Consent, capacity and shared decision-making — structured SAQ (15 marks)

(a) Immediate actions before theatre (5 marks)

One mark per action, maximum five. Reasoning marks awarded for why each action is taken. ^[1][4][5]

• Stop the surgical pathway — the patient cannot presently name procedure, alternatives or risks; the signed form is evidence of a process, not the process itself. ^[1]
• Address language access first — arrange a qualified interpreter in her preferred language; do not use the partner as the sole interpreter. Document interpreter name, mode and language. ^[4][5]
• Offer private time and ask who she wants involved — speak with her alone in the interpreter's presence to assess voluntariness, possible coercion and personal values. ^[6]
• Use shared decision-making structure — choice talk (she may defer), option talk (hysterectomy, myomectomy, medical management, observation), decision talk (what matters to her). ^[10]
• Reschedule if uncertainty persists — once capacity, voluntariness and informed choice are confirmed, proceed with documented consent; if doubt remains, postpone and re-discuss. ^[1][6]

(b) Defensible consent discussion and the material-risk standard (4 marks)

Two marks for the elements, two marks for the materiality standard. ^[1][3]

• Three elements: decision-making capacity, adequate information and voluntariness — all three must be present; the absence of any one invalidates consent. ^[1][5]
• Adequate information: diagnosis and natural history, proposed procedure, expected benefits, material risks, reasonable alternatives including no treatment, recovery, fertility and sexual consequences, costs and uncertainties, and the right to refuse or withdraw. ^[1][6]
• Material risk (Montgomery/Rogers): any risk a reasonable person in this patient's position would attach significance to, plus any risk the clinician knows or should know this particular patient would attach significance to. There is no fixed percentage; severity, fertility and sexual consequences may make a rare risk material. Disclose reasonable alternatives. ^[2][3]

(c) Capacity assessment and the unwise-decision point (3 marks)

One mark per capacity criterion, one mark for the unwise-decision reasoning, one mark for support and reversible causes. ^[4][6]

• Assess after supporting communication and addressing reversible causes: arrange interpreter, treat pain, provide glasses or hearing aids, choose a quiet setting, repeat information and use teach-back. ^[6]
• Four functional criteria: ability to understand the relevant information, retain it, use or weigh it in choosing, and communicate a decision. Memory aids and assistive communication are permitted. ^[4][6]
• An unwise decision is not incapacity. Capacity is decision-specific and time-specific; a diagnosis, an emotional state, cultural difference or refusal of recommended treatment does not establish incapacity. Where incapacity is found, follow the advance directive and lawful substitute decision-maker hierarchy. ^[4][5]

(d) Contemporaneous documentation with the patient's own words (3 marks)

One mark per documentation element; two marks for two short quoted examples. ^[1][5][6]

• Essential components: clinical problem, proposed procedure and purpose; reasonable options discussed including no treatment; material risks named; benefits and uncertainties; patient's goals, concerns and questions; information aids and decision aids used; interpreter name, mode and language; people present and private time offered; capacity assessment including support and reversible causes addressed; voluntariness check including coercion screening; teach-back in the patient's own words; decision, scope, exclusions and contingencies; review date and signatures. ^[1][5][6]
• Patient's own words — example 1: “I want to stop the bleeding and the pain; I am not ready to give up the chance of a pregnancy.”
• Patient's own words — example 2: “No one has pressured me, and I have time to change my mind.”