const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// ─── Fetch images ────────────────────────────────────────────────────────────
const imageUrls = [
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_0ae328d856921139cd5f46478283bf9c20ab5cdd8592f1453d89e22b25707a46.jpg", // consent flowchart
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_ff173dea13b44b5140de206287e334fbc0268ddbd57399ce2d7290b1566e7a80.jpg", // RT patient setup
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_9c88f8e989d4e7e81a1c7c3b2a877ef08915a8fdf54167602ca7765907f5244b.jpg", // LINAC room
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_0bd071daa3ae92ef0ad11e664593fda013b79358bfb1a16ebf36a391737da946.jpg", // IGRT linac panels
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_ab90daa301021dd64927e79928aedeaef16150e1ec8e99d5be53fe2da7315ca1.jpg", // SBRT planning vertebra
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_1c3e29745346770105bd4fe0bcc73335469f7d77a28ab30c70377dde9517a38f.jpg", // IMRT SBRT head neck
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_33239c910c0aa489e07003b48bd2f6ab8b97b33e38d642e6d5c1f95fb942a711.jpg", // SBRT lung liver
  "https://cdn.orris.care/cdss_images/GLGCA_1020481_1766750786940_c87dbfd0-0cec-4af1-a169-5c1cc47d020f_6cbe80c8-23de-411b-96a5-d36f8637d8c4.png", // shared decision making diagram
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_25f468eeae33e273ff5a22a330e4ac9873b711eb2db2cb2ba1cae355dd0f227a.jpg", // oncology patient clinical
  "https://cdn.orris.care/cdss_images/9f124eca0603bf87cc796aa058df561ed4ccb0fa0e47a70babae8cd5ac675705.png"  // radiation dose fetal chart
];

console.log("Fetching images...");
let images = [];
try {
  const result = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${imageUrls.map(u => `"${u}"`).join(" ")}`,
    { maxBuffer: 50 * 1024 * 1024 }
  ).toString();
  images = JSON.parse(result);
  console.log(`Fetched ${images.filter(i => !i.error).length}/${images.length} images`);
} catch (e) {
  console.error("Image fetch error:", e.message);
  images = imageUrls.map(url => ({ url, base64: null, error: "fetch failed" }));
}

function getImg(index) {
  const img = images[index];
  return img && !img.error ? img.base64 : null;
}

// ─── Presentation setup ──────────────────────────────────────────────────────
let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Informed Consent in Medical & Radiation Oncology";
pres.author = "Clinical Oncology Department";

// ─── Color palette (white-background clinical) ───────────────────────────────
const C = {
  WHITE:   "FFFFFF",
  NAVY:    "1A3A5C",
  TEAL:    "0D7377",
  ACCENT:  "C8102E",   // red accent
  LGRAY:   "F2F4F7",
  MGRAY:   "8C9BAB",
  DGRAY:   "2D3748",
  GOLD:    "D4A017",
  LBLUE:   "EAF3FB",
};

// ─── Helper functions ─────────────────────────────────────────────────────────
function addSlideHeader(slide, title, subtitle) {
  // White background
  slide.background = { color: C.WHITE };
  // Navy top bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.85, fill: { color: C.NAVY } });
  // Title text
  slide.addText(title, {
    x: 0.3, y: 0.06, w: 9.4, h: 0.6,
    fontSize: 20, bold: true, color: C.WHITE,
    fontFace: "Calibri", valign: "middle", margin: 0
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 0.3, y: 0.62, w: 9.4, h: 0.28,
      fontSize: 10, color: C.MGRAY,
      fontFace: "Calibri", valign: "top", margin: 0
    });
  }
}

function addFooter(slide, ref) {
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 5.3, w: "100%", h: 0.32, fill: { color: C.LGRAY } });
  slide.addText(ref || "ACR-ARS Practice Parameter on Informed Consent in Radiation Oncology, 2023 | RANZCR Guidelines 2017", {
    x: 0.2, y: 5.32, w: 9.6, h: 0.28,
    fontSize: 7, color: C.MGRAY, fontFace: "Calibri", valign: "middle"
  });
}

function bulletText(items, options) {
  return items.map((item, i) => ({
    text: item,
    options: { bullet: { type: "bullet", indent: 15 }, breakLine: i < items.length - 1, ...options }
  }));
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE SLIDE
// ═══════════════════════════════════════════════════════════════════
let s1 = pres.addSlide();
s1.background = { color: C.NAVY };

// Deep teal accent stripe
s1.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: "100%", fill: { color: C.TEAL } });
s1.addShape(pres.ShapeType.rect, { x: 0, y: 4.5, w: "100%", h: 0.05, fill: { color: C.ACCENT } });

// RT patient image (right panel)
const img2 = getImg(1);
if (img2) s1.addImage({ data: img2, x: 6.2, y: 0.3, w: 3.7, h: 4.1, rounding: true });

s1.addText("INFORMED CONSENT", {
  x: 0.4, y: 0.6, w: 5.6, h: 0.6,
  fontSize: 28, bold: true, color: C.GOLD, fontFace: "Calibri",
  charSpacing: 4
});
s1.addText("in Medical & Radiation Oncology", {
  x: 0.4, y: 1.25, w: 5.6, h: 0.5,
  fontSize: 19, color: C.WHITE, fontFace: "Calibri"
});
s1.addShape(pres.ShapeType.rect, { x: 0.4, y: 1.82, w: 3.5, h: 0.04, fill: { color: C.TEAL } });
s1.addText("Clinical Evidence-Based Practice\nACR-ARS · RANZCR · ASTRO Guidelines", {
  x: 0.4, y: 1.9, w: 5.6, h: 0.7,
  fontSize: 11, color: C.MGRAY, fontFace: "Calibri"
});

s1.addShape(pres.ShapeType.rect, { x: 0.4, y: 2.9, w: 5.2, h: 0.9, fill: { color: C.TEAL }, line: { color: C.TEAL } });
s1.addText("Key Guideline: ACR-ARS Practice Parameter on\nInformed Consent Radiation Oncology (2023)\nPMID: 36882916 | Am J Clin Oncol", {
  x: 0.5, y: 2.95, w: 5.0, h: 0.8,
  fontSize: 9.5, color: C.WHITE, fontFace: "Calibri"
});

s1.addText("May 2026", { x: 0.4, y: 5.0, w: 3, h: 0.3, fontSize: 9, color: C.MGRAY, fontFace: "Calibri" });

// ═══════════════════════════════════════════════════════════════════
// SLIDE 2 — TABLE OF CONTENTS
// ═══════════════════════════════════════════════════════════════════
let s2 = pres.addSlide();
addSlideHeader(s2, "Presentation Overview", "25 slides covering foundations, clinical application, and documentation");
addFooter(s2);

const sections = [
  ["01", "Definition & Historical Foundations"],
  ["02", "Ethical & Legal Basis"],
  ["03", "Elements of Informed Consent"],
  ["04", "Informed Consent in Medical Oncology"],
  ["05", "Radiation Oncology: ACR-ARS Guidelines"],
  ["06", "Procedures Requiring Consent (Radiation)"],
  ["07", "Patient Capacity & Surrogate Decision-Making"],
  ["08", "Special Populations"],
  ["09", "Telehealth & Remote Consent"],
  ["10", "Documentation Standards"],
  ["11", "Radiation Treatment Planning & Consent"],
  ["12", "Risk Communication & Radiation Doses"],
];

const sections2 = [
  ["13", "Side Effects & Toxicity Disclosure"],
  ["14", "Shared Decision-Making Model"],
  ["15", "Refusal of Treatment"],
  ["16", "Clinical Trials & Research Consent"],
  ["17", "AI & Emerging Technologies in Consent"],
  ["18", "Consent for Brachytherapy"],
  ["19", "Consent for SBRT/SRS"],
  ["20", "Pediatric Oncology Consent"],
  ["21", "Barriers to Effective Consent"],
  ["22", "Best Practices & Communication Tips"],
  ["23", "Medicolegal Implications"],
  ["24", "Case Studies"],
  ["25", "Summary & Key Takeaways"],
];

// Two-column layout
sections.forEach(([num, label], i) => {
  const col = 0.3;
  const row = 1.0 + i * 0.33;
  s2.addShape(pres.ShapeType.rect, { x: col, y: row, w: 0.38, h: 0.25, fill: { color: C.TEAL } });
  s2.addText(num, { x: col, y: row, w: 0.38, h: 0.25, fontSize: 8, bold: true, color: C.WHITE, align: "center", valign: "middle" });
  s2.addText(label, { x: col + 0.45, y: row, w: 4.2, h: 0.25, fontSize: 9, color: C.DGRAY, valign: "middle" });
});
sections2.forEach(([num, label], i) => {
  const col = 5.1;
  const row = 1.0 + i * 0.33;
  s2.addShape(pres.ShapeType.rect, { x: col, y: row, w: 0.38, h: 0.25, fill: { color: C.NAVY } });
  s2.addText(num, { x: col, y: row, w: 0.38, h: 0.25, fontSize: 8, bold: true, color: C.WHITE, align: "center", valign: "middle" });
  s2.addText(label, { x: col + 0.45, y: row, w: 4.2, h: 0.25, fontSize: 9, color: C.DGRAY, valign: "middle" });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 3 — DEFINITION & HISTORY
// ═══════════════════════════════════════════════════════════════════
let s3 = pres.addSlide();
addSlideHeader(s3, "1. Definition & Historical Foundations", "Evolution of the doctrine from Schloendorff (1914) to Montgomery (2015)");
addFooter(s3, "Berek & Novak's Gynecology | Goldman-Cecil Medicine | RANZCR Guidelines 2017");

s3.addShape(pres.ShapeType.rect, { x: 0.3, y: 0.95, w: 9.4, h: 0.85, fill: { color: C.LBLUE }, line: { color: C.TEAL, pt: 1.2 } });
s3.addText('"Informed consent is a communication process between patient and provider enabling autonomous, voluntary, and competent decision-making about medical treatment."', {
  x: 0.45, y: 0.98, w: 9.1, h: 0.8,
  fontSize: 11, italic: true, color: C.NAVY, fontFace: "Calibri", valign: "middle"
});

const histItems = [
  { year: "1914", event: "Schloendorff v. Society of NY Hospital — foundational US case establishing patient autonomy" },
  { year: "1957", event: "Salgo v. Leland Stanford — coin of the term 'informed consent'; disclosure of risks required" },
  { year: "1972", event: "Canterbury v. Spence — 'material risk' standard; reasonable patient test adopted" },
  { year: "1997", event: "Belmont Report principles codified: Respect for Persons, Beneficence, Justice" },
  { year: "2015", event: "Montgomery v. Lanarkshire (UK) — clinician must discuss material risks important to the patient" },
  { year: "2022-23", event: "ACR-ARS Practice Parameter updated — telehealth, COVID-era adaptations for radiation oncology" },
];

histItems.forEach(({ year, event }, i) => {
  const y = 1.9 + i * 0.52;
  s3.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 0.85, h: 0.38, fill: { color: C.NAVY } });
  s3.addText(year, { x: 0.3, y, w: 0.85, h: 0.38, fontSize: 9, bold: true, color: C.GOLD, align: "center", valign: "middle" });
  s3.addText(event, { x: 1.25, y: y + 0.04, w: 8.5, h: 0.32, fontSize: 9.5, color: C.DGRAY, valign: "middle" });
  if (i < histItems.length - 1) {
    s3.addShape(pres.ShapeType.rect, { x: 0.72, y: y + 0.38, w: 0.03, h: 0.14, fill: { color: C.TEAL } });
  }
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 4 — ETHICAL & LEGAL BASIS
// ═══════════════════════════════════════════════════════════════════
let s4 = pres.addSlide();
addSlideHeader(s4, "2. Ethical & Legal Basis", "The four principles of biomedical ethics underpinning consent");
addFooter(s4, "Berek & Novak's Gynecology; Pellegrino's definition of autonomy — textbook source");

// 4 principle cards
const principles = [
  { title: "Autonomy", color: C.NAVY, icon: "▶", desc: "Patient's right to decide about their own body, including the right to refuse treatment — even if refusal may cause harm. Consent cannot be coerced or manipulated." },
  { title: "Beneficence", color: C.TEAL, icon: "▶", desc: "Clinician acts in the patient's best interest, providing accurate information about benefits of recommended treatment options." },
  { title: "Non-Maleficence", color: C.ACCENT, icon: "▶", desc: '"Do no harm." Disclosing risks, side effects, and alternatives prevents uninformed harm. Failure to disclose is itself unethical.' },
  { title: "Justice", color: "4A6741", icon: "▶", desc: "Equal access to information regardless of literacy, language, culture, or socioeconomic status. Consent forms at 6th–8th grade reading level." },
];

principles.forEach(({ title, color, desc }, i) => {
  const col = i % 2 === 0 ? 0.3 : 5.2;
  const row = i < 2 ? 1.0 : 3.2;
  s4.addShape(pres.ShapeType.rect, { x: col, y: row, w: 4.6, h: 1.9, fill: { color: "F8FAFB" }, line: { color, pt: 2 } });
  s4.addShape(pres.ShapeType.rect, { x: col, y: row, w: 4.6, h: 0.45, fill: { color } });
  s4.addText(title, { x: col + 0.12, y: row + 0.04, w: 4.2, h: 0.38, fontSize: 13, bold: true, color: C.WHITE, fontFace: "Calibri", valign: "middle" });
  s4.addText(desc, { x: col + 0.18, y: row + 0.52, w: 4.22, h: 1.3, fontSize: 9.5, color: C.DGRAY, fontFace: "Calibri", valign: "top" });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 5 — ELEMENTS OF INFORMED CONSENT
// ═══════════════════════════════════════════════════════════════════
let s5 = pres.addSlide();
addSlideHeader(s5, "3. Core Elements of Informed Consent", "Six essential components — ACR-ARS & RANZCR consensus");
addFooter(s5, "ACR-ARS Practice Parameter 2023 | RANZCR Faculty of Radiation Oncology Guidelines 2017 | Pfenninger & Fowler");

const elements = [
  { num: "1", title: "Diagnosis", desc: "Nature of the condition, stage of disease, and prognosis with/without treatment" },
  { num: "2", title: "Proposed Treatment", desc: "Technique, fractionation schedule, simulation, immobilisation, tattoo placement" },
  { num: "3", title: "Risks & Toxicities", desc: "Acute and late side effects, probability and severity, dose to organs at risk" },
  { num: "4", title: "Expected Benefits", desc: "Curative vs. palliative intent, tumour control probability, quality-of-life outcomes" },
  { num: "5", title: "Alternatives", desc: "Surgery, chemotherapy, watchful waiting, palliative care, clinical trials" },
  { num: "6", title: "Right to Refuse", desc: "Patient may withdraw consent at any time without penalty; consequences explained" },
];

