Shared decision-making and assent in children — formative SAQs

SAQ 1 — Preference-sensitive imaging decision (10 marks)

A well-appearing 5-year-old presents after a minor head injury. There is no indication for immediate imaging on clinical rules. The parent is anxious and asks "can't you just scan him to be sure?" [9] [11]

Questions

1. Frame this encounter using the three-talk model of shared decision-making. (4 marks) [4]
2. What is the role and evidence base for a decision aid here? (3 marks) [9] [11]
3. How do you seek the child's assent and document the encounter? (3 marks) [1] [10]

Model answer

Three-talk framing (4). Team talk: name that a decision point has arrived (observe at home versus CT), and offer a partnership role. Option talk: present the reasonable options with benefits, harms and uncertainties — observation avoids radiation and is safe given low pre-test probability, while CT gives certainty but carries a small radiation burden and occasional incidental findings. Decision talk: elicit what the family values most (reassurance now versus avoiding radiation), check understanding with teach-back, and agree a choice. [4]

Decision aid role and evidence (3). A validated head CT choice decision aid structures options and harms. In a cluster-randomised trial it reduced CT use without an increase in missed clinically important injuries, and it reached potentially vulnerable parents. The aid supports but does not replace the values conversation. [9] [11]

Assent and documentation (3). Seek developmentally appropriate assent from the 5-year-old using simple language about what observation means and what would bring them back. Record the options discussed, the values that drove the choice, the child's view, and a concrete safety-net and review plan. [1] [10]

SAQ 2 — Adolescent chronic-disease disagreement (10 marks)

A 15-year-old with inflammatory bowel disease disagrees with her parents and her team about switching to a biologic. She wants to try diet changes alone. She appears competent and articulate. [5]

Questions

1. How do you assess her capacity to participate in and potentially make this decision? (4 marks) [1] [2]
2. Describe a structured shared decision-making approach to the disagreement. (4 marks) [4] [5]
3. When and how do you escalate? (2 marks) [1]

Model answer

Capacity assessment (4). Capacity is decision-specific. Assess whether she understands the condition, the proposed biologic and its benefits and risks, the alternative (diet alone) and its likely consequences, and that she can reason with this information and communicate a stable choice. If she meets the mature-minor standard for this decision under local law, her consent may be valid; otherwise parental permission plus her assent applies. Document the assessment. [1] [2]

Structured SDM for disagreement (4). Diagnose the decision as preference-sensitive and longitudinal. Team talk: name the fork and the partnership. Option talk: present biologic, conventional therapy and the diet-only approach with honest benefits, harms and uncertainties, and acknowledge her stated preference without dismissing it. Elicit her values (fear of injections, body image, control) and her parents' values (disease control, future risk). Decision talk: look for a values-concordant option, such as a time-limited trial of optimised therapy with defined review criteria. Revisit at milestones. [4] [5]

Escalation (2). Escalate to clinical ethics, a second opinion, and where a life-preserving treatment is refused by a competent minor, the local legal pathway. Keep the therapeutic relationship intact throughout. [1]