It is the responsibility of the interventionalist to act in the patient s best interest in these circumstances. Informed consent before emergency procedures is partic- ularly difficult.312 314 The patient presenting with STEMI is usually in distress and often sedated, making true informed consent impossible. Rapid triage, transport, and treatment of STEMI patients create a pressured atmosphere that by neces- sity limits a prolonged and detailed informed consent process. Nevertheless, the interventionist must attempt to provide information about the risks and benefits of different strategies to the patient and family and balance the benefit of thorough discussion with the benefits of rapid intervention. 4.2.2. Potential Conflicts of Interest Decisions about the performance and timing of PCI may pose additional ethical dilemmas. When considering whether to perform multivessel PCI in 1 stage versus 2 stages, safety and convenience for the patient must guide the decision, regard- less of payment policies that maximize reimbursement when PCI is staged.311 A separate issue is self-referral, through which diagnostic catheterization often leads seamlessly to PCI by the same operator.315 The interventionist has an ethical obligation to the patient to consider all treatment options, consult with additional specialists (eg, cardiac sur- geons) when their input would be helpful to the patient, avoid unnecessary interventional procedures, and allow the patient to consult family members and other physicians.311 4.3. Radiation Safety: Recommendation Class I 1. Cardiac catheterization laboratories should rou- tinely record relevant available patient procedural radiation dose data (eg, total air kerma at the international reference point [Ka,r], air kerma air product [PKA], fluoroscopy time, number of cine images), and should define thresholds with corre- sponding follow-up protocols for patients who re- ceive a high procedural radiation dose. 