elements.forEach(({ num, title, desc }, i) => {
  const col = i % 3 === 0 ? 0.3 : i % 3 === 1 ? 3.6 : 6.9;
  const row = i < 3 ? 1.0 : 3.1;
  s5.addShape(pres.ShapeType.rect, { x: col, y: row, w: 2.9, h: 1.8, fill: { color: C.WHITE }, line: { color: C.NAVY, pt: 1.5 } });
  s5.addShape(pres.ShapeType.rect, { x: col, y: row, w: 0.5, h: 1.8, fill: { color: C.NAVY } });
  s5.addText(num, { x: col, y: row, w: 0.5, h: 1.8, fontSize: 18, bold: true, color: C.WHITE, align: "center", valign: "middle" });
  s5.addText(title, { x: col + 0.6, y: row + 0.08, w: 2.2, h: 0.38, fontSize: 11, bold: true, color: C.NAVY, fontFace: "Calibri" });
  s5.addText(desc, { x: col + 0.6, y: row + 0.5, w: 2.2, h: 1.1, fontSize: 9, color: C.DGRAY, fontFace: "Calibri", valign: "top" });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 6 — INFORMED CONSENT IN MEDICAL ONCOLOGY
// ═══════════════════════════════════════════════════════════════════
let s6 = pres.addSlide();
addSlideHeader(s6, "4. Informed Consent in Medical Oncology", "Chemotherapy, targeted agents, immunotherapy & clinical trials");
addFooter(s6, "Goldman-Cecil Medicine | Am J Clin Oncol 2023 | Curr Oncol Rep 2025");

const img9 = getImg(8); // oncology patient clinical photo
if (img9) s6.addImage({ data: img9, x: 6.6, y: 0.95, w: 3.1, h: 2.8 });

s6.addText("Chemotherapy-Specific Disclosure Requirements", {
  x: 0.3, y: 0.95, w: 6.0, h: 0.35,
  fontSize: 12, bold: true, color: C.NAVY, fontFace: "Calibri"
});

const chemoItems = [
  "Drug name, mechanism, and administration route",
  "Short-term toxicities: myelosuppression, nausea, alopecia, mucositis",
  "Long-term risks: cardiotoxicity (anthracyclines), neuropathy, secondary malignancy",
  "Fertility impact and fertility preservation options",
  "Monitoring requirements and follow-up schedule",
  "Emergency contacts and what warrants urgent review",
];

s6.addText(bulletText(chemoItems, { fontSize: 9.5, color: C.DGRAY }), {
  x: 0.3, y: 1.35, w: 6.0, h: 2.2, fontFace: "Calibri"
});

s6.addShape(pres.ShapeType.rect, { x: 0.3, y: 3.65, w: 9.4, h: 0.04, fill: { color: C.TEAL } });
s6.addText("Immunotherapy & Targeted Therapy Considerations", {
  x: 0.3, y: 3.75, w: 6.5, h: 0.3, fontSize: 11, bold: true, color: C.TEAL
});
s6.addText([
  { text: "Immune-related adverse events (irAEs)", options: { bullet: true, breakLine: true } },
  { text: "Biomarker testing requirements (PD-L1, MSI, TMB, HER2, EGFR)", options: { bullet: true, breakLine: true } },
  { text: "AI-assisted decision-making disclosure — Froicu et al., Curr Oncol Rep 2025 (PMID 40526332)", options: { bullet: true, breakLine: false } },
], { x: 0.3, y: 4.1, w: 9.4, h: 1.0, fontSize: 9.5, color: C.DGRAY, fontFace: "Calibri" });

// ═══════════════════════════════════════════════════════════════════
// SLIDE 7 — ACR-ARS PRACTICE PARAMETER 2023
// ═══════════════════════════════════════════════════════════════════
let s7 = pres.addSlide();
addSlideHeader(s7, "5. ACR-ARS Practice Parameter on Informed Consent (2023)", "Authoritative guideline for radiation oncology consent — PMID 36882916");
addFooter(s7, "Hurwitz MD et al. Am J Clin Oncol. 2023;46(6). DOI:10.1097/COC.0000000000000994");

// Citation box
s7.addShape(pres.ShapeType.rect, { x: 0.3, y: 0.95, w: 9.4, h: 0.75, fill: { color: C.LBLUE }, line: { color: C.TEAL, pt: 1 } });
s7.addText([
  { text: "ACR-ARS Practice Parameter on Informed Consent Radiation Oncology ", options: { bold: true } },
  { text: "| Hurwitz MD, Chundury A, Goodman CR et al. | ", options: { italic: true } },
  { text: "Am J Clin Oncol 2023 | PMID: 36882916", options: { color: C.TEAL } }
], { x: 0.45, y: 0.98, w: 9.1, h: 0.68, fontSize: 9.5, color: C.NAVY, fontFace: "Calibri", valign: "middle" });

s7.addText("Key Objectives", { x: 0.3, y: 1.8, w: 9.4, h: 0.32, fontSize: 12, bold: true, color: C.NAVY });
const acrItems = [
  "Protect patient autonomy in decision-making within the asymmetric clinician-patient relationship",
  "Reduce opportunity for abusive conduct or conflicts of interest in treatment planning",
  "Raise levels of trust between patients and the radiation oncology team",
  "Provide educational framework applicable to evolving radiation technologies",
  "Address new challenges including telehealth/remote consent and COVID-era adaptations",
  "Incorporate proxy/health-care surrogate consent procedures",
];
s7.addText(bulletText(acrItems, { fontSize: 10, color: C.DGRAY }), {
  x: 0.3, y: 2.15, w: 9.4, h: 2.8, fontFace: "Calibri"
});

s7.addText("Practice Guideline (Evidence Level: Expert Consensus) | Jointly developed by ACR Commission on Radiation Oncology & ARS", {
  x: 0.3, y: 5.0, w: 9.4, h: 0.25,
  fontSize: 8, color: C.MGRAY, italic: true
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 8 — PROCEDURES REQUIRING CONSENT (RADIATION)
// ═══════════════════════════════════════════════════════════════════
let s8 = pres.addSlide();
addSlideHeader(s8, "6. Radiation Oncology: Procedures Requiring Formal Consent", "Per ACR-ARS 2022 revised parameter — mandatory list");
addFooter(s8, "ACR-ARS Practice Parameter | ACROinsights Issue 4, 2022");

const procs = [
  { num: "1", label: "CT Simulation & Imaging", detail: "Field placement, treatment planning, contrast agents, tattoo placement" },
  { num: "2", label: "External Beam Radiotherapy", detail: "EBRT, IMRT, VMAT, 3D-CRT — all dose levels and fractionations" },
  { num: "3", label: "SBRT / SABR / SRS", detail: "Stereotactic body/ablative RT; radiosurgery with high per-fraction doses" },
  { num: "4", label: "Brachytherapy", detail: "LDR/HDR intracavitary, interstitial, surface applicators" },
  { num: "5", label: "Radioactive Implants", detail: "Permanent seeds (prostate I-125, Pd-103); iodine-131 therapy" },
  { num: "6", label: "Intraoperative RT (IORT)", detail: "Single-fraction during surgery; specific consent separate from surgical consent" },
  { num: "7", label: "Special Procedures", detail: "Total body irradiation (TBI), total skin electron beam (TSEBT)" },
  { num: "8", label: "Re-irradiation", detail: "Prior radiation history must be documented; cumulative dose implications disclosed" },
];

procs.forEach(({ num, label, detail }, i) => {
  const col = i % 2 === 0 ? 0.3 : 5.15;
  const row = 1.0 + Math.floor(i / 2) * 1.0;
  s8.addShape(pres.ShapeType.rect, { x: col, y: row, w: 4.5, h: 0.85, fill: { color: i % 2 === 0 ? C.LGRAY : "EDF7F6" }, line: { color: i % 2 === 0 ? C.NAVY : C.TEAL, pt: 1 } });
  s8.addShape(pres.ShapeType.rect, { x: col, y: row, w: 0.4, h: 0.85, fill: { color: i % 2 === 0 ? C.NAVY : C.TEAL } });
  s8.addText(num, { x: col, y: row, w: 0.4, h: 0.85, fontSize: 12, bold: true, color: C.WHITE, align: "center", valign: "middle" });
  s8.addText(label, { x: col + 0.5, y: row + 0.05, w: 3.9, h: 0.3, fontSize: 10, bold: true, color: C.NAVY });
  s8.addText(detail, { x: col + 0.5, y: row + 0.38, w: 3.9, h: 0.45, fontSize: 8.5, color: C.DGRAY });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 9 — PATIENT CAPACITY & SURROGATE DECISION-MAKING
// ═══════════════════════════════════════════════════════════════════
let s9 = pres.addSlide();
addSlideHeader(s9, "7. Patient Capacity & Surrogate Decision-Making", "Four Criteria for Decisional Capacity (MacArthur) & proxy hierarchy");
addFooter(s9, "Pfenninger & Fowler's Procedures for Primary Care | ACR-ARS 2023");

// Capacity criteria
s9.addText("MacArthur Competency Assessment — 4 Criteria", {
  x: 0.3, y: 1.0, w: 9.4, h: 0.35, fontSize: 12, bold: true, color: C.NAVY
});

const criteria = [
  { n: "1", c: C.NAVY, t: "Understanding", d: "Patient comprehends the information about diagnosis and proposed treatment" },
  { n: "2", c: C.TEAL, t: "Appreciation", d: "Patient recognises how the information applies to their own situation and consequences" },
  { n: "3", c: C.ACCENT, t: "Reasoning", d: "Patient can weigh treatment options and provide rational reasons for their choice" },
  { n: "4", c: "4A6741", t: "Expression", d: "Patient can communicate a consistent, stable choice to the treating team" },
];

criteria.forEach(({ n, c, t, d }, i) => {
  const x = 0.3 + i * 2.4;
  s9.addShape(pres.ShapeType.rect, { x, y: 1.4, w: 2.2, h: 2.2, fill: { color: "F8FAFB" }, line: { color: c, pt: 2 } });
  s9.addShape(pres.ShapeType.rect, { x, y: 1.4, w: 2.2, h: 0.5, fill: { color: c } });
  s9.addText(n, { x, y: 1.4, w: 2.2, h: 0.5, fontSize: 16, bold: true, color: C.WHITE, align: "center", valign: "middle" });
  s9.addText(t, { x: x + 0.12, y: 1.96, w: 1.96, h: 0.32, fontSize: 10.5, bold: true, color: c, fontFace: "Calibri" });
  s9.addText(d, { x: x + 0.12, y: 2.32, w: 1.96, h: 1.1, fontSize: 8.5, color: C.DGRAY, fontFace: "Calibri" });
});

s9.addShape(pres.ShapeType.rect, { x: 0.3, y: 3.72, w: 9.4, h: 0.04, fill: { color: C.TEAL } });
s9.addText("Surrogate Hierarchy (when patient lacks capacity)", {
  x: 0.3, y: 3.8, w: 9.4, h: 0.3, fontSize: 11, bold: true, color: C.TEAL
});
s9.addText([
  { text: "1. Legal guardian or court-appointed proxy  ", options: { bold: true, breakLine: false } },
  { text: "→  ", options: { color: C.MGRAY, breakLine: false } },
  { text: "2. Healthcare proxy (durable POA)  ", options: { bold: true, breakLine: false } },
  { text: "→  ", options: { color: C.MGRAY, breakLine: false } },
  { text: "3. Spouse/partner  ", options: { bold: true, breakLine: false } },
  { text: "→  ", options: { color: C.MGRAY, breakLine: false } },
  { text: "4. Adult children  ", options: { bold: true, breakLine: false } },
  { text: "→  ", options: { color: C.MGRAY, breakLine: false } },
  { text: "5. Parents → 6. Siblings", options: { bold: true } },
], { x: 0.3, y: 4.14, w: 9.4, h: 0.5, fontSize: 9.5, color: C.DGRAY, fontFace: "Calibri" });
s9.addText("The patient's previously expressed wishes and best interest standard must guide surrogate decisions. Document all surrogate consent interactions.", {
  x: 0.3, y: 4.7, w: 9.4, h: 0.35, fontSize: 9, color: C.ACCENT, italic: true
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 10 — SPECIAL POPULATIONS
// ═══════════════════════════════════════════════════════════════════
let s10 = pres.addSlide();
addSlideHeader(s10, "8. Special Populations", "Paediatric, cognitive impairment, language barriers & pregnancy");
addFooter(s10, "ACR-ARS 2023 | Roberts & Hedges' Clinical Procedures in Emergency Medicine | Berek & Novak");

const pops = [
  { icon: "🧒", title: "Paediatric Patients", color: C.NAVY, items: ["Consent from parent/legal guardian mandatory (<18 years)", "Child assent sought whenever developmentally appropriate", "Adolescent autonomy increasingly recognised ≥14–16 yrs", "Oncofertility discussions: Barlevy et al., PMID 28949840"] },
  { icon: "🧠", title: "Cognitive Impairment", color: C.TEAL, items: ["Formal capacity assessment required before obtaining consent", "Substitute decision-maker appointed per state/national law", "Simplified language, visual aids, teach-back methods", "Advance directives and advance care plans should be reviewed"] },
  { icon: "🌐", title: "Language & Cultural Barriers", color: "4A6741", items: ["Certified medical interpreter — NOT family member", "Consent forms translated to patient's primary language", "6th–8th grade reading level — plain language mandate", "Cultural and religious values integrated into discussion"] },
  { icon: "🤰", title: "Pregnancy", color: C.ACCENT, items: ["Fetal dose quantified and disclosed (ICRP Pub 84)", "For fetal dose <100 mrad: verbal reassurance sufficient", "For fetal dose >100 mrad: detailed written disclosure required", "Alternatives, teratogenic risk, and NRC thresholds discussed"] },
];

pops.forEach(({ title, color, items }, i) => {
  const col = i % 2 === 0 ? 0.3 : 5.15;
  const row = i < 2 ? 1.05 : 3.15;
  s10.addShape(pres.ShapeType.rect, { x: col, y: row, w: 4.5, h: 1.85, fill: { color: "FAFBFC" }, line: { color, pt: 1.5 } });
  s10.addShape(pres.ShapeType.rect, { x: col, y: row, w: 4.5, h: 0.42, fill: { color } });
  s10.addText(title, { x: col + 0.12, y: row + 0.04, w: 4.2, h: 0.36, fontSize: 11, bold: true, color: C.WHITE, valign: "middle" });
  items.forEach((item, j) => {
    s10.addText("• " + item, { x: col + 0.15, y: row + 0.5 + j * 0.32, w: 4.2, h: 0.3, fontSize: 8.5, color: C.DGRAY });
  });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 11 — TELEHEALTH & REMOTE CONSENT
// ═══════════════════════════════════════════════════════════════════
let s11 = pres.addSlide();
addSlideHeader(s11, "9. Telehealth & Remote Consent", "New ACR-ARS 2023 guidance — COVID-era and post-pandemic practice");
addFooter(s11, "ACR-ARS Practice Parameter 2023 | ACROinsights Issue 4, 2022");

