
      3. Airway management issues including the difficult airway
      4. Renal insufficiency; acute or chronic
      5. CNS pathology including meningitis, encephalopathy, head injury with or without increased ICP, post-operative tumor removal, and status epilepticus
      6. Metabolic, endocrine and electrolyte abnormalities including hypo- or hypernatremic dehydration, diabetic ketoacidosis, and urea cycle defects
      7. Infectious diseases including differentiation of immunocompetent versus immunodeficient patients
      8. Shock including neurogenic, cardiogenic, septic, and hypovolemic shock
      9. Hematologic disorders including anemia, neutropenia, thrombocytopenia, and coagulation disorders
      10. Gastrointestinal diseases including acute and chronic liver failure, pancreatitis, upper and lower GI hemorrhage, chronic malabsorptive syndromes
      11. Solid Organ Transplantation including liver, small bowel, and kidney 
      12. Oncology complications including the treatment of shock, fever, and neutropenia as well as the intensive care unit complications from chemotherapy and bone marrow transplantation
      13. Toxic ingestions, including their presenting symptoms, complications, and treatment strategies 
    15. Recognize broad needs of patients and families during critical illness and discuss application of palliative care
  1. Year Three

    1. Provide advanced titrated bedside care for patients in the PICU with decreased need for faculty modification of plans
    2. Supervise residents and first and second year fellows providing care in the PICU
    3. Demonstrate mature ability to Interpret complex laboratory and physiologic data, synthesize it to recognize patient deterioration or improvement, and make fundamentally sound decisions regarding patient support
    4. Demonstrate appropriate management for a child following major surgery, including solid organ transplantation, and manage common complications
    5. Demonstrate appropriate management of trauma patients including those with multi-system trauma, airway management in patients with cervical spine fracture, head trauma patients with increased intracranial pressure, and patients with spinal cord injuries
    6. Demonstrate appropriate airway management for Level I trauma patients in the CHP trauma bay and supervise junior fellows in trauma bay
    7. Refine approach and titration for patient sedation and analgesia in the PICU
    8. Demonstrate advanced proficiency and efficiency performing PICU procedures and supervise junior fellows performing procedures
    9. Perform consultations to emergency room and pediatric floors and supervise junior fellows as they learn to consult outside of the PICU
    10. Initiate appropriate invasive monitoring; evaluate data, and develop and implement appropriate treatment plans. Anticipate and manage potential complications
    11. Initiate and titrate appropriate advanced pharmacologic support for hypertension, hypotension, and arrhythmias, and evaluate the effectiveness of the intervention
    12. Competently and proactively manage patients before, during, and after ECMO to minimize complications and demonstrating appropriate judgment in initiating and discontinuing ECMO
    13. Order appropriate and timely laboratory tests for ICU patients
    14. Demonstrate mature ability to initiate advanced levels of support for acute, life-threatening illnesses in children ranging from newborn to adolescents who do not respond adequately to basic support. Specifically, this includes generating a complete differential diagnosis addressing the problem, understanding the pathophysiology, and implementing cutting edge approach to management of pediatric patients with:
      1. Cardiovascular instability including arrhythmias, congestive heart failure, cardiomyopathy, and vascular abnormalities
      2. Respiratory failure including acute respiratory distress syndrome, status asthmaticus, upper airway obstruction, pneumonia, and bronchiolitis
      3. Airway management issues including the difficult airway
      4. Renal insufficiency; acute or chronic
      5. CNS pathology including meningitis, encephalopathy, head injury with or without increased ICP, post-operative tumor removal, and status epilepticus
      6. Metabolic, endocrine and electrolyte abnormalities including hypo- or hypernatremic dehydration, diabetic ketoacidosis, and urea cycle defects
      7. Infectious diseases including differentiation of immunocompetent versus immunodeficient patients
      8. Shock including neurogenic, cardiogenic, septic, and hypovolemic shock
      9. Hematologic disorders including anemia, neutropenia, thrombocytopenia, and coagulation disorders
      10. Gastrointestinal diseases including acute and chronic liver failure, pancreatitis, upper and lower GI hemorrhage, chronic malabsorptive syndromes
      11. Transplantation including liver, small bowel, heart, lung, and kidney 
      12. Oncology complications including the treatment of shock, fever, and neutropenia as well as the intensive care unit complications from chemotherapy
      13. Toxic ingestions, including their presenting symptoms, complications, and treatment strategies 
    15. Recognize broad needs of patients and families during critical illness and initiate appropriate application of palliative care

