Procedural consent, preparation and child-life support — formative SAQs

SAQ 1 (10 marks)

A 4-year-old previously well child is admitted for intravenous antibiotic therapy for a soft-tissue infection. A cannula needs to be sited on the ward. The child is awake, alert and clingy with an anxious parent. The team proposes to "just hold her down and get it done." You are the paediatric registrar. [1] [4]

1. Outline the structured pre-procedure assessment you perform before the cannula is sited. (4) [1]
2. Describe the consent, assent and preparation conversation you have with the parent and child for this elective ward cannula, citing the framework you are using. (3) [1] [3]
3. Describe the bedside comfort bundle you assemble, including the specific sucrose considerations that do NOT apply here, and explain why holding the child down is not the preferred approach. (3) [4] [5] [6]

Model answer — SAQ 1

(1) Pre-procedure assessment (4). I run a short, structured assessment asking four questions. Who decides: I identify the person with parental responsibility (here the parent present) and assess whether the child can give meaningful assent at age four — she cannot give legal consent, but I will seek her assent and record any dissent. What the child understands: I place her in the preschool preparation band, note her current clingy state, and ask the parent about her prior needle experiences and what helped. What is the child's current state: I rate her distress behaviourally (a young child uses a Faces scale or behavioural observation), and I look specifically for freeze or dissociation rather than assuming a quiet child is assenting. Is this procedure right, now, for this child: I confirm the indication and that the procedure is needed, check who will do it and their competence, and check there is no fasting or bleeding issue; if the child is in severe distress I defer to prepare, refer to child-life, or arrange a more experienced operator or sedation. [1]

(2) Consent, assent and preparation (3). I take parental permission from the parent holding responsibility, layered with developmentally appropriate assent from the child — I do not treat her silence as agreement. I use the AAP framework that distinguishes informed consent (for those with capacity), parental permission (for the young child) and affirmative child assent, and I document the conversation. For preparation, because she is a preschool child, I prepare 30 to 60 minutes before with play and a simple, honest, concrete sequence: I show the equipment on a doll first, use short concrete words (squeeze, cold, push), explicitly avoid saying it will not hurt, and offer a real choice only where one genuinely exists (which arm, watch or look away). I document the basis on which I am acting. [1] [3]

(3) Bedside comfort bundle and restraint (3). I assemble a layered bundle: topical anaesthesia on intact skin 30 to 60 minutes before, comfort positioning (chest-to-chest on the parent or hugging a wrapped toy), distraction (a bubbles toy, a video, a child-life specialist using medical play and coping coaching), and a calm, briefed parent given a specific helpful task such as a comfort hold. The sucrose consideration that does not apply here is the infant sucrose dose: oral sucrose is an infant measure (typically 0.1 to 2 mL of 24% to 33% solution as an absolute volume onto the tongue or soother, with a maximum of about 2 mL per dose); this four-year-old does not use sucrose. Breastfeeding for procedural pain similarly applies to infants. Holding the child down is restraint, not a comfort position: restraint is the use of force to overcome active resistance, it injures and traumatises, it breaches trust, and it usually fails; for a non-emergency procedure the least-restrictive alternative — enhanced preparation, child-life referral, comfort positioning, rescheduling, or sedation — is the right approach, and restraint is reserved for a genuine, proportionate, least-restrictive emergency. [4] [5] [6]

SAQ 2 (10 marks)

A 13-year-old boy with type 1 diabetes presents to the emergency department with ketoacidosis and needs an intravenous cannula for insulin and fluids. He is anxious, says he "hates needles," and states he does not want a cannula. His mother, who holds parental responsibility, asks the team to "just do it." You are the paediatric registrar. [1] [2]

1. Explain how you assess this adolescent's capacity to consent to or refuse the cannula, naming the framework and its components. (4) [1] [2]
2. Given the urgency of his diabetic ketoacidosis, outline the consent basis on which you proceed, and how you would manage the situation if he continues to refuse a clearly necessary, time-critical intervention. (3) [1]
3. Describe how you modify the procedural preparation and comfort approach for an adolescent with needle fear, including the management of a vasovagal episode should one occur. (3) [4]

Model answer — SAQ 2

(1) Capacity assessment (4). I assess this adolescent's capacity functionally and for this specific decision using the four Appelbaum domains: whether he can understand the relevant information (he has diabetic ketoacidosis and needs intravenous insulin and fluids to correct it), appreciate the situation and its consequences for himself (the risk of worsening acidosis, coma and death without treatment), reason about the options (cannula now versus the consequences of refusal), and express a stable choice. Capacity is decision-specific and is eroded transiently by acute states — here the acidosis itself, dehydration, fear and pain — so I treat the reversible contributors and re-assess; I do not assume a frightened, acidotic adolescent lacks capacity, nor that age alone confers it. I document the capacity findings. I also offer him a private conversation and address his needle fear and any confidentiality or autonomy concerns directly. [1] [2]

(2) Consent basis and refusal (3). If, after assessment and treatment of reversible contributors, he is found not to have capacity for this decision, the basis for proceeding is parental permission from his mother, layered with his assent to the extent possible, with his dissent recorded and weighed. If the intervention is time-critical and consent cannot be adequately resolved in time, the doctrine of necessity authorises and requires treatment to prevent death or serious harm: I treat first, document the clinical basis and the attempts to engage him and his mother, and revisit consent when he is stable. If a young person assessed as capable refuses life-saving treatment, I do not simply over-ride the refusal: I escalate to a senior clinician, hospital management and (in ANZ) the statutory authority or (in the UK) the courts, treating the child's best interests as overriding a refusal that endangers the child, while continuing to engage the young person throughout. [1]

(3) Adolescent preparation, needle fear and vasovagal management (3). For an adolescent I offer a private conversation, a direct capacity and confidentiality discussion, and respect for his autonomy wherever safe. I address his needle fear head-on: a fainting history is common in this age band, so I position him lying down with legs raised, ensure hydration where clinically appropriate, and use a calm, slow approach with topical anaesthesia and a chosen coping strategy. I avoid the false promise that it will not hurt, and I use distraction or a child-life coping coach if available. If he has a vasovagal episode — pallor, diaphoresis, nausea, brief loss of consciousness with rapid recovery on lying flat — I manage it supportively: lie him flat, raise the legs, ensure the airway is safe, and observe for rapid spontaneous recovery; it is almost always benign but is a marker of clinically significant needle fear that should change the plan for next time, including referral for graded exposure and coping-skills work if needed. Features that would shift the differential to a cardiac event — chest pain, palpitations, exertional onset, family history of sudden death, or a prolonged atypical collapse — would prompt urgent cardiac assessment. [4]