s11.addShape(pres.ShapeType.rect, { x: 0.3, y: 0.95, w: 9.4, h: 0.7, fill: { color: "FFF8E7" }, line: { color: C.GOLD, pt: 1.5 } });
s11.addText("⚠  Key Update (2022–23): COVID-19 pandemic drove expansion of telehealth consent. ACR-ARS updated its parameter to address remote and telephone-based consent processes.", {
  x: 0.45, y: 0.98, w: 9.1, h: 0.64, fontSize: 9.5, color: C.NAVY, fontFace: "Calibri", valign: "middle"
});

const teleItems = [
  { title: "In-Person (Preferred)", color: C.NAVY, items: ["Gold standard for complex radiation oncology consent", "Allows physical demonstration, visual aids, models", "Direct observation of patient comprehension and affect"] },
  { title: "Telehealth (Video)", color: C.TEAL, items: ["Acceptable when in-person is not feasible", "Must verify patient identity — two-factor verification", "Staff witness required; document the modality used", "State regulations on telehealth consent must be followed"] },
  { title: "Telephone Only", color: C.ACCENT, items: ["Lowest preference — limited non-verbal assessment", "Necessity must be documented in the medical record", "Radiation oncologist's responsibility to ensure comprehension", "Follow-up written materials strongly recommended"] },
];

teleItems.forEach(({ title, color, items }, i) => {
  const x = 0.3 + i * 3.2;
  s11.addShape(pres.ShapeType.rect, { x, y: 1.75, w: 3.0, h: 3.25, fill: { color: "F8FAFB" }, line: { color, pt: 1.5 } });
  s11.addShape(pres.ShapeType.rect, { x, y: 1.75, w: 3.0, h: 0.42, fill: { color } });
  s11.addText(title, { x: x + 0.1, y: 1.78, w: 2.8, h: 0.38, fontSize: 10.5, bold: true, color: C.WHITE, valign: "middle" });
  items.forEach((item, j) => {
    s11.addText("• " + item, { x: x + 0.12, y: 2.24 + j * 0.55, w: 2.76, h: 0.5, fontSize: 9, color: C.DGRAY });
  });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 12 — DOCUMENTATION STANDARDS
// ═══════════════════════════════════════════════════════════════════
let s12 = pres.addSlide();
addSlideHeader(s12, "10. Documentation Standards", "Mandatory elements of the consent form and medical record");
addFooter(s12, "ACR-ARS 2023 | ACROinsights Issue 4, 2022 | RANZCR Appendix A");

s12.addText("Minimum Required Elements of Consent Documentation", {
  x: 0.3, y: 0.95, w: 9.4, h: 0.32, fontSize: 12, bold: true, color: C.NAVY
});

const docItems = [
  ["Two-patient identifiers", "Name + DOB (or MRN) — prevents wrong-patient treatment"],
  ["Authorising physician name", "Name of radiation oncologist performing/overseeing procedure"],
  ["First-person patient statement", "Statement in patient's own words authorising treatment"],
  ["Treatment description", "Type, fractionation, technique, estimated duration"],
  ["Risks, benefits & alternatives", "All three explicitly listed and discussed"],
  ["Refusal of treatment right", "Patient acknowledges understanding of consequences of refusal"],
  ["Special disclosures", "Tattoo placement, photography, pregnancy risk, research participation"],
  ["Opportunity for questions", "Statement that questions were offered and answered"],
  ["Witness/translator signature", "If applicable, with relationship and date"],
  ["Patient/surrogate signature & date", "Plus relationship to patient if surrogate"],
];

docItems.forEach(([item, note], i) => {
  const row = 1.35 + i * 0.37;
  const bgColor = i % 2 === 0 ? C.WHITE : C.LGRAY;
  s12.addShape(pres.ShapeType.rect, { x: 0.3, y: row, w: 9.4, h: 0.35, fill: { color: bgColor } });
  s12.addShape(pres.ShapeType.rect, { x: 0.3, y: row, w: 0.04, h: 0.35, fill: { color: C.TEAL } });
  s12.addText(item, { x: 0.42, y: row + 0.04, w: 3.0, h: 0.28, fontSize: 9.5, bold: true, color: C.NAVY });
  s12.addText(note, { x: 3.5, y: row + 0.04, w: 6.1, h: 0.28, fontSize: 9, color: C.DGRAY });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 13 — RADIATION TREATMENT PLANNING & CONSENT
// ═══════════════════════════════════════════════════════════════════
let s13 = pres.addSlide();
addSlideHeader(s13, "11. Radiation Treatment Planning & Consent", "Patient setup, simulation, target volumes, and dose constraints");
addFooter(s13, "Clinical image: RT patient immobilization setup | Image-guided RT (IGRT) suite");

const imgRTSetup = getImg(1);
const imgIGRT = getImg(3);
if (imgRTSetup) s13.addImage({ data: imgRTSetup, x: 0.3, y: 1.0, w: 4.5, h: 3.0 });
if (imgIGRT) s13.addImage({ data: imgIGRT, x: 5.0, y: 1.0, w: 4.8, h: 3.0 });

s13.addText("LEFT: Patient immobilisation with vacuum cushion & laser alignment for RT", {
  x: 0.3, y: 4.05, w: 4.5, h: 0.25, fontSize: 7.5, color: C.MGRAY, align: "center"
});
s13.addText("RIGHT: IGRT suite with stereoscopic X-ray for real-time fiducial tracking", {
  x: 5.0, y: 4.05, w: 4.8, h: 0.25, fontSize: 7.5, color: C.MGRAY, align: "center"
});

s13.addText([
  { text: "Consent must cover: ", options: { bold: true } },
  { text: "simulation CT ± contrast · immobilisation device placement · skin tattoo marks · daily image-guidance · treatment positioning · duration of daily sessions (~10–30 min)", options: {} }
], { x: 0.3, y: 4.35, w: 9.4, h: 0.5, fontSize: 9.5, color: C.DGRAY, fontFace: "Calibri" });

s13.addShape(pres.ShapeType.rect, { x: 0.3, y: 4.85, w: 9.4, h: 0.3, fill: { color: C.LBLUE } });
s13.addText("Target volume terminology (GTV, CTV, PTV) and organ-at-risk dose constraints should be explained in lay terms at the consent discussion.", {
  x: 0.35, y: 4.88, w: 9.3, h: 0.26, fontSize: 9, color: C.NAVY, valign: "middle"
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 14 — RISK COMMUNICATION & RADIATION DOSES
// ═══════════════════════════════════════════════════════════════════
let s14 = pres.addSlide();
addSlideHeader(s14, "12. Risk Communication & Radiation Dose Disclosure", "Fetal exposure, stochastic & deterministic effects");
addFooter(s14, "Roberts & Hedges Clinical Procedures — ICRP Publication 84 | Annals ICRP fetal dose summary");

const imgFetal = getImg(9);
if (imgFetal) s14.addImage({ data: imgFetal, x: 5.2, y: 0.95, w: 4.5, h: 3.2 });

s14.addText("Stochastic vs. Deterministic Risk Disclosure", { x: 0.3, y: 0.98, w: 4.8, h: 0.32, fontSize: 11, bold: true, color: C.NAVY });

const riskRows = [
  { type: "Stochastic", ex: "Secondary malignancy, heritable genetic effects", th: "No threshold — probability proportional to dose" },
  { type: "Deterministic", ex: "Radiation pneumonitis, fibrosis, myelopathy, cataracts", th: "Threshold-dependent; severity ↑ with dose above threshold" },
];

riskRows.forEach(({ type, ex, th }, i) => {
  const y = 1.38 + i * 0.85;
  const c = i === 0 ? C.TEAL : C.ACCENT;
  s14.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 4.8, h: 0.8, fill: { color: "F8FAFB" }, line: { color: c, pt: 1.5 } });
  s14.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 1.1, h: 0.8, fill: { color: c } });
  s14.addText(type, { x: 0.3, y, w: 1.1, h: 0.8, fontSize: 9, bold: true, color: C.WHITE, align: "center", valign: "middle" });
  s14.addText(ex, { x: 1.48, y: y + 0.04, w: 3.5, h: 0.34, fontSize: 9, bold: true, color: C.DGRAY });
  s14.addText(th, { x: 1.48, y: y + 0.4, w: 3.5, h: 0.34, fontSize: 9, color: C.MGRAY });
});

s14.addText("Fetal Radiation Exposure — ICRP Pub 84 Disclosure Thresholds", { x: 0.3, y: 3.12, w: 4.8, h: 0.3, fontSize: 11, bold: true, color: C.NAVY });

const fetalData = [
  ["< 100 mrad", "Verbal reassurance sufficient", C.TEAL],
  ["100 mrad – 5 rad (50 mGy)", "Detailed written disclosure required; alternatives discussed", C.GOLD],
  ["> 10 rad (100 mGy)", "Highest risk — teratogenesis, growth retardation risk period-dependent", C.ACCENT],
];

fetalData.forEach(([dose, note, c], i) => {
  s14.addShape(pres.ShapeType.rect, { x: 0.3, y: 3.48 + i * 0.5, w: 4.8, h: 0.44, fill: { color: "FAFBFC" }, line: { color: c, pt: 1 } });
  s14.addShape(pres.ShapeType.rect, { x: 0.3, y: 3.48 + i * 0.5, w: 1.5, h: 0.44, fill: { color: c } });
  s14.addText(dose, { x: 0.3, y: 3.48 + i * 0.5, w: 1.5, h: 0.44, fontSize: 8.5, bold: true, color: C.WHITE, align: "center", valign: "middle" });
  s14.addText(note, { x: 1.88, y: 3.54 + i * 0.5, w: 3.1, h: 0.34, fontSize: 8.5, color: C.DGRAY });
});

s14.addText("Chart: Comparison of common radiographic studies vs. accepted 50 mGy fetal exposure limit (Roberts & Hedges, Fig 71.4)", {
  x: 5.2, y: 4.2, w: 4.5, h: 0.35, fontSize: 7.5, color: C.MGRAY, align: "center"
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 15 — SIDE EFFECTS & TOXICITY DISCLOSURE
// ═══════════════════════════════════════════════════════════════════
let s15 = pres.addSlide();
addSlideHeader(s15, "13. Acute & Late Side Effects — Disclosure Requirements", "Site-specific toxicity communication in radiation oncology");
addFooter(s15, "Cummings Otolaryngology | ACR-ARS 2023 | CTCAE v5.0");

const sites = [
  { site: "Brain / CNS", acute: "Fatigue, headache, alopecia, somnolence", late: "Radiation necrosis, neurocognitive decline, hypopituitarism" },
  { site: "Head & Neck", acute: "Mucositis, xerostomia, dysphagia, skin reaction", late: "Osteoradionecrosis, xerostomia (permanent), trismus, fibrosis" },
  { site: "Thorax / Lung", acute: "Oesophagitis, fatigue, cough, skin erythema", late: "Radiation pneumonitis, fibrosis, cardiac toxicity (left-sided)" },
  { site: "Abdomen / Pelvis", acute: "Nausea, diarrhoea, cystitis, skin reaction", late: "Bowel obstruction, fistula, proctitis, sexual dysfunction" },
  { site: "Breast", acute: "Skin erythema, fatigue, breast oedema", late: "Fibrosis, lymphoedema, secondary malignancy, cardiac (left)" },
  { site: "Spine / SBRT", acute: "Pain flare (30%), nausea, fatigue", late: "Vertebral fracture, myelopathy (<1% with constraints met)" },
];

// Table header
s15.addShape(pres.ShapeType.rect, { x: 0.3, y: 0.97, w: 9.4, h: 0.36, fill: { color: C.NAVY } });
s15.addText("Treatment Site", { x: 0.35, y: 0.99, w: 1.9, h: 0.32, fontSize: 9.5, bold: true, color: C.WHITE });
s15.addText("Acute Toxicities (during/shortly after RT)", { x: 2.3, y: 0.99, w: 3.5, h: 0.32, fontSize: 9.5, bold: true, color: C.WHITE });
s15.addText("Late/Chronic Toxicities (months–years)", { x: 5.85, y: 0.99, w: 3.8, h: 0.32, fontSize: 9.5, bold: true, color: C.WHITE });

sites.forEach(({ site, acute, late }, i) => {
  const y = 1.37 + i * 0.63;
  const bg = i % 2 === 0 ? C.WHITE : C.LGRAY;
  s15.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 9.4, h: 0.6, fill: { color: bg } });
  s15.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 0.04, h: 0.6, fill: { color: i % 2 === 0 ? C.TEAL : C.NAVY } });
  s15.addText(site, { x: 0.38, y: y + 0.1, w: 1.88, h: 0.42, fontSize: 9.5, bold: true, color: C.NAVY });
  s15.addText(acute, { x: 2.3, y: y + 0.06, w: 3.5, h: 0.5, fontSize: 9, color: C.DGRAY });
  s15.addText(late, { x: 5.85, y: y + 0.06, w: 3.8, h: 0.5, fontSize: 9, color: C.ACCENT });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 16 — SHARED DECISION-MAKING
// ═══════════════════════════════════════════════════════════════════
let s16 = pres.addSlide();
addSlideHeader(s16, "14. Shared Decision-Making Model", "Integrating evidence-based medicine with patient values and preferences");
addFooter(s16, "Coronary Artery Revascularization Guidelines | RANZCR 2017 | van Lent et al. Cancer Treat Rev 2021");

const imgSDM = getImg(7); // shared decision-making diagram
if (imgSDM) s16.addImage({ data: imgSDM, x: 0.4, y: 1.0, w: 4.0, h: 3.0 });

s16.addText("Three-Talk Model of Shared Decision-Making", {
  x: 4.6, y: 1.0, w: 5.1, h: 0.32, fontSize: 11, bold: true, color: C.NAVY
});

const sdmSteps = [
  { talk: "Team Talk", desc: "Clinician introduces that a decision needs to be made and that patient's preferences matter. Support is offered during deliberation." },
  { talk: "Option Talk", desc: "More detailed description of all options including no treatment, curative RT, surgery, and combined modality — with risks and benefits." },
  { talk: "Decision Talk", desc: "Focus on eliciting patient preferences; patient-specific values are integrated with clinical evidence to reach a collaborative decision." },
];

sdmSteps.forEach(({ talk, desc }, i) => {
  const y = 1.4 + i * 1.05;
  const c = [C.NAVY, C.TEAL, "4A6741"][i];
  s16.addShape(pres.ShapeType.rect, { x: 4.6, y, w: 5.0, h: 0.95, fill: { color: "F8FAFB" }, line: { color: c, pt: 1.5 } });
  s16.addShape(pres.ShapeType.rect, { x: 4.6, y, w: 1.3, h: 0.95, fill: { color: c } });
  s16.addText(talk, { x: 4.6, y, w: 1.3, h: 0.95, fontSize: 9.5, bold: true, color: C.WHITE, align: "center", valign: "middle" });
  s16.addText(desc, { x: 5.98, y: y + 0.1, w: 3.52, h: 0.78, fontSize: 9, color: C.DGRAY });
});