 

III.  Interpersonal and Communication Skills

Goal:  Demonstrate interpersonal and communication skills that enable you to establish and maintain professional relationships with patients, families and other members of health care teams; demonstrate effective and compassionate communication skills with parents and patients

Objectives:

  1. Year One

    1. Demonstrate ability to obtain a comprehensive history from patient or family member
    2. Perform professional and effective consultations to other physicians and health care professionals under close supervision
    3. Provide concise, respectful, and  appropriate advice to physicians requesting patient transport
    4. Develop therapeutic and ethically sound professional relationships with patients, their families, colleagues and students
    5. Describe and attend to cultural preferences of patients and families derived from conversations with them
    6. Employ effective listening, nonverbal, questioning, and narrative skills while communicating with patients and their families
    7. Attend monthly ethics conferences and work with multidisciplinary team to understand family communication needs
    8. Maintain comprehensive, timely, and legible medical records
  1. Year Two

    1. Perform professional and effective consultations to other physicians and health care professionals with increased independence
    2. Develop therapeutic and ethically sound professional relationships with patients, their families, colleagues and students
    3. Demonstrate maturing ability to interact with challenging colleagues and families
    4. Employ effective listening, nonverbal, questioning, and narrative skills while communicating with patients and their families
    5. Attend monthly ethics conferences and work with multidisciplinary team to understand family communication needs
    6. Maintain comprehensive, timely, and legible medical records.
    7. Demonstrate ability to synthesize complex information and provide a concise summary of a patient’s course
  1. Year Three

    1. Perform mature professional and effective consultations to other physicians and health care professionals under decreased supervision
    2. Develop therapeutic and ethically sound professional relationships with patients, their families, colleagues and students
    3. Employ  effective listening, nonverbal, questioning, and narrative skills while communicating with patients and their families
    4. Demonstrate ability to manage complex family interactions
    5. Attend monthly ethics conferences and work with multidisciplinary team to understand family communication needs
    6. Initiate and participate in family care conferences
    7. Maintain comprehensive, timely, and legible medical records
    8. Demonstrate mature ability to synthesize complex information and provide a concise summary of a patient’s course

 

 

IV.  Professionalism

Goal: Demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession and society

Objectives:

  1. Year One

    1. Demonstrate respect, compassion, integrity and altruism in relationships with patients, families and colleagues
    2. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues
    3. Apply principles of confidentiality, scientific/academic integrity, and informed consent to patient care
    4. Recognize and support family communication needs as an individual and within a team framework
    5. Discuss ethical issues of particular relevance to patient care in the PICU including surrogate decision making, limiting support, and withdrawal of support
    6. Adhere to institutional policies
  1. Year Two

    1. Demonstrate respect, compassion, integrity and altruism in relationships with patients, families and colleagues
    2. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues
    3. Apply principles of confidentiality, scientific/academic integrity, and informed consent to patient care
    4. Recognize and support family communication needs as an individual and within a team framework
    5. Adhere to institutional policies
  1. Year Three

    1. Demonstrate respect, compassion, integrity and altruism in relationships with patients, families and colleagues
    2. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues
    3. Apply  principles of confidentiality, scientific/academic integrity, and informed consent
    4. Recognize and support family communication needs as an individual and within a team framework
    5. Adhere to institutional policies

 

 

V. Practice-Based Learning and Improvement

Goal: Use scientific evidence and methods to investigate, evaluate and improve patient care practices

Objectives:

  1. Year One

    1. Develop and maintain a willingness to learn from successes/errors in the workplace
    2. Read classic literature related to patients admitted to support management decisions
    3. Participate in M&M, professor rounds, and other case conferences
    4. Apply information gathered from successes/errors to improve the system or processes of care,
    5. Share errors and near-miss experiences with team members to help correct system weaknesses
    6. Examine feedback and incorporate into improvement activities
    7. Apply information technology and other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education
    8. Establish individualized learning plan and formalize patient care learning goals for the first year of fellowship
    9. Demonstrate basic teaching skills with respect to residents and students
  1. Year Two

