Shared decision-making and assent in children — branching viva

Stem

You are running decision encounters across an acute and chronic paediatric service. The examiner will challenge the ethics, the structure and the limits of partnership. [4] [1]

Branch 1 — Definitions

Examiner: Define shared decision-making in one sentence, and distinguish it from consent and assent. [4] [1]

Strong answer: Shared decision-making is a conversation where clinician and family jointly bring best evidence and the family's values to reach an agreed choice. Consent is the legal authorisation by the parent or mature minor; assent is the developmentally able child's affirmative agreement. They overlap in time but answer different questions. [1] [4]

Examiner: Name the AAP seven elements of assent. [1]

Strong answer: Help the child understand purpose, what to expect, benefits and risks, and alternatives; affirm their right to refuse and to ask questions; and confirm their agreement is voluntary. [1] [2]

Branch 2 — Minor head injury imaging

Examiner: A well-appearing 5-year-old after minor head trauma, no imaging rule trigger, anxious parent asking for a scan. Walk me through the conversation. [9]

Strong answer: Diagnose the decision as preference-sensitive. Team talk: name the fork between observation and CT. Option talk: observation avoids radiation and is safe at low pre-test probability; CT gives certainty but adds radiation and possible incidental findings. Use the validated head CT choice decision aid, which reduced CT use without missed injuries in a cluster-randomised trial. Decision talk: elicit values, teach-back, agree observation with a concrete safety-net. [9] [11]

Branch 3 — ADHD treatment start

Examiner: Diagnosis confirmed by multi-informant assessment. How do you share the treatment decision? [7]

Strong answer: The stimulant-versus-behavioural-versus-combined choice is preference-sensitive. Use a shared decision-making tool to lay out side-effect profiles, school timing and family routines. Seek the child's assent at a developmentally appropriate level. Document the options, values and agreed plan, and schedule review. [7]

Branch 4 — Adolescent biologic disagreement

Examiner: A competent 15-year-old with inflammatory bowel disease wants diet alone and refuses the biologic her parents support. What now? [5]

Strong answer: Assess decision-specific capacity first. If she meets the mature-minor standard, her view carries real weight. Run structured SDM: elicit her values (fear of injections, control, body image) and her parents' values (disease control, future risk). Look for a values-concordant option such as a time-limited trial of optimised therapy with defined review criteria. Revisit at milestones. Do not coerce. [4] [5]

Examiner: The disease is severe and a biologic is the recommended life-preserving option. She still refuses. [1]

Strong answer: Escalate to clinical ethics, second opinion, and where a life-preserving treatment is refused, the local legal pathway. Keep the relationship intact and document everything, including her dissent. [1] [2]

Branch 5 — Emergency limit

Examiner: A child in haemorrhagic shock needs transfusion and parents refuse. Does SDM apply? [1]

Strong answer: Life-saving treatment proceeds under implied consent and is not delayed for deliberation. SDM does not apply in the time-critical emergency except in compressed form. Escalate immediately to senior, ethics and legal pathways under local emergency-treatment provisions. Explain to the child afterwards once stable. [1] [3]

Examiner extras

• Decision aid versus the SDM conversation — a tool is not the whole process. [9] [4]
• Token versus authentic assent. [1] [10]
• Equity: SDM must reach language-discordant and low-literacy families. [3]
• Cochrane uncertainty in cancer participation. [6]