s16.addText("Evidence: van Lent et al. identified patient values critical to clinical trial participation — emphasizing that shared decision-making is fundamental, not optional. PMID 33965892", {
  x: 4.6, y: 4.55, w: 5.0, h: 0.5, fontSize: 8.5, color: C.TEAL, italic: true
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 17 — REFUSAL OF TREATMENT
// ═══════════════════════════════════════════════════════════════════
let s17 = pres.addSlide();
addSlideHeader(s17, "15. Refusal of Treatment", "Patient rights, documentation, and clinical obligations");
addFooter(s17, "RANZCR Faculty of Radiation Oncology Guidelines 2017 | ACR-ARS 2023");

s17.addShape(pres.ShapeType.rect, { x: 0.3, y: 0.97, w: 9.4, h: 0.7, fill: { color: "FFF0F0" }, line: { color: C.ACCENT, pt: 1.5 } });
s17.addText([
  { text: "Fundamental Right: ", options: { bold: true, color: C.ACCENT } },
  { text: "A competent patient has the absolute right to refuse any treatment, even when refusal may result in their death. This right is protected by law in all jurisdictions.", options: { color: C.NAVY } }
], { x: 0.45, y: 1.0, w: 9.1, h: 0.64, fontSize: 10.5, fontFace: "Calibri", valign: "middle" });

s17.addText("Clinical Obligations When Facing Refusal", { x: 0.3, y: 1.76, w: 4.6, h: 0.3, fontSize: 11, bold: true, color: C.NAVY });
const refObs = [
  "Ensure patient fully understands why the treatment is recommended",
  "Confirm understanding of the potential consequences of refusal",
  "Reassess for potential barriers: fear, misinformation, financial concerns",
  "Offer alternative treatment approaches if available",
  "Document the discussion, patient's reasoning, and their decision",
  "Request patient sign a formal 'refusal of treatment' certificate",
  "Never abandon the patient — continue supportive/palliative care",
];
s17.addText(bulletText(refObs, { fontSize: 9.5, color: C.DGRAY }), {
  x: 0.3, y: 2.1, w: 4.5, h: 2.5, fontFace: "Calibri"
});

s17.addText("Exceptions to Standard Refusal Rights", { x: 5.1, y: 1.76, w: 4.6, h: 0.3, fontSize: 11, bold: true, color: C.ACCENT });
const exceptions = [
  { ex: "Lack of Capacity", note: "Surrogate or court must make decision; patient's advance directive governs" },
  { ex: "Paediatric Refusal", note: "Court may override parental refusal when clearly in child's best interest" },
  { ex: "Therapeutic Privilege", note: "Extremely narrow exception: information may be withheld only if serious psychological harm to patient proven" },
  { ex: "Emergency RT", note: "Implied consent for urgent/emergency radiotherapy when patient unconscious" },
];
exceptions.forEach(({ ex, note }, i) => {
  const y = 2.12 + i * 0.62;
  s17.addShape(pres.ShapeType.rect, { x: 5.1, y, w: 4.5, h: 0.55, fill: { color: i % 2 === 0 ? C.LGRAY : C.WHITE }, line: { color: C.ACCENT, pt: 0.5 } });
  s17.addText(ex + ":", { x: 5.2, y: y + 0.05, w: 4.3, h: 0.22, fontSize: 9.5, bold: true, color: C.ACCENT });
  s17.addText(note, { x: 5.2, y: y + 0.28, w: 4.3, h: 0.24, fontSize: 9, color: C.DGRAY });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 18 — CLINICAL TRIALS & RESEARCH CONSENT
// ═══════════════════════════════════════════════════════════════════
let s18 = pres.addSlide();
addSlideHeader(s18, "16. Clinical Trials & Research Consent", "Additional regulatory requirements beyond standard clinical consent");
addFooter(s18, "Droste et al. BMC Med Ethics 2011 PMID 21496244 | van Lent et al. PMID 33965892 | Declaration of Helsinki");

const imgConsFlowchart = getImg(0);
if (imgConsFlowchart) s18.addImage({ data: imgConsFlowchart, x: 5.1, y: 0.95, w: 4.6, h: 3.5 });

s18.addText("Research Consent: Beyond Clinical Consent", { x: 0.3, y: 0.95, w: 4.6, h: 0.32, fontSize: 11, bold: true, color: C.NAVY });

const researchItems = [
  "Research nature, purpose, and expected duration of participation",
  "Experimental vs. standard-of-care treatment distinction",
  "Foreseeable risks or discomforts and benefits to subject/society",
  "Alternative procedures or courses of treatment",
  "Extent of confidentiality of records",
  "Compensation and treatment for injury if research-related harm occurs",
  "Contact information for questions about research and participant rights",
  "Voluntary nature — right to withdraw without penalty at any time",
  "Right to refuse to answer any questions without penalty",
];
s18.addText(bulletText(researchItems, { fontSize: 9.5, color: C.DGRAY }), {
  x: 0.3, y: 1.33, w: 4.6, h: 3.6, fontFace: "Calibri"
});
s18.addText("Image: 5-stage informed consent process in clinical research (feedback throughout)", {
  x: 5.1, y: 4.5, w: 4.6, h: 0.25, fontSize: 7.5, color: C.MGRAY, align: "center"
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 19 — AI & EMERGING TECHNOLOGIES
// ═══════════════════════════════════════════════════════════════════
let s19 = pres.addSlide();
addSlideHeader(s19, "17. AI & Emerging Technologies in Consent", "New ethical challenges — PMID 40526332 | Curr Oncol Rep 2025");
addFooter(s19, "Froicu EM et al. Artificial Intelligence and Decision-Making in Oncology. Curr Oncol Rep 2025. PMID 40526332");

s19.addShape(pres.ShapeType.rect, { x: 0.3, y: 0.97, w: 9.4, h: 0.65, fill: { color: C.LBLUE }, line: { color: C.TEAL } });
s19.addText([
  { text: "Systematic Review (2025): ", options: { bold: true } },
  { text: "Froicu et al. identify ethical, legal, and informed consent challenges introduced by AI in oncology decision-making. Patients must be informed when AI tools influence diagnosis, treatment planning, or prognosis.", options: {} }
], { x: 0.45, y: 1.0, w: 9.1, h: 0.6, fontSize: 9.5, color: C.NAVY, fontFace: "Calibri", valign: "middle" });

const aiItems = [
  { title: "AI-Assisted Diagnosis", concern: "Patients must be informed if AI (e.g., deep learning) contributed to cancer detection or staging diagnosis" },
  { title: "RT Treatment Planning AI", concern: "Auto-contouring, AI-based plan optimisation — clinician remains responsible; patient should know AI tools used" },
  { title: "Prognostic AI Models", concern: "Algorithmic bias and population-level predictions may not reflect individual prognosis — must be disclosed" },
  { title: "Consent Form Generation", concern: "AI-generated consent forms must be reviewed by responsible clinician; accuracy and personalisation required" },
  { title: "Digital Health & Apps", concern: "Patient-reported outcomes, wearables in clinical trials — data ownership and privacy disclosure required" },
  { title: "Accountability", concern: "AI does not have legal responsibility — the treating physician retains full accountability for all AI-assisted decisions" },
];

aiItems.forEach(({ title, concern }, i) => {
  const col = i % 2 === 0 ? 0.3 : 5.1;
  const row = 1.72 + Math.floor(i / 2) * 1.0;
  const c = [C.NAVY, C.TEAL, "4A6741"][Math.floor(i / 2)];
  s19.addShape(pres.ShapeType.rect, { x: col, y: row, w: 4.5, h: 0.88, fill: { color: "F8FAFB" }, line: { color: c, pt: 1.2 } });
  s19.addText("▶ " + title, { x: col + 0.12, y: row + 0.05, w: 4.2, h: 0.28, fontSize: 10, bold: true, color: c });
  s19.addText(concern, { x: col + 0.12, y: row + 0.36, w: 4.2, h: 0.46, fontSize: 8.5, color: C.DGRAY });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 20 — BRACHYTHERAPY CONSENT
// ═══════════════════════════════════════════════════════════════════
let s20 = pres.addSlide();
addSlideHeader(s20, "18. Informed Consent for Brachytherapy", "LDR/HDR intracavitary & interstitial — site-specific requirements");
addFooter(s20, "ACR-ARS 2023 | Campbell Walsh Wein Urology | Grainger & Allison's Diagnostic Radiology");

const brachySites = [
  { site: "Cervical / Gynaecologic", type: "HDR intracavitary", risks: "Vaginal stenosis, fistula (vesico/recto-vaginal), bowel injury, bladder injury, pain during insertion" },
  { site: "Prostate", type: "LDR seeds (I-125 / Pd-103)", risks: "Urinary retention, dysuria, proctitis, seed migration, permanent implant risks, sexual dysfunction (ED)" },
  { site: "Breast", type: "HDR interstitial/intracavitary (APBI)", risks: "Infection, wound healing, cosmesis, fat necrosis, skin reaction at catheter sites" },
  { site: "Head & Neck", type: "HDR interstitial", risks: "Necrosis, fistula, bleeding, infection, pain — proximity to critical structures" },
];

brachySites.forEach(({ site, type, risks }, i) => {
  const y = 1.0 + i * 1.05;
  const c = i % 2 === 0 ? C.NAVY : C.TEAL;
  s20.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 9.4, h: 0.95, fill: { color: i % 2 === 0 ? C.LGRAY : "EDF7F6" }, line: { color: c, pt: 1 } });
  s20.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 0.06, h: 0.95, fill: { color: c } });
  s20.addText(site, { x: 0.45, y: y + 0.06, w: 2.5, h: 0.3, fontSize: 11, bold: true, color: c });
  s20.addText("Type: " + type, { x: 0.45, y: y + 0.4, w: 2.5, h: 0.3, fontSize: 9, color: C.MGRAY, italic: true });
  s20.addText("Key risks to disclose: " + risks, { x: 3.1, y: y + 0.1, w: 6.5, h: 0.75, fontSize: 9.5, color: C.DGRAY });
});

s20.addText("All brachytherapy consent must address: anaesthesia risks · hospitalisation requirements · radioactivity precautions · fertility implications · prior radiation impacts on cumulative dose", {
  x: 0.3, y: 5.1, w: 9.4, h: 0.18, fontSize: 8, color: C.MGRAY
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 21 — SBRT/SRS CONSENT
// ═══════════════════════════════════════════════════════════════════
let s21 = pres.addSlide();
addSlideHeader(s21, "19. Consent for SBRT / SRS / SABR", "High-precision ablative radiation — unique consent considerations");
addFooter(s21, "SBRT/SABR planning images: spinal metastases and lung/liver cases");

const imgSBRT1 = getImg(4); // spinal SBRT
const imgSBRT2 = getImg(6); // SBRT lung/liver
if (imgSBRT1) s21.addImage({ data: imgSBRT1, x: 0.3, y: 1.0, w: 4.5, h: 3.2 });
if (imgSBRT2) s21.addImage({ data: imgSBRT2, x: 5.0, y: 1.0, w: 4.7, h: 3.2 });

s21.addText("LEFT: SBRT dose plan — spinal metastasis (T6), spinal cord sparing critical", {
  x: 0.3, y: 4.25, w: 4.5, h: 0.2, fontSize: 7.5, color: C.MGRAY, align: "center"
});
s21.addText("RIGHT: SBRT lung & liver dose distribution with isodose lines", {
  x: 5.0, y: 4.25, w: 4.7, h: 0.2, fontSize: 7.5, color: C.MGRAY, align: "center"
});

s21.addShape(pres.ShapeType.rect, { x: 0.3, y: 4.5, w: 9.4, h: 0.75, fill: { color: C.LBLUE } });
s21.addText([
  { text: "SBRT/SRS-Specific Consent Items: ", options: { bold: true, color: C.NAVY } },
  { text: "High dose per fraction (8–34 Gy) • Limited fractions (1–5) • Fiducial marker placement (invasive) • Respiratory motion management • Imaging simulation CT/4DCT • Risk of radiation necrosis (brain SRS) • Pain flare (spinal SBRT ~30%) • Re-irradiation cumulative limits", options: { color: C.DGRAY } }
], { x: 0.4, y: 4.52, w: 9.2, h: 0.7, fontSize: 9, fontFace: "Calibri", valign: "middle" });

// ═══════════════════════════════════════════════════════════════════
// SLIDE 22 — BARRIERS TO EFFECTIVE CONSENT
// ═══════════════════════════════════════════════════════════════════
let s22 = pres.addSlide();
addSlideHeader(s22, "20. Barriers to Effective Informed Consent", "Clinician, patient, and systemic barriers — and solutions");
addFooter(s22, "ACROinsights Issue 4 2022 | RANZCR 2017 | Cancer.org ACS resources");

const barriers = [
  { category: "Patient Factors", color: C.ACCENT, items: ["Health literacy: ~36% adults have below basic or basic health literacy (NAAL 2003)", "Language barriers — 8% of US population LEP", "Emotional distress at time of diagnosis impairs information processing", "Cultural beliefs about disclosure of cancer diagnosis", "Time pressure — 'rush to start treatment' anxiety"] },
  { category: "Clinician Factors", color: C.NAVY, items: ["Time constraints in clinic — consent treated as paperwork not dialogue", "Overuse of medical jargon and technical terminology", "Inadequate training in communication and shared decision-making", "Assumption of comprehension without formal teach-back", "Discomfort with discussing uncertainty and side effects"] },
  { category: "Systemic Barriers", color: C.TEAL, items: ["Consent forms written above recommended reading level (>8th grade)", "No interpreter services or inadequate access", "EMR-generated forms lack individualisation", "Institutional time pressure reduces consultation length", "Variable state/national legal requirements create inconsistency"] },
];

barriers.forEach(({ category, color, items }, i) => {
  const x = 0.3 + i * 3.2;
  s22.addShape(pres.ShapeType.rect, { x, y: 0.97, w: 3.0, h: 4.35, fill: { color: "FAFBFC" }, line: { color, pt: 1.5 } });
  s22.addShape(pres.ShapeType.rect, { x, y: 0.97, w: 3.0, h: 0.45, fill: { color } });
  s22.addText(category, { x: x + 0.1, y: 0.99, w: 2.8, h: 0.4, fontSize: 11, bold: true, color: C.WHITE, valign: "middle" });
  items.forEach((item, j) => {
    s22.addText("• " + item, { x: x + 0.12, y: 1.48 + j * 0.68, w: 2.76, h: 0.62, fontSize: 8.5, color: C.DGRAY });
  });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 23 — BEST PRACTICES & COMMUNICATION TIPS
// ═══════════════════════════════════════════════════════════════════
let s23 = pres.addSlide();
addSlideHeader(s23, "21. Best Practices in Consent Communication", "Evidence-based techniques to improve consent quality");
addFooter(s23, "ACR-ARS 2023 | RANZCR 2017 | ACROinsights 2022");

