Informed and Written Consent in Anaesthesia

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm, mm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus import ListFlowable, ListItem

OUTPUT = "/tmp/workspace/consent-notes/Informed_Written_Consent_Anaesthesia.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=2*cm,
    leftMargin=2*cm,
    topMargin=2.2*cm,
    bottomMargin=2*cm,
    title="Informed & Written Consent in Anaesthesia",
    author="Orris Medical AI",
)

# ── Colour palette ──────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1a3c5e")
MID_BLUE    = colors.HexColor("#2563a8")
LIGHT_BLUE  = colors.HexColor("#dbeafe")
ACCENT      = colors.HexColor("#e76f24")
LIGHT_GREY  = colors.HexColor("#f3f4f6")
DARK_GREY   = colors.HexColor("#374151")
BOX_BG      = colors.HexColor("#eff6ff")
TABLE_HEAD  = colors.HexColor("#1e40af")
TABLE_ALT   = colors.HexColor("#eff6ff")
BLACK       = colors.black
WHITE       = colors.white

W = A4[0] - 4*cm   # usable width

# ── Styles ──────────────────────────────────────────────────────
styles = getSampleStyleSheet()

cover_title = ParagraphStyle("cover_title",
    fontSize=22, fontName="Helvetica-Bold",
    textColor=WHITE, alignment=TA_CENTER, spaceAfter=6)

cover_sub = ParagraphStyle("cover_sub",
    fontSize=12, fontName="Helvetica",
    textColor=colors.HexColor("#bfdbfe"), alignment=TA_CENTER, spaceAfter=4)

h1 = ParagraphStyle("h1",
    fontSize=13, fontName="Helvetica-Bold",
    textColor=WHITE, spaceBefore=10, spaceAfter=4,
    borderPad=6, backColor=DARK_BLUE, leftIndent=-5)

h2 = ParagraphStyle("h2",
    fontSize=11, fontName="Helvetica-Bold",
    textColor=DARK_BLUE, spaceBefore=8, spaceAfter=3,
    borderColor=ACCENT, borderWidth=0, leftIndent=0)

h3 = ParagraphStyle("h3",
    fontSize=10, fontName="Helvetica-Bold",
    textColor=MID_BLUE, spaceBefore=5, spaceAfter=2)

body = ParagraphStyle("body",
    fontSize=9.5, fontName="Helvetica",
    textColor=DARK_GREY, leading=15, spaceAfter=4,
    alignment=TA_JUSTIFY)

bullet = ParagraphStyle("bullet",
    fontSize=9.5, fontName="Helvetica",
    textColor=DARK_GREY, leading=14, spaceAfter=2,
    leftIndent=14, firstLineIndent=-10)

sub_bullet = ParagraphStyle("sub_bullet",
    fontSize=9, fontName="Helvetica",
    textColor=DARK_GREY, leading=13, spaceAfter=1,
    leftIndent=28, firstLineIndent=-10)

ref_style = ParagraphStyle("ref",
    fontSize=8.5, fontName="Helvetica-Oblique",
    textColor=colors.HexColor("#6b7280"), leading=12, spaceAfter=2,
    leftIndent=10)

note_style = ParagraphStyle("note",
    fontSize=9, fontName="Helvetica-Oblique",
    textColor=colors.HexColor("#b45309"), leading=13, spaceAfter=4,
    leftIndent=8, rightIndent=8)

footer_style = ParagraphStyle("footer",
    fontSize=7.5, fontName="Helvetica",
    textColor=colors.HexColor("#9ca3af"), alignment=TA_CENTER)

# ── Helper functions ─────────────────────────────────────────────
def section_heading(text, num=""):
    """Blue banner heading."""
    label = f"{num}. {text}" if num else text
    tbl = Table([[Paragraph(f'<font color="white"><b>{label}</b></font>', h1)]],
                colWidths=[W])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), DARK_BLUE),
        ("LEFTPADDING",  (0,0), (-1,-1), 8),
        ("RIGHTPADDING", (0,0), (-1,-1), 8),
        ("TOPPADDING",   (0,0), (-1,-1), 5),
        ("BOTTOMPADDING",(0,0), (-1,-1), 5),
        ("ROUNDEDCORNERS", (0,0), (-1,-1), 4),
    ]))
    return tbl

def sub_heading(text):
    return Paragraph(f'<font color="{MID_BLUE.hexval()}"><b>{text}</b></font>', h2)

def sub3(text):
    return Paragraph(f'<font color="{MID_BLUE.hexval()}"><b>{text}</b></font>', h3)

def bp(text):
    return Paragraph(f"<bullet>&bull;</bullet> {text}", bullet)

def sbp(text):
    return Paragraph(f"<bullet>&#9702;</bullet> {text}", sub_bullet)

def B(text):  # body paragraph
    return Paragraph(text, body)

