Performance measurement should re ect this process as much as possible. Many patients will want to be involved in these crucial decisions, and physicians performance with these patients ideally would be assessed in part by surveying patients about whether their input was solicited and their preferences drove or at least in uenced the decision. Alternatively, some patients will prefer that their physician make their decisions for them, and physicians who do so in such instances should be regarded as giving patient-centered care. In addition, all patients should be educated about their options. This education can be very brief in urgent settings, such as when a patient is having an ST-elevation myocardial infarction with cardiogenic shock. However, if any uncertainty exists about the superiority of PCI versus optimal medical therapy or surgical revascularization (as is usually the case with elective PCI), then the patient should be provided an opportunity to learn about the relative risks and bene ts of therapies under consideration. The writing committee struggled with whether to include process measures that focused on decision making and education through patient surveys. Surveys might be able to address general quality of decisions and ask patients about whether they were involved as much or as little as they desired. Survey results could then be shared at the physician and hospital levels, so both individual clinicians and institutions could understand and improve their decision-making processes. However, there are as yet no validated instruments addressing these domains, nor have other critical details been worked out. These limitations left the writing committee less enthusiastic about sup- porting a measure at the present time, but this should be a priority area for future investigation. 4.2. 