const practices = [
  { tip: "Use Plain Language", detail: "Avoid jargon; consent forms at 6th–8th grade level; explain 'radiation therapy' not 'EBRT'" },
  { tip: "Teach-Back Method", detail: "Ask patient to explain back key information in their own words — not 'do you understand?'" },
  { tip: "Allow Adequate Time", detail: "Initial consultation ≥ 45 min; dedicated consent visit separate from simulation if needed" },
  { tip: "Written + Verbal", detail: "Combine written consent form with verbal explanation; provide take-home information sheets" },
  { tip: "Involve Support Person", detail: "Encourage patient to bring family member or advocate to consent consultation" },
  { tip: "Use Visual Aids", detail: "Diagrams of treatment field, dose distribution images, anatomical models increase comprehension" },
  { tip: "Check for Numeracy", detail: "Present risks as natural frequencies (1 in 100) not percentages when literacy is uncertain" },
  { tip: "Document Thoroughly", detail: "Record the process, not just the signature — who, when, what was discussed, understanding assessed" },
];

practices.forEach(({ tip, detail }, i) => {
  const col = i % 2 === 0 ? 0.3 : 5.1;
  const row = 1.0 + Math.floor(i / 2) * 1.05;
  const c = i % 4 < 2 ? C.TEAL : C.NAVY;
  s23.addShape(pres.ShapeType.rect, { x: col, y: row, w: 4.5, h: 0.92, fill: { color: "F8FAFB" }, line: { color: c, pt: 1.2 } });
  s23.addShape(pres.ShapeType.rect, { x: col, y: row, w: 0.08, h: 0.92, fill: { color: c } });
  s23.addText("✓ " + tip, { x: col + 0.18, y: row + 0.05, w: 4.2, h: 0.3, fontSize: 10.5, bold: true, color: c });
  s23.addText(detail, { x: col + 0.18, y: row + 0.4, w: 4.2, h: 0.45, fontSize: 9, color: C.DGRAY });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 24 — MEDICOLEGAL IMPLICATIONS
// ═══════════════════════════════════════════════════════════════════
let s24 = pres.addSlide();
addSlideHeader(s24, "22. Medicolegal Implications of Consent in Oncology", "Liability, litigation, and professional obligations");
addFooter(s24, "Montgomery v Lanarkshire [2015] | ACR-ARS 2023 | RANZCR 2017");

s24.addShape(pres.ShapeType.rect, { x: 0.3, y: 0.97, w: 9.4, h: 0.65, fill: { color: "FFF8E7" }, line: { color: C.GOLD, pt: 1.5 } });
s24.addText([
  { text: "Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015): ", options: { bold: true, color: C.NAVY } },
  { text: "Clinicians must disclose material risks — those that a reasonable person in the patient's position would likely attach significance to. Standard shifted from doctor-centred to patient-centred disclosure.", options: { color: C.DGRAY } }
], { x: 0.45, y: 1.0, w: 9.1, h: 0.6, fontSize: 9.5, fontFace: "Calibri", valign: "middle" });

const legalItems = [
  { heading: "Duty to Disclose", content: "Material risks must be disclosed proactively — not only when patient asks. Applies to common, minor risks AND rare, severe risks." },
  { heading: "Battery vs. Negligence", content: "Consent to wrong procedure = battery. Failure to disclose risk = negligence (if undisclosed risk eventuates and causes harm)." },
  { heading: "Causation Standard", content: "Patient must prove: (1) failure to disclose a material risk AND (2) they would have refused or chosen differently had they been informed." },
  { heading: "Documentation Defence", content: "Thorough documentation of the consent process is the primary defence against medicolegal claims. 'If it's not written, it didn't happen.'" },
  { heading: "Institutional Policies", content: "Hospitals must have consent policies; institutional requirements may exceed state/national minimum legal standards." },
  { heading: "Time Pressure Defence", content: "Courts do not accept time constraints as justification for inadequate consent. The process must be completed properly regardless." },
];

legalItems.forEach(({ heading, content }, i) => {
  const col = i % 2 === 0 ? 0.3 : 5.1;
  const row = 1.72 + Math.floor(i / 2) * 1.0;
  s24.addShape(pres.ShapeType.rect, { x: col, y: row, w: 4.5, h: 0.88, fill: { color: i % 2 === 0 ? C.LGRAY : "EDF7F6" } });
  s24.addShape(pres.ShapeType.rect, { x: col, y: row, w: 0.06, h: 0.88, fill: { color: C.ACCENT } });
  s24.addText(heading, { x: col + 0.14, y: row + 0.05, w: 4.2, h: 0.28, fontSize: 10, bold: true, color: C.ACCENT });
  s24.addText(content, { x: col + 0.14, y: row + 0.37, w: 4.2, h: 0.44, fontSize: 8.5, color: C.DGRAY });
});

// ═══════════════════════════════════════════════════════════════════
// SLIDE 25 — SUMMARY & KEY TAKEAWAYS
// ═══════════════════════════════════════════════════════════════════
let s25 = pres.addSlide();
s25.background = { color: C.WHITE };
s25.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.85, fill: { color: C.NAVY } });
s25.addText("Key Takeaways — Informed Consent in Medical & Radiation Oncology", {
  x: 0.3, y: 0.1, w: 9.4, h: 0.65,
  fontSize: 18, bold: true, color: C.WHITE, fontFace: "Calibri", valign: "middle"
});

const takeaways = [
  { num: "1", text: "Informed consent is a PROCESS, not a signature — it is an ongoing communication throughout the treatment journey" },
  { num: "2", text: "ACR-ARS 2023 Practice Parameter (PMID 36882916) is the authoritative US standard for radiation oncology consent" },
  { num: "3", text: "Six core elements: Diagnosis · Treatment · Risks · Benefits · Alternatives · Right to Refuse — all must be addressed" },
  { num: "4", text: "Radiation oncology requires consent for simulation, EBRT, SBRT, brachytherapy, IORT, TBI, and re-irradiation" },
  { num: "5", text: "Shared decision-making integrates clinical evidence with patient values — use the 3-talk model (Team, Option, Decision)" },
  { num: "6", text: "Patient capacity must be formally assessed; surrogate hierarchy applies when capacity is absent" },
  { num: "7", text: "Special populations (paediatric, pregnant, LEP, cognitively impaired) require tailored consent processes" },
  { num: "8", text: "Telehealth consent is acceptable in specific circumstances but in-person remains the preferred standard" },
  { num: "9", text: "Documentation must include two identifiers, authorising physician, first-person statement, and signed form" },
  { num: "10", text: "AI tools in oncology decision-making create new disclosure obligations — physician accountability remains unchanged" },
];

takeaways.forEach(({ num, text }, i) => {
  const col = i < 5 ? 0.3 : 5.1;
  const row = 0.98 + (i % 5) * 0.82;
  const c = i < 5 ? C.TEAL : C.NAVY;
  s25.addShape(pres.ShapeType.rect, { x: col, y: row, w: 4.5, h: 0.72, fill: { color: "F8FAFB" }, line: { color: c, pt: 1 } });
  s25.addShape(pres.ShapeType.rect, { x: col, y: row, w: 0.45, h: 0.72, fill: { color: c } });
  s25.addText(num, { x: col, y: row, w: 0.45, h: 0.72, fontSize: 14, bold: true, color: C.WHITE, align: "center", valign: "middle" });
  s25.addText(text, { x: col + 0.55, y: row + 0.08, w: 3.85, h: 0.58, fontSize: 8.5, color: C.DGRAY, valign: "middle" });
});

// Footer references
s25.addShape(pres.ShapeType.rect, { x: 0, y: 5.3, w: "100%", h: 0.32, fill: { color: C.LGRAY } });
s25.addText("References: ACR-ARS PMID 36882916 | Froicu PMID 40526332 | van Lent PMID 33965892 | Barlevy PMID 28949840 | RANZCR Guidelines 2017 | ACROinsights 2022 | Roberts & Hedges (ICRP Pub 84) | Berek & Novak Gynecology", {
  x: 0.2, y: 5.32, w: 9.6, h: 0.28,
  fontSize: 6.5, color: C.MGRAY, fontFace: "Calibri", valign: "middle"
});

// ─── Write file ──────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/informed-consent-pptx/Informed_Consent_Oncology.pptx" })
  .then(() => console.log("✅ Presentation written successfully!"))
  .catch(err => { console.error("Error writing file:", err); process.exit(1); });

const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// ─── Fetch all images ────────────────────────────────────────────────────────
const imageUrls = [
  // 0  - consent flowchart (5-stage process)
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_0ae328d856921139cd5f46478283bf9c20ab5cdd8592f1453d89e22b25707a46.jpg",
  // 1  - Elekta LINAC patient on couch (chest RT)
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_aefeb3dc6688dd398c80b0f90e8b9c6036046e12a28d2f853c35e6026a7dd3da.jpg",
  // 2  - IGRT suite Varian iX + BrainLAB
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_e060a59fa38c2eec97b79acf0edb1976d6d159ecf019789ff29a5f9a5a429f09.jpg",
  // 3  - Shared decision-making diagram
  "https://cdn.orris.care/cdss_images/GLGCA_1020481_1766750786940_c87dbfd0-0cec-4af1-a169-5c1cc47d020f_6cbe80c8-23de-411b-96a5-d36f8637d8c4.png",
  // 4  - SBRT spine plan (T6)
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_ab90daa301021dd64927e79928aedeaef16150e1ec8e99d5be53fe2da7315ca1.jpg",
  // 5  - SBRT lung+liver isodose
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_33239c910c0aa489e07003b48bd2f6ab8b97b33e38d642e6d5c1f95fb942a711.jpg",
  // 6  - Prostate brachy CT seeds
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_1832c264a988182a609a70313e3733a416c69a9f456cad1ee83fe6a751976856.jpg",
  // 7  - Oncology patient consultation (brain MRI on screen)
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_865a712674ffa1c8f14ec7a305e4c64ad12ed6211ff2f6eb91580d1c8e2c6330.jpg",
  // 8  - Chemo IV bag warning label
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_7b645cbaf807ddf3910e533c21f5765709cba9b32475c2a15a0c54093ff32b63.jpg",
  // 9  - Pediatric oncology patient in hospital bed
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_6a1fb898870d8508e4f77ab6e667b60a7f92eec1811171adf1540e368aee2239.jpg",
  // 10 - Patient setup RT vacuum cushion + lasers
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_ff173dea13b44b5140de206287e334fbc0268ddbd57399ce2d7290b1566e7a80.jpg",
  // 11 - IMRT SBRT H&N dose plan
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_1c3e29745346770105bd4fe0bcc73335469f7d77a28ab30c70377dde9517a38f.jpg",
  // 12 - Oncology patient + clinician (resource-limited)
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_25f468eeae33e273ff5a22a330e4ac9873b711eb2db2cb2ba1cae355dd0f227a.jpg",
  // 13 - RT + CT dual modality suite
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_5fdaa685e7523292edfeaae460bc23e8063e8f268e9fa0f251b58789086b9c61.jpg",
  // 14 - Fetal radiation dose bar chart
  "https://cdn.orris.care/cdss_images/9f124eca0603bf87cc796aa058df561ed4ccb0fa0e47a70babae8cd5ac675705.png",
  // 15 - Pediatric RT gamified prep app
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_463b3471fd122a1c2329852a4b7e60f3e5e7f96ce51d9b0310269d2304fa5a19.jpg",
];

console.log("Fetching images...");
let images = [];
try {
  const result = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${imageUrls.map(u => `"${u}"`).join(" ")}`,
    { maxBuffer: 80 * 1024 * 1024 }
  ).toString();
  images = JSON.parse(result);
  const ok = images.filter(i => !i.error).length;
  console.log(`Fetched ${ok}/${images.length} images`);
} catch (e) {
  console.error("Image fetch error:", e.message);
  images = imageUrls.map(url => ({ url, base64: null, error: "failed" }));
}

function img(index) {
  const i = images[index];
  return i && !i.error ? i.base64 : null;
}

// ─── Presentation ────────────────────────────────────────────────────────────
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Informed Consent in Medical & Radiation Oncology";
pres.author = "Clinical Oncology";

// Palette
const NAVY   = "1A3A5C";
const TEAL   = "0D7377";
const RED    = "C8102E";
const WHITE  = "FFFFFF";
const LGRAY  = "F2F4F7";
const DGRAY  = "2D3748";
const MGRAY  = "8C9BAB";
const GOLD   = "D4A017";
const LBLUE  = "EAF3FB";

// ─── Helper: slim white-background slide header ──────────────────────────────
function hdr(slide, title, sub) {
  slide.background = { color: WHITE };
  // thick left accent bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.12, h: "100%", fill: { color: TEAL } });
  // header band
  slide.addShape(pres.ShapeType.rect, { x: 0.12, y: 0, w: "100%", h: 0.78, fill: { color: NAVY } });
  slide.addText(title, {
    x: 0.28, y: 0.06, w: 9.4, h: 0.5,
    fontSize: 20, bold: true, color: WHITE, fontFace: "Calibri", valign: "middle", margin: 0
  });
  if (sub) slide.addText(sub, {
    x: 0.28, y: 0.56, w: 9.4, h: 0.22,
    fontSize: 9, color: MGRAY, fontFace: "Calibri", valign: "top", margin: 0
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}

function footer(slide, ref) {
  slide.addShape(pres.ShapeType.rect, { x: 0.12, y: 5.32, w: 9.88, h: 0.28, fill: { color: LGRAY } });
  slide.addText(ref || "ACR-ARS Practice Parameter on Informed Consent Radiation Oncology, 2023 · PMID 36882916  |  RANZCR Guidelines 2017", {
    x: 0.2, y: 5.34, w: 9.7, h: 0.24,
    fontSize: 6.5, color: MGRAY, fontFace: "Calibri", valign: "middle"
  });
}

// ─── Slide builder helpers ───────────────────────────────────────────────────
function pill(slide, x, y, w, h, color) {
  slide.addShape(pres.ShapeType.rect, { x, y, w, h, fill: { color }, line: { color, pt: 0 } });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE (full-bleed image right, dark left panel)
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: NAVY };
  // Teal vertical accent
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.2, h: "100%", fill: { color: TEAL } });
  // Red bottom stripe
  s.addShape(pres.ShapeType.rect, { x: 0, y: 5.2, w: "100%", h: 0.05, fill: { color: RED } });