    1. Develop and maintain a willingness to learn from successes/errors in the workplace
    2. Read classic and current literature related to patients admitted to support management decisions
    3. Participate in M&M, professor rounds, and other case conferences
    4. Apply information gathered from successes/errors to improve the system or processes of care,
    5. Share errors and near-miss experiences with team members to help correct system weaknesses
    6. Examine feedback and incorporate into improvement activities
    7. Apply information technology and other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education
    8. Examine individualized learning plan, identify achievement of patient care learning goals for year one of fellowship and develop goals for year two of fellowship
    9. Provide effective teaching for residents and junior fellows based on one’s growing clinical experience and command of the literature
  1. Year Three

    1. Develop and maintain a willingness to learn from successes/errors in the workplace
    2. Seek literature to address particularly complex and/or perplexing patient care issues
    3. Participate in M&M, professor rounds, and other case conferences
    4. Share errors and near-miss experiences with team members to help correct system weaknesses
    5. Apply information gathered from successes/errors to improve the system or processes of care,
    6. Examine feedback and incorporate into improvement activities
    7. Apply information technology and other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education
    8. Examine individualized learning plan, identify  achievement of patient care learning goals for year one of fellowship and develop goals for year two of fellowship
    9. Provide teaching for residents and junior fellows based on one’s growing clinical experience and command of the literature on rounds and at the bedside as well as formal lectures for junior learners as well as faculty

 

 

VI. Systems-Based Practice

Goal: Demonstrate both an understanding of the contexts and systems in which health care, in particular critical care, is provided, and the ability to apply this knowledge to improve and optimize health care

Objectives

  1. Year One

    1. Utilize the resources, providers and systems necessary to provide optimal care (social services, PharmDs, nutrition service, case managers, physical therapists, etc.)
    2. Apply evidence-based strategies to prevention, diagnosis and disease management
    3. Collaborate with other members of the health care team at Condition A and triage patients to appropriate level of care
    4. Participate in bed allocation decisions with senior fellows and nurse leaders at times of high census
    5. Operate as Command Physician for CHP Transport team, taking calls from referring physicians, providing advice on the evaluation and management of referred patients, triaging patients to appropriate care at CHP, providing medical leadership to the team during transport, communicating with appropriate receiving personnel at CHP, and accompanying team on transport when requested
    6. Recognize requisites necessary for administering a pediatric critical care program
  1. Year Two

    1. Utilize the resources, providers and systems necessary to provide optimal care (social services, PharmDs, nutrition service, case managers, physical therapists, etc.)
    2. Apply evidence-based strategies to prevention, diagnosis and disease management with increased application of current literature
    3. Collaborate with other members of the health care team at Condition A and triage patients to appropriate level of care
    4. Demonstrate practice leadership skills during Condition A/C crisis responses
    5. Recognize of requisites necessary for administering a pediatric critical care program via professionalism lecture series and experience in PICU
    6. Participate in bed allocation decisions with nurse leaders at times of high census
    7. Operate as Command Physician for CHP Transport team, taking calls from referring physicians, providing advice on the evaluation and management of referred patients, triaging patients to appropriate care at CHP, providing medical leadership to the team during transport, communicating with appropriate receiving personnel at CHP, and accompanying team on transport when requested
    8. Participate in quality improvement efforts, particularly those related to patient flow and handoffs from one portion of the system to another, e.g transport, ED, ICU, OR, routine patient unity
    9. Demonstrate ability to understand problems from the perspective of other services
    10. Recognize and discuss cost-benefit considerations in patient-care decisions
  1. Year Three

    1. Utilize the resources, providers and systems necessary to provide optimal care (social services, PharmDs, nutrition service, case managers, physical therapists, etc.)
    2. Apply evidence-based strategies to prevention, diagnosis and disease management with progressively greater application of contemporary literature
    3. Collaborate with other members of the health care team at Condition A and triage patients to appropriate level of care
    4. Demonstrate leadership skills during Condition A/C crisis responses
    5. Recognize requisites necessary for administering a pediatric critical care program via professionalism lecture series and experience in PICU
    6. Participate in bed allocation decision with nurse leaders in times of high census
    7. Operate as Command Physician for CHP Transport team, taking calls from referring physicians, providing advice on the evaluation and management of referred patients, triaging patients to appropriate care at CHP, providing medical leadership to the team during transport, communicating with appropriate receiving personnel at CHP, and accompanying team on transport when requested
    8. Participate in quality improvement efforts, particularly those related to patient flow and handoffs from one portion of the system to another, e.g transport, ED, ICU, OR, routine patient unity
    9. Demonstrate ability to understand problems from the perspective of other services
    10. Demonstrate understanding of cost-benefit considerations in patient-care decisions and apply as appropriate