  // Right image — clinician reviewing MRI with patient
  const i7 = img(7);
  if (i7) s.addImage({ data: i7, x: 5.4, y: 0, w: 4.6, h: 5.625 });
  // dark overlay on image for readability
  s.addShape(pres.ShapeType.rect, { x: 5.4, y: 0, w: 4.6, h: 5.625, fill: { color: NAVY, transparency: 30 } });

  s.addText("INFORMED CONSENT", {
    x: 0.35, y: 0.55, w: 5.0, h: 0.72,
    fontSize: 30, bold: true, color: GOLD, fontFace: "Calibri", charSpacing: 3
  });
  s.addText("Medical & Radiation Oncology", {
    x: 0.35, y: 1.32, w: 5.0, h: 0.45,
    fontSize: 18, color: WHITE, fontFace: "Calibri"
  });
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 1.84, w: 3.8, h: 0.05, fill: { color: TEAL } });
  s.addText("Clinical Evidence-Based Practice\nACR·ARS · ASTRO · RANZCR", {
    x: 0.35, y: 1.96, w: 5.0, h: 0.55,
    fontSize: 11, color: MGRAY, fontFace: "Calibri"
  });
  // Key citation box
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 2.8, w: 4.8, h: 1.05, fill: { color: TEAL }, line: { color: TEAL } });
  s.addText([
    { text: "Key Guideline\n", options: { bold: true, fontSize: 10 } },
    { text: "ACR-ARS Practice Parameter on Informed\nConsent Radiation Oncology (2023)\nHurwitz MD et al. · PMID: 36882916", options: { fontSize: 9 } }
  ], { x: 0.5, y: 2.85, w: 4.55, h: 0.95, color: WHITE, fontFace: "Calibri", valign: "top" });
  s.addText("May 2026", { x: 0.35, y: 5.1, w: 2, h: 0.3, fontSize: 9, color: MGRAY });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 2 — WHAT IS INFORMED CONSENT? (definition + historical pillars)
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "What Is Informed Consent?", "A communication process — not merely a signature");
  footer(s, "Berek & Novak's Gynecology — Pellegrino's definition of autonomy · RANZCR Faculty of Radiation Oncology Guidelines 2017");

  // Large image left
  const i12 = img(12);
  if (i12) s.addImage({ data: i12, x: 0.2, y: 0.88, w: 4.2, h: 4.3 });

  // Right: definition box + 4 milestones
  s.addShape(pres.ShapeType.rect, { x: 4.6, y: 0.88, w: 5.2, h: 0.9, fill: { color: LBLUE }, line: { color: TEAL, pt: 1 } });
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    { text: '"', options: { fontSize: 18, bold: true, color: TEAL } },
    { text: "A communication process enabling autonomous, voluntary, and competent decision-making — protecting the patient in an asymmetric clinician-patient relationship.", options: { fontSize: 9.5, color: NAVY, italic: true } }
  ], { x: 4.72, y: 0.9, w: 4.96, h: 0.84, fontFace: "Calibri", valign: "middle" });

  const milestones = [
    ["1914", "Schloendorff v. NY Hospital — patient autonomy established in US law"],
    ["1957", "Salgo v. Leland Stanford — term 'informed consent' first used"],
    ["1972", "Canterbury v. Spence — 'material risk' / reasonable patient standard"],
    ["2015", "Montgomery v. Lanarkshire — clinician must disclose risks material to the patient"],
  ];
  milestones.forEach(([year, text], i) => {
    const y = 1.88 + i * 0.76;
    pill(s, 4.6, y, 0.9, 0.55, i % 2 === 0 ? NAVY : TEAL);
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    s.addText(text, { x: 5.65, y: y + 0.08, w: 4.1, h: 0.4, fontSize: 9, color: DGRAY, valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 3 — ETHICAL PRINCIPLES (4 pillars visual)
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Ethical Foundations", "Four principles of biomedical ethics — Beauchamp & Childress");
  footer(s);

  const cards = [
    { t: "Autonomy",        c: NAVY,  sub: "Patient decides. Right to accept or refuse any treatment, even life-saving intervention.", icon: "⚖" },
    { t: "Beneficence",     c: TEAL,  sub: "Act in the patient's best interest. Accurate disclosure of benefits is mandatory.", icon: "❤" },
    { t: "Non-Maleficence", c: RED,   sub: '"Do no harm." Failure to disclose risks constitutes harm. Undisclosed risks = unethical.', icon: "🛡" },
    { t: "Justice",         c: "4A6741", sub: "Equal, fair access to information — plain language (6th–8th grade), medical interpreters, cultural sensitivity.", icon: "⚖" },
  ];

  cards.forEach(({ t, c, sub }, i) => {
    const x = 0.22 + i * 2.42;
    // tall card
    s.addShape(pres.ShapeType.rect, { x, y: 0.85, w: 2.22, h: 4.35, fill: { color: "F8FAFB" }, line: { color: c, pt: 2 } });
    s.addShape(pres.ShapeType.rect, { x, y: 0.85, w: 2.22, h: 1.6, fill: { color: c } });
    // number
    s.addText(String(i + 1), { x, y: 0.85, w: 2.22, h: 0.85, fontSize: 36, bold: true, color: WHITE, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(t, { x: x + 0.1, y: 1.7, w: 2.02, h: 0.6, fontSize: 12, bold: true, color: WHITE, align: "center", valign: "middle" });
    s.addShape(pres.ShapeType.rect, { x: x + 0.4, y: 2.5, w: 1.4, h: 0.04, fill: { color: c } });
    s.addText(sub, { x: x + 0.14, y: 2.62, w: 1.94, h: 2.4, fontSize: 9.5, color: DGRAY, fontFace: "Calibri", valign: "top" });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 4 — 6 CORE ELEMENTS (icon grid, minimal text)
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "6 Core Elements of Valid Informed Consent", "ACR-ARS 2023 · RANZCR 2017 · Pfenninger & Fowler");
  footer(s);

  const els = [
    { n: "01", t: "Diagnosis", d: "Nature, stage, and prognosis with and without treatment", c: NAVY },
    { n: "02", t: "Proposed Treatment", d: "Technique, fractions, simulation, immobilisation", c: TEAL },
    { n: "03", t: "Risks & Toxicities", d: "Acute and late; probability and severity by site", c: RED },
    { n: "04", t: "Expected Benefits", d: "Curative vs palliative intent; tumour control probability", c: "4A6741" },
    { n: "05", t: "Alternatives", d: "Surgery, systemic therapy, observation, clinical trial", c: "7B5EA7" },
    { n: "06", t: "Right to Refuse", d: "May withdraw at any time; no penalty; consequences explained", c: GOLD },
  ];

  els.forEach(({ n, t, d, c }, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.2 + col * 3.27;
    const y = 0.9 + row * 2.15;
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    s.addText(n, { x, y, w: 0.7, h: 0.55, fontSize: 14, bold: true, color: WHITE, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(t, { x: x + 0.75, y: y + 0.08, w: 2.25, h: 0.42, fontSize: 11.5, bold: true, color: WHITE, valign: "middle" });
    s.addText(d, { x: x + 0.15, y: y + 0.65, w: 2.8, h: 1.2, fontSize: 9.5, color: DGRAY, fontFace: "Calibri", valign: "top" });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 5 — MEDICAL ONCOLOGY CONSENT (big chemo image + bullets)
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Consent in Medical Oncology", "Chemotherapy · Targeted Therapy · Immunotherapy");
  footer(s, "Goldman-Cecil Medicine | Froicu et al. Curr Oncol Rep 2025, PMID 40526332");

  // Full-height image left
  const i8 = img(8);
  if (i8) s.addImage({ data: i8, x: 0.2, y: 0.88, w: 3.8, h: 4.3 });
  s.addText("Chemotherapy bag with cytotoxic handling warning", {
    x: 0.2, y: 5.2, w: 3.8, h: 0.2, fontSize: 7, color: MGRAY, align: "center"
  });

  // Right panel
  const rows = [
    { hd: "Chemotherapy", items: ["Drug name, mechanism, administration route", "Acute: myelosuppression, nausea, alopecia, mucositis", "Long-term: cardiotoxicity, neuropathy, secondary cancer"], c: NAVY },
    { hd: "Targeted / Immunotherapy", items: ["Biomarker testing (PD-L1, HER2, EGFR, MSI)", "Immune-related adverse events (irAEs)", "Duration of therapy and monitoring schedule"], c: TEAL },
    { hd: "All Agents", items: ["Fertility impact & preservation options", "Pregnancy avoidance; teratogenicity", "AI-assisted decisions must be disclosed (PMID 40526332)"], c: RED },
  ];
  rows.forEach(({ hd, items, c }, i) => {
    const y = 0.9 + i * 1.45;
    s.addShape(pres.ShapeType.rect, { x: 4.2, y, w: 5.6, h: 0.38, fill: { color: c } });
    s.addText(hd, { x: 4.3, y: y + 0.04, w: 5.4, h: 0.32, fontSize: 11, bold: true, color: WHITE, valign: "middle" });
    items.forEach((item, j) => {
      s.addShape(pres.ShapeType.rect, { x: 4.2, y: y + 0.38 + j * 0.34, w: 5.6, h: 0.32, fill: { color: j % 2 === 0 ? WHITE : LGRAY } });
      s.addText("▸  " + item, { x: 4.3, y: y + 0.4 + j * 0.34, w: 5.4, h: 0.28, fontSize: 9, color: DGRAY, valign: "middle" });
    });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 6 — ACR-ARS 2023 GUIDELINE (large citation + key points)
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "ACR-ARS Practice Parameter 2023", "The authoritative US standard for radiation oncology informed consent");
  footer(s, "Hurwitz MD, Chundury A, Goodman CR et al. Am J Clin Oncol. 2023;46(6). DOI:10.1097/COC.0000000000000994");

  // Citation banner
  s.addShape(pres.ShapeType.rect, { x: 0.2, y: 0.88, w: 9.6, h: 0.72, fill: { color: LBLUE }, line: { color: TEAL, pt: 1.2 } });
  s.addText([
    { text: "ACR-ARS Practice Parameter on Informed Consent Radiation Oncology  ", options: { bold: true, fontSize: 10 } },
    { text: "| Hurwitz MD et al. |  ", options: { italic: true, fontSize: 9.5 } },
    { text: "Am J Clin Oncol 2023  |  PMID 36882916  |  PMC10425961", options: { color: TEAL, fontSize: 9.5 } }
  ], { x: 0.35, y: 0.92, w: 9.3, h: 0.65, color: NAVY, fontFace: "Calibri", valign: "middle" });

  // 6 key points as large cards
  const pts = [
    { n: "01", t: "Protect Autonomy", d: "Consent counters the inherent power asymmetry between patient and healthcare system" },
    { n: "02", t: "Reduce Abuse Risk", d: "Formal consent process reduces conflicts of interest and abusive conduct opportunities" },
    { n: "03", t: "Build Trust", d: "Proper consent raises trust levels between patients, families, and the oncology team" },
    { n: "04", t: "COVID-Era Updates", d: "2022 revision addresses telehealth, remote, and telephone consent modalities" },
    { n: "05", t: "Surrogate Consent", d: "Guidance for health-care proxy and surrogate decision-making when patient lacks capacity" },
    { n: "06", t: "Re-irradiation", d: "Prior radiation history must be fully documented before any new course of RT begins" },
  ];
  pts.forEach(({ n, t, d }, i) => {
    const col = i % 3; const row = Math.floor(i / 3);
    const x = 0.2 + col * 3.22; const y = 1.72 + row * 1.68;
    const c = [NAVY, TEAL, "4A6741"][col];
    s.addShape(pres.ShapeType.rect, { x, y, w: 3.04, h: 1.55, fill: { color: "F8FAFB" }, line: { color: c, pt: 1.5 } });
    pill(s, x, y, 0.55, 1.55, c);
    s.addText(n, { x, y, w: 0.55, h: 1.55, fontSize: 13, bold: true, color: WHITE, align: "center", valign: "middle" });
    s.addText(t, { x: x + 0.65, y: y + 0.12, w: 2.3, h: 0.38, fontSize: 11, bold: true, color: c });
    s.addText(d, { x: x + 0.65, y: y + 0.55, w: 2.3, h: 0.85, fontSize: 9, color: DGRAY });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 7 — PROCEDURES REQUIRING CONSENT (RT)
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Radiation Oncology: Procedures Requiring Formal Consent", "Per ACR-ARS 2022 revised parameter — mandatory list");
  footer(s, "ACR-ARS Practice Parameter | ACROinsights Issue 4, 2022");

  // Image: RT+CT dual suite (full left column)
  const i13 = img(13);
  if (i13) s.addImage({ data: i13, x: 0.2, y: 0.88, w: 3.7, h: 4.25 });

  const procs = [
    ["Imaging for Simulation",    "CT sim ± contrast, field placement, tattoo placement"],
    ["External Beam RT (EBRT)",   "3D-CRT, IMRT, VMAT — all dose levels and fractionation"],
    ["SBRT / SABR / SRS",         "Stereotactic body/ablative RT; radiosurgery"],
    ["Brachytherapy",             "LDR/HDR intracavitary, interstitial, surface applicators"],
    ["Radioactive Implants",      "Permanent seeds (I-125, Pd-103); I-131 systemic therapy"],
    ["Intraoperative RT (IORT)",  "Single-fraction intraoperative — separate from surgical consent"],
    ["TBI / TSEBT",               "Total body irradiation; total skin electron beam therapy"],
    ["Re-irradiation",            "Cumulative dose impacts; prior RT history mandatory disclosure"],
  ];

  procs.forEach(([proc, detail], i) => {
    const y = 0.9 + i * 0.53;
    const c = i % 2 === 0 ? NAVY : TEAL;
    s.addShape(pres.ShapeType.rect, { x: 4.1, y, w: 5.7, h: 0.48, fill: { color: i % 2 === 0 ? WHITE : LGRAY } });
    pill(s, 4.1, y, 0.08, 0.48, c);
    s.addShape(pres.ShapeType.rect, { x: 4.18, y, w: 1.9, h: 0.48, fill: { color: i % 2 === 0 ? LGRAY : WHITE } });
    s.addText(proc, { x: 4.22, y: y + 0.06, w: 1.82, h: 0.36, fontSize: 9, bold: true, color: c, valign: "middle" });
    s.addText(detail, { x: 6.14, y: y + 0.06, w: 3.6, h: 0.36, fontSize: 8.5, color: DGRAY, valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 8 — RT PATIENT SETUP (big image + setup consent items)
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Consent for Simulation & Treatment Setup", "What patients must understand before lying on the treatment couch");
  footer(s, "ACR-ARS 2023 | Clinical image: Elekta Versa HD LINAC — patient positioning for thoracic RT");

  // Two large images side by side
  const iLinac = img(1);
  const iSetup = img(10);
  if (iLinac) s.addImage({ data: iLinac, x: 0.2, y: 0.88, w: 4.7, h: 3.5 });
  if (iSetup) s.addImage({ data: iSetup, x: 5.1, y: 0.88, w: 4.7, h: 3.5 });
  s.addText("Elekta Versa HD LINAC — arms-up position for thoracic field", { x: 0.2, y: 4.4, w: 4.7, h: 0.22, fontSize: 7.5, color: MGRAY, align: "center" });
  s.addText("Vacuum cushion + laser alignment marks — reproducible daily setup", { x: 5.1, y: 4.4, w: 4.7, h: 0.22, fontSize: 7.5, color: MGRAY, align: "center" });

  s.addShape(pres.ShapeType.rect, { x: 0.2, y: 4.65, w: 9.6, h: 0.58, fill: { color: LBLUE }, line: { color: TEAL, pt: 1 } });
  s.addText([
    { text: "Consent must cover: ", options: { bold: true, color: NAVY } },
    { text: "CT simulation · contrast agents · skin tattoo/marks · daily image guidance (CBCT/kV) · immobilisation device · session duration (15–30 min) · GTV/CTV/PTV terminology explained in plain language", options: { color: DGRAY } }
  ], { x: 0.35, y: 4.68, w: 9.3, h: 0.55, fontSize: 9.5, fontFace: "Calibri", valign: "middle" });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 9 — IGRT / ADVANCED TECHNOLOGY
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Advanced RT Technology & Consent", "IGRT · IMRT · VMAT · Adaptive RT — patient must understand what is used");
  footer(s, "ACR-ARS 2023 | Clinical images: Varian iX IGRT suite; IMRT/SBRT dose plan head & neck");

  const iIGRT = img(2);
  const iHN = img(11);
  if (iIGRT) s.addImage({ data: iIGRT, x: 0.2, y: 0.88, w: 4.7, h: 3.6 });
  if (iHN) s.addImage({ data: iHN, x: 5.1, y: 0.88, w: 4.7, h: 3.6 });
  s.addText("Varian iX IGRT suite — stereoscopic X-ray + 6D robotic couch", { x: 0.2, y: 4.5, w: 4.7, h: 0.22, fontSize: 7.5, color: MGRAY, align: "center" });
  s.addText("IMRT+SBRT dose plan — parotid SCC: 80 Gy conformal with brainstem sparing", { x: 5.1, y: 4.5, w: 4.7, h: 0.22, fontSize: 7.5, color: MGRAY, align: "center" });

  s.addShape(pres.ShapeType.rect, { x: 0.2, y: 4.75, w: 9.6, h: 0.48, fill: { color: NAVY } });
  s.addText("Patients must be informed of: technology used for treatment (IMRT/VMAT/SBRT) · daily imaging modality · couch movement · tattoos as permanent skin marks · duration of each fraction", {
    x: 0.35, y: 4.78, w: 9.3, h: 0.42, fontSize: 9, color: WHITE, fontFace: "Calibri", valign: "middle"
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 10 — SBRT/SRS CONSENT
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Consent for SBRT / SABR / SRS", "High-dose-per-fraction ablative radiation — unique disclosures required");
  footer(s, "Clinical dose plans: spinal SBRT (T6 metastasis) · SBRT lung & liver isodose distributions");

  const iSBRT1 = img(4);
  const iSBRT2 = img(5);
  if (iSBRT1) s.addImage({ data: iSBRT1, x: 0.2, y: 0.88, w: 5.6, h: 3.3 });
  if (iSBRT2) s.addImage({ data: iSBRT2, x: 6.0, y: 0.88, w: 3.8, h: 3.3 });
  s.addText("SBRT plan — T6 vertebral metastasis. Spinal cord sparing is a critical safety constraint.", { x: 0.2, y: 4.2, w: 5.6, h: 0.22, fontSize: 7.5, color: MGRAY, align: "center" });
  s.addText("SBRT lung (a) & liver (b) — tight isodose lines = steep dose gradient", { x: 6.0, y: 4.2, w: 3.8, h: 0.22, fontSize: 7.5, color: MGRAY, align: "center" });

  const pts = [
    "High dose/fraction: 8–34 Gy × 1–5 fractions",
    "Fiducial marker placement (invasive procedure)",
    "Respiratory gating / motion management",
    "Pain flare risk: ~30% spinal SBRT",
    "Radiation necrosis risk (brain SRS)",
    "Re-irradiation cumulative limits",
  ];
  pts.forEach((p, i) => {
    const col = i < 3 ? 0.2 : 5.0;
    const row = i % 3;
    const c = i < 3 ? TEAL : NAVY;
    s.addShape(pres.ShapeType.rect, { x: col, y: 4.48 + row * 0.36, w: 4.6, h: 0.32, fill: { color: i % 2 === 0 ? WHITE : LGRAY } });
    pill(s, col, 4.48 + row * 0.36, 0.06, 0.32, c);
    s.addText("▸ " + p, { x: col + 0.14, y: 4.5 + row * 0.36, w: 4.4, h: 0.28, fontSize: 8.5, color: DGRAY, valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 11 — BRACHYTHERAPY CONSENT
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Informed Consent for Brachytherapy", "LDR prostate seed implant — site-specific risks must be disclosed");
  footer(s, "ACR-ARS 2023 | Campbell Walsh Wein Urology | Clinical image: post-implant prostate brachytherapy CT dosimetry");

  const iBrachy = img(6);
  if (iBrachy) s.addImage({ data: iBrachy, x: 0.2, y: 0.88, w: 4.6, h: 4.0 });
  s.addText("Post-implant CT dosimetry — prostate LDR brachytherapy. Red contour = prostate; green = 95 Gy isodose. White dots = I-125 seeds.", {
    x: 0.2, y: 4.9, w: 4.6, h: 0.28, fontSize: 7.5, color: MGRAY, align: "center"
  });

  const sites = [
    { site: "Prostate (LDR seeds)", risks: "Urinary retention · dysuria · proctitis · seed migration · ED · permanent implant" },
    { site: "Gynaecologic (HDR)", risks: "Vaginal stenosis · vesico/rectovaginal fistula · bowel/bladder injury" },
    { site: "Breast (HDR APBI)", risks: "Infection · fat necrosis · skin reaction at catheter sites · cosmesis" },
    { site: "Head & Neck (HDR)", risks: "Necrosis · fistula · bleeding · infection · proximity to critical structures" },
  ];
  sites.forEach(({ site, risks }, i) => {
    const y = 0.9 + i * 1.0;
    const c = i % 2 === 0 ? NAVY : TEAL;
    s.addShape(pres.ShapeType.rect, { x: 5.0, y, w: 4.8, h: 0.88, fill: { color: i % 2 === 0 ? LGRAY : "EDF7F6" }, line: { color: c, pt: 1 } });
    pill(s, 5.0, y, 0.08, 0.88, c);
    s.addText(site, { x: 5.14, y: y + 0.06, w: 4.5, h: 0.3, fontSize: 10, bold: true, color: c });
    s.addText(risks, { x: 5.14, y: y + 0.42, w: 4.5, h: 0.38, fontSize: 8.5, color: DGRAY });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 12 — PATIENT CAPACITY & SURROGATE
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Patient Capacity & Surrogate Decision-Making", "MacArthur 4 Criteria · Surrogate hierarchy when capacity is absent");
  footer(s, "ACR-ARS 2023 | Pfenninger & Fowler's Procedures for Primary Care");

  // 4 capacity cards horizontal
  const criteria = [
    { n: "1", t: "Understanding",  c: NAVY,      d: "Comprehends the information about diagnosis and proposed treatment" },
    { n: "2", t: "Appreciation",   c: TEAL,      d: "Recognises how the information applies to their own situation" },
    { n: "3", t: "Reasoning",      c: RED,       d: "Can weigh options and provide rational reasons for their choice" },
    { n: "4", t: "Expression",     c: "4A6741",  d: "Can communicate a clear, consistent, stable choice" },
  ];
  criteria.forEach(({ n, t, c, d }, i) => {
    const x = 0.2 + i * 2.45;
    s.addShape(pres.ShapeType.rect, { x, y: 0.88, w: 2.3, h: 2.65, fill: { color: "FAFBFC" }, line: { color: c, pt: 1.8 } });
    pill(s, x, 0.88, 2.3, 0.72, c);
    s.addText(n, { x, y: 0.88, w: 2.3, h: 0.72, fontSize: 24, bold: true, color: WHITE, align: "center", valign: "middle" });
    s.addText(t, { x: x + 0.12, y: 1.65, w: 2.06, h: 0.38, fontSize: 11.5, bold: true, color: c });
    s.addShape(pres.ShapeType.rect, { x: x + 0.4, y: 2.08, w: 1.5, h: 0.04, fill: { color: c } });
    s.addText(d, { x: x + 0.12, y: 2.18, w: 2.06, h: 1.2, fontSize: 9, color: DGRAY });
  });

  // Surrogate hierarchy — horizontal chain
  s.addText("Surrogate Hierarchy (when patient lacks capacity)", {
    x: 0.2, y: 3.65, w: 9.6, h: 0.32, fontSize: 12, bold: true, color: NAVY
  });
  const surr = ["Legal Guardian", "Healthcare Proxy / POA", "Spouse / Partner", "Adult Children", "Parents", "Siblings"];
  surr.forEach((label, i) => {
    const x = 0.2 + i * 1.62;
    const c = i % 2 === 0 ? NAVY : TEAL;
    s.addShape(pres.ShapeType.rect, { x, y: 4.05, w: 1.48, h: 0.6, fill: { color: c } });
    s.addText(label, { x, y: 4.05, w: 1.48, h: 0.6, fontSize: 8.5, bold: true, color: WHITE, align: "center", valign: "middle" });
    if (i < surr.length - 1) {
      s.addText("→", { x: x + 1.48, y: 4.18, w: 0.14, h: 0.32, fontSize: 12, color: MGRAY, align: "center" });
    }
  });
  s.addText("Patient's previously expressed wishes and 'best interest' standard guide ALL surrogate decisions. Document every proxy consent interaction.", {
    x: 0.2, y: 4.74, w: 9.6, h: 0.3, fontSize: 9, color: RED, italic: true
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 13 — SHARED DECISION-MAKING
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Shared Decision-Making", "3-Talk Model — Team Talk · Option Talk · Decision Talk");
  footer(s, "van Lent et al. Cancer Treat Rev 2021, PMID 33965892 | RANZCR 2017 | Clinical diagram: Coronary Artery Revascularization Guidelines");

  const iSDM = img(3);
  if (iSDM) s.addImage({ data: iSDM, x: 0.2, y: 0.88, w: 4.2, h: 3.6 });
  s.addText("Informed consent + patient-centred care → shared decision", { x: 0.2, y: 4.5, w: 4.2, h: 0.22, fontSize: 7.5, color: MGRAY, align: "center" });

  const talks = [
    { talk: "Team Talk",     c: NAVY, desc: "Introduce that a choice exists. Offer support. Patient's preferences matter. Do not rush." },
    { talk: "Option Talk",  c: TEAL, desc: "Detailed description of all options including no treatment, RT, surgery, combined modality — with probabilities." },
    { talk: "Decision Talk", c: "4A6741", desc: "Elicit patient values. Integrate evidence + preference. Reach a documented collaborative decision." },
  ];
  talks.forEach(({ talk, c, desc }, i) => {
    const y = 0.92 + i * 1.35;
    s.addShape(pres.ShapeType.rect, { x: 4.55, y, w: 5.25, h: 1.22, fill: { color: "FAFBFC" }, line: { color: c, pt: 1.8 } });
    pill(s, 4.55, y, 1.65, 1.22, c);
    s.addText(talk, { x: 4.55, y, w: 1.65, h: 1.22, fontSize: 11, bold: true, color: WHITE, align: "center", valign: "middle" });
    s.addText(desc, { x: 6.3, y: y + 0.18, w: 3.4, h: 0.88, fontSize: 9.5, color: DGRAY, fontFace: "Calibri" });
  });

  s.addShape(pres.ShapeType.rect, { x: 4.55, y: 4.15, w: 5.25, h: 0.45, fill: { color: LBLUE } });
  s.addText([
    { text: "Evidence: ", options: { bold: true } },
    { text: "van Lent et al. found patient values critical to trial participation — SDM is mandatory, not optional. PMID 33965892", options: {} }
  ], { x: 4.65, y: 4.17, w: 5.1, h: 0.4, fontSize: 8.5, color: NAVY, fontFace: "Calibri", valign: "middle" });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 14 — SIDE EFFECTS & TOXICITY TABLE
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Side Effects & Toxicity — Disclosure by Site", "Acute (during/after RT) vs Late (months–years) — must be disclosed");
  footer(s, "Cummings Otolaryngology | ACR-ARS 2023 | CTCAE v5.0");

  // Header row
  pill(s, 0.2, 0.88, 9.6, 0.42, NAVY);
  s.addText("Site", { x: 0.25, y: 0.9, w: 1.9, h: 0.38, fontSize: 10, bold: true, color: WHITE, valign: "middle" });
  s.addText("Acute Toxicities  (during/shortly after RT)", { x: 2.2, y: 0.9, w: 3.7, h: 0.38, fontSize: 10, bold: true, color: WHITE, valign: "middle" });
  s.addText("Late Toxicities  (months–years)", { x: 5.95, y: 0.9, w: 3.82, h: 0.38, fontSize: 10, bold: true, color: WHITE, valign: "middle" });

  const rows = [
    ["Brain/CNS",     "Fatigue, headache, alopecia, somnolence",                "Radiation necrosis, neurocognitive decline, hypopituitarism"],
    ["Head & Neck",   "Mucositis, xerostomia, dysphagia, skin reaction",         "Osteoradionecrosis, permanent xerostomia, trismus, fibrosis"],
    ["Thorax/Lung",   "Oesophagitis, fatigue, cough, skin erythema",             "Radiation pneumonitis, fibrosis, cardiac toxicity (left)"],
    ["Abdomen/Pelvis","Nausea, diarrhoea, cystitis, skin reaction",              "Bowel obstruction, fistula, proctitis, sexual dysfunction"],
    ["Breast",        "Skin erythema, fatigue, breast oedema",                   "Fibrosis, lymphoedema, secondary malignancy, cardiac (L)"],
    ["Spine SBRT",    "Pain flare (~30%), nausea, fatigue",                      "Vertebral fracture, myelopathy (<1% with dose constraints)"],
    ["Prostate",      "Urinary frequency, dysuria, rectal urgency",              "Urinary stricture, erectile dysfunction, secondary cancers"],
  ];
  rows.forEach(([site, acute, late], i) => {
    const y = 1.32 + i * 0.56;
    const bg = i % 2 === 0 ? WHITE : LGRAY;
    s.addShape(pres.ShapeType.rect, { x: 0.2, y, w: 9.6, h: 0.52, fill: { color: bg } });
    pill(s, 0.2, y, 0.06, 0.52, i % 2 === 0 ? TEAL : NAVY);
    s.addText(site, { x: 0.32, y: y + 0.06, w: 1.8, h: 0.4, fontSize: 9.5, bold: true, color: NAVY });
    s.addText(acute, { x: 2.2, y: y + 0.06, w: 3.7, h: 0.4, fontSize: 8.5, color: DGRAY });
    s.addText(late, { x: 5.95, y: y + 0.06, w: 3.82, h: 0.4, fontSize: 8.5, color: RED });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 15 — DOCUMENTATION REQUIREMENTS
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Consent Documentation — What Must Be Recorded", "Mandatory form elements — ACR-ARS 2023 · RANZCR Appendix A");
  footer(s, "ACR-ARS 2023 | ACROinsights Issue 4, 2022 | RANZCR Faculty of Radiation Oncology Guidelines 2017");

  const docRows = [
    ["Two Patient Identifiers",      "Name + DOB or MRN — mandatory; prevents wrong-patient treatment"],
    ["Authorising Physician",        "Name of radiation oncologist responsible for the procedure"],
    ["First-Person Patient Statement","Statement in patient's name authorising specific treatment"],
    ["Treatment Description",        "Type, fractionation, technique, estimated number of sessions"],
    ["Risks, Benefits & Alternatives","All three explicitly documented as having been discussed"],
    ["Right to Refuse Acknowledged", "Patient understands right to refuse and consequences thereof"],
    ["Special Disclosures",          "Tattoo marks, photography, pregnancy risk, research participation"],
    ["Questions Offered & Answered", "Statement that patient had opportunity to ask questions"],
    ["Signature + Date",             "Patient or legal representative; relationship if surrogate"],
    ["Witness / Translator",         "Signature, identity, and role of any witness or interpreter"],
  ];

  docRows.forEach(([item, note], i) => {
    const y = 0.9 + i * 0.43;
    const bg = i % 2 === 0 ? WHITE : LGRAY;
    s.addShape(pres.ShapeType.rect, { x: 0.2, y, w: 9.6, h: 0.4, fill: { color: bg } });
    pill(s, 0.2, y, 0.06, 0.4, i % 2 === 0 ? TEAL : NAVY);
    s.addText(`${String(i + 1).padStart(2, "0")}  ${item}`, { x: 0.32, y: y + 0.06, w: 3.5, h: 0.3, fontSize: 9.5, bold: true, color: NAVY });
    s.addText(note, { x: 3.88, y: y + 0.06, w: 5.88, h: 0.3, fontSize: 9, color: DGRAY, valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 16 — SPECIAL POPULATIONS
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Special Populations", "Paediatric · Cognitive Impairment · Language Barriers · Pregnancy");
  footer(s, "ACR-ARS 2023 | Roberts & Hedges' Clinical Procedures (ICRP Pub 84) | Barlevy et al. PMID 28949840");

  // Peds image left
  const iPeds = img(9);
  if (iPeds) s.addImage({ data: iPeds, x: 0.2, y: 0.88, w: 3.6, h: 4.3 });
  s.addText("Paediatric oncology patient — pain management and distraction therapy", { x: 0.2, y: 5.2, w: 3.6, h: 0.18, fontSize: 7, color: MGRAY, align: "center" });

  const pops = [
    { t: "Paediatric (<18 yrs)", c: NAVY, items: ["Parent/guardian consent mandatory", "Child assent sought when developmentally appropriate", "Adolescent autonomy increasingly recognised ≥14–16 yrs", "Oncofertility discussion (Barlevy PMID 28949840)"] },
    { t: "Cognitive Impairment", c: TEAL, items: ["Formal capacity assessment before consent", "Surrogate/guardian appointed per jurisdiction", "Teach-back, visual aids, simplified language", "Advance directive review mandatory"] },
    { t: "Language / Cultural", c: "4A6741", items: ["Certified medical interpreter — NOT a family member", "Translated consent forms at ≤8th grade reading level", "Cultural and religious values integrated", "Document interpreter name and language"] },
    { t: "Pregnancy", c: RED, items: ["Fetal dose quantified and disclosed (ICRP Pub 84)", "<100 mrad: verbal reassurance sufficient", ">100 mrad: written detailed disclosure required", "NRC thresholds and alternatives discussed"] },
  ];
  pops.forEach(({ t, c, items }, i) => {
    const y = 0.9 + i * 1.06;
    s.addShape(pres.ShapeType.rect, { x: 3.95, y, w: 5.85, h: 0.95, fill: { color: "FAFBFC" }, line: { color: c, pt: 1.5 } });
    pill(s, 3.95, y, 0.08, 0.95, c);
    s.addShape(pres.ShapeType.rect, { x: 4.03, y, w: 5.77, h: 0.38, fill: { color: c } });
    s.addText(t, { x: 4.1, y: y + 0.04, w: 5.6, h: 0.32, fontSize: 11, bold: true, color: WHITE, valign: "middle" });
    items.forEach((item, j) => {
      s.addText(`• ${item}`, { x: 4.1, y: y + 0.42 + j * 0.13, w: 5.6, h: 0.12, fontSize: 8.5, color: DGRAY });
    });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 17 — TELEHEALTH & REMOTE CONSENT
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Telehealth & Remote Consent", "ACR-ARS 2023 update — COVID-era and post-pandemic guidance");
  footer(s, "ACR-ARS Practice Parameter 2023 | ACROinsights Issue 4, 2022");

  s.addShape(pres.ShapeType.rect, { x: 0.2, y: 0.9, w: 9.6, h: 0.58, fill: { color: "FFF8E7" }, line: { color: GOLD, pt: 1.5 } });
  s.addText("⚠  New 2022-23: COVID-19 pandemic drove telehealth expansion. ACR-ARS now explicitly addresses remote and telephone-based consent. State-specific regulations apply.", {
    x: 0.35, y: 0.93, w: 9.3, h: 0.52, fontSize: 9.5, color: NAVY, fontFace: "Calibri", valign: "middle"
  });

  const modes = [
    {
      title: "In-Person (Gold Standard)", c: NAVY,
      items: [
        "Preferred for ALL complex radiation oncology consent",
        "Allows physical demonstration, visual aids, models",
        "Non-verbal assessment of comprehension and distress",
        "Staff witness easily documented",
      ]
    },
    {
      title: "Video Telehealth (Acceptable)", c: TEAL,
      items: [
        "Acceptable when in-person is not feasible",
        "Two-factor patient identity verification required",
        "Staff member must witness and document the session",
        "Must comply with state telehealth regulations",
      ]
    },
    {
      title: "Telephone Only (Lowest Preference)", c: RED,
      items: [
        "Use only when video is not available",
        "Necessity of telephone consent must be documented",
        "Cannot assess non-verbal cues — comprehension harder to confirm",
        "Follow-up written materials strongly recommended",
      ]
    },
  ];
  modes.forEach(({ title, c, items }, i) => {
    const x = 0.2 + i * 3.27;
    s.addShape(pres.ShapeType.rect, { x, y: 1.56, w: 3.1, h: 3.58, fill: { color: "FAFBFC" }, line: { color: c, pt: 1.8 } });
    pill(s, x, 1.56, 3.1, 0.52, c);
    s.addText(title, { x: x + 0.12, y: 1.58, w: 2.86, h: 0.48, fontSize: 9.5, bold: true, color: WHITE, valign: "middle" });
    items.forEach((item, j) => {
      s.addShape(pres.ShapeType.rect, { x, y: 2.12 + j * 0.74, w: 3.1, h: 0.68, fill: { color: j % 2 === 0 ? WHITE : LGRAY } });
      s.addText("▸  " + item, { x: x + 0.15, y: 2.15 + j * 0.74, w: 2.8, h: 0.62, fontSize: 9, color: DGRAY });
    });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 18 — CLINICAL TRIALS & AI CONSENT
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Research Consent & AI in Oncology", "Clinical trials · AI-assisted decisions — additional disclosure obligations");
  footer(s, "Froicu EM et al. Curr Oncol Rep 2025 PMID 40526332 | van Lent et al. PMID 33965892 | Declaration of Helsinki");

  const iFlow = img(0);
  if (iFlow) s.addImage({ data: iFlow, x: 0.2, y: 0.9, w: 4.5, h: 3.8 });
  s.addText("5-stage informed consent process in clinical research (feedback throughout)", { x: 0.2, y: 4.72, w: 4.5, h: 0.22, fontSize: 7.5, color: MGRAY, align: "center" });

  // Clinical trials column
  s.addText("Clinical Trials — Additional Requirements", { x: 4.85, y: 0.9, w: 5.0, h: 0.3, fontSize: 11, bold: true, color: NAVY });
  const trialItems = [
    "Experimental vs standard-of-care clearly distinguished",
    "Foreseeable risks/discomforts vs potential benefits",
    "Compensation for research-related injury",
    "Confidentiality of records extent",
    "Voluntary participation — withdraw without penalty",
  ];
  trialItems.forEach((item, i) => {
    s.addShape(pres.ShapeType.rect, { x: 4.85, y: 1.28 + i * 0.43, w: 5.0, h: 0.38, fill: { color: i % 2 === 0 ? WHITE : LGRAY } });
    pill(s, 4.85, 1.28 + i * 0.43, 0.06, 0.38, TEAL);
    s.addText("▸  " + item, { x: 5.0, y: 1.31 + i * 0.43, w: 4.8, h: 0.3, fontSize: 9, color: DGRAY, valign: "middle" });
  });

  // AI section
  s.addShape(pres.ShapeType.rect, { x: 4.85, y: 3.45, w: 5.0, h: 0.36, fill: { color: NAVY } });
  s.addText("AI & Emerging Technology (PMID 40526332)", { x: 4.92, y: 3.47, w: 4.86, h: 0.3, fontSize: 10, bold: true, color: WHITE, valign: "middle" });
  const aiItems = [
    "Patients informed when AI contributed to diagnosis, staging, or plan",
    "AI-assisted auto-contouring/plan optimisation must be disclosed",
    "Algorithmic bias risk: population predictions ≠ individual prognosis",
    "Physician retains full legal accountability for all AI-assisted decisions",
  ];
  aiItems.forEach((item, i) => {
    s.addShape(pres.ShapeType.rect, { x: 4.85, y: 3.85 + i * 0.33, w: 5.0, h: 0.3, fill: { color: i % 2 === 0 ? LGRAY : WHITE } });
    s.addText("▸  " + item, { x: 5.0, y: 3.87 + i * 0.33, w: 4.8, h: 0.25, fontSize: 8.5, color: DGRAY, valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 19 — BARRIERS & BEST PRACTICES
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  hdr(s, "Barriers & Best Practices", "Evidence-based communication strategies to improve consent quality");
  footer(s, "ACR-ARS 2023 | RANZCR 2017 | ACROinsights 2022 | National Adult Literacy Assessment");

  // Barriers left (red/amber)
  s.addShape(pres.ShapeType.rect, { x: 0.2, y: 0.88, w: 4.55, h: 0.4, fill: { color: RED } });
  s.addText("Common Barriers", { x: 0.3, y: 0.9, w: 4.35, h: 0.36, fontSize: 12, bold: true, color: WHITE, valign: "middle" });

  const barriers = [
    ["Health Literacy",      "~36% adults have below-basic literacy (NAAL)"],
    ["Language Barriers",    "8% US population limited English proficiency"],
    ["Emotional Distress",   "Diagnosis shock impairs information processing"],
    ["Medical Jargon",       "Clinician overuse of technical terminology"],
    ["Time Constraints",     "Consent treated as paperwork, not dialogue"],
    ["Form Complexity",      "Forms written above 8th-grade reading level"],
  ];
  barriers.forEach(([b, note], i) => {
    s.addShape(pres.ShapeType.rect, { x: 0.2, y: 1.32 + i * 0.6, w: 4.55, h: 0.54, fill: { color: i % 2 === 0 ? WHITE : LGRAY } });
    pill(s, 0.2, 1.32 + i * 0.6, 0.06, 0.54, RED);
    s.addText("✗  " + b, { x: 0.32, y: 1.36 + i * 0.6, w: 2.0, h: 0.3, fontSize: 9.5, bold: true, color: RED });
    s.addText(note, { x: 2.38, y: 1.36 + i * 0.6, w: 2.3, h: 0.3, fontSize: 8.5, color: DGRAY, valign: "middle" });
  });

  // Best practices right (green/teal)
  s.addShape(pres.ShapeType.rect, { x: 5.05, y: 0.88, w: 4.75, h: 0.4, fill: { color: TEAL } });
  s.addText("Best Practices", { x: 5.15, y: 0.9, w: 4.55, h: 0.36, fontSize: 12, bold: true, color: WHITE, valign: "middle" });

  const practices = [
    ["Plain Language",    "6th–8th grade reading level; avoid acronyms"],
    ["Teach-Back",        "Ask patient to explain key information back"],
    ["Adequate Time",     "≥45 min consult; separate consent visit if needed"],
    ["Written + Verbal",  "Combine form with verbal explanation + take-home sheet"],
    ["Visual Aids",       "Diagrams, dose plan images, anatomical models"],
    ["Support Person",    "Encourage patient to bring family member or advocate"],
  ];
  practices.forEach(([p, note], i) => {
    s.addShape(pres.ShapeType.rect, { x: 5.05, y: 1.32 + i * 0.6, w: 4.75, h: 0.54, fill: { color: i % 2 === 0 ? WHITE : LGRAY } });
    pill(s, 5.05, 1.32 + i * 0.6, 0.06, 0.54, TEAL);
    s.addText("✓  " + p, { x: 5.17, y: 1.36 + i * 0.6, w: 1.85, h: 0.3, fontSize: 9.5, bold: true, color: TEAL });
    s.addText(note, { x: 7.08, y: 1.36 + i * 0.6, w: 2.65, h: 0.3, fontSize: 8.5, color: DGRAY, valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════════════════════
// SLIDE 20 — SUMMARY / KEY TAKEAWAYS
// ═══════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: WHITE };
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.88, fill: { color: NAVY } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: "100%", fill: { color: TEAL } });
  s.addText("Key Takeaways", {
    x: 0.35, y: 0.08, w: 7, h: 0.55,
    fontSize: 22, bold: true, color: WHITE, fontFace: "Calibri", valign: "middle"
  });
  s.addText("Informed Consent in Medical & Radiation Oncology", {
    x: 0.35, y: 0.6, w: 9.3, h: 0.25,
    fontSize: 10, color: MGRAY, fontFace: "Calibri"
  });

  const takeaways = [
    { n: "1",  c: TEAL,      t: "A process, not a signature — ongoing communication throughout treatment journey" },
    { n: "2",  c: NAVY,      t: "ACR-ARS 2023 (PMID 36882916) is the authoritative standard for radiation oncology" },
    { n: "3",  c: TEAL,      t: "6 elements: Diagnosis · Treatment · Risks · Benefits · Alternatives · Right to Refuse" },
    { n: "4",  c: NAVY,      t: "RT consent required for simulation, EBRT, SBRT, brachytherapy, IORT, TBI & re-RT" },
    { n: "5",  c: TEAL,      t: "Shared decision-making: 3-Talk Model — Team · Option · Decision" },
    { n: "6",  c: NAVY,      t: "MacArthur 4 criteria for capacity; surrogate hierarchy when capacity absent" },
    { n: "7",  c: TEAL,      t: "Special populations require tailored processes — paediatric, LEP, pregnancy, cognitive impairment" },
    { n: "8",  c: NAVY,      t: "Telehealth consent acceptable — in-person preferred; two-factor ID verification mandatory" },
    { n: "9",  c: TEAL,      t: "Documentation: two identifiers, physician name, first-person statement, signature, date" },
    { n: "10", c: RED,       t: "AI in oncology creates new disclosure obligations — physician accountability unchanged" },
  ];

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// ─── Write ───────────────────────────────────────────────────────────────────
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