def sp(n=4):
    return Spacer(1, n*mm)

def hr():
    return HRFlowable(width="100%", thickness=0.5,
                      color=colors.HexColor("#cbd5e1"), spaceAfter=4)

def info_box(title, items):
    """Light blue box with title + bullets."""
    content = [Paragraph(f'<b><font color="{DARK_BLUE.hexval()}">{title}</font></b>', h3)]
    for i in items:
        content.append(Paragraph(f"<bullet>&bull;</bullet> {i}", bullet))
    tbl = Table([[content]], colWidths=[W])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), BOX_BG),
        ("BOX", (0,0), (-1,-1), 0.8, MID_BLUE),
        ("LEFTPADDING",  (0,0), (-1,-1), 10),
        ("RIGHTPADDING", (0,0), (-1,-1), 10),
        ("TOPPADDING",   (0,0), (-1,-1), 7),
        ("BOTTOMPADDING",(0,0), (-1,-1), 7),
    ]))
    return tbl

# ── COVER PAGE ───────────────────────────────────────────────────
def make_cover():
    cover_tbl = Table([[
        Paragraph("INFORMED &amp; WRITTEN CONSENT", cover_title),
        Paragraph("IN ANAESTHESIA", cover_title),
        Paragraph("10 Marks | Anaesthesia Residency Assignment", cover_sub),
        Paragraph("References: Miller's · Morgan &amp; Mikhail · Barash · Stoelting · Lee's Synopsis · Forensic Medicine Texts", cover_sub),
    ]], colWidths=[W])
    cover_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), DARK_BLUE),
        ("TOPPADDING",    (0,0), (-1,-1), 22),
        ("BOTTOMPADDING", (0,0), (-1,-1), 22),
        ("LEFTPADDING",   (0,0), (-1,-1), 14),
        ("RIGHTPADDING",  (0,0), (-1,-1), 14),
        ("ROUNDEDCORNERS",(0,0), (-1,-1), 8),
    ]))
    return cover_tbl

# ── BUILD CONTENT ────────────────────────────────────────────────
story = []

# COVER
story.append(make_cover())
story.append(sp(6))
story.append(hr())
story.append(sp(2))

# ---------- 1. DEFINITION ----------
story.append(section_heading("DEFINITION AND ETHICAL FOUNDATION", "1"))
story.append(sp(2))
story.append(B("<b>Informed consent</b> is the process by which an <b>autonomous, competent patient</b> — "
               "after receiving adequate disclosure of relevant information — voluntarily agrees to a "
               "proposed medical treatment or procedure."))
story.append(sp(2))
story.append(B("It operationalizes the bioethical principle of <b>patient autonomy</b>: every competent "
               "adult has the right to decide what happens to their own body. Without valid consent, any "
               "intervention including anaesthesia constitutes a <b>battery (assault)</b> on the patient, "
               "regardless of clinical outcome."))
story.append(sp(2))
story.append(info_box("Key Textbook Definitions", [
    "Barash, 9e: Preoperative evaluation is used to 'educate the patient about anesthesia and the perioperative period, answer all questions, and obtain informed consent.'",
    "Morgan & Mikhail, 7e: Documentation of the informed consent discussion must be part of the preoperative note.",
    "Essentials of Forensic Medicine & Toxicology (2026): To be legally valid, consent must be given after understanding what it is given for, and the risks involved.",
]))
story.append(sp(3))

# ---------- 2. TYPES ----------
story.append(section_heading("TYPES OF CONSENT", "2"))
story.append(sp(2))

types_data = [
    [Paragraph("<b><font color='white'>Type</font></b>", h3),
     Paragraph("<b><font color='white'>Description</font></b>", h3),
     Paragraph("<b><font color='white'>Anaesthesia Context</font></b>", h3)],
    [Paragraph("<b>Implied</b>", body),
     Paragraph("Patient's behaviour implies acceptance (e.g., extending arm for IV, cooperating with examination)", body),
     Paragraph("Routine minor procedures; cooperation with positioning", body)],
    [Paragraph("<b>Verbal (Oral)</b>", body),
     Paragraph("Expressed verbally; witnessed by a disinterested third party (e.g., nurse)", body),
     Paragraph("Minor interventions; documented in clinical notes", body)],
    [Paragraph("<b>Written (Express)</b>", body),
     Paragraph("Specifically stated, signed, and witnessed; the gold standard", body),
     Paragraph("All elective surgeries; mandatory for GA, regional blocks, invasive monitoring", body)],
]

types_tbl = Table(types_data, colWidths=[W*0.2, W*0.42, W*0.38])
types_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), TABLE_HEAD),
    ("BACKGROUND",    (0,1), (-1,1), WHITE),
    ("BACKGROUND",    (0,2), (-1,2), TABLE_ALT),
    ("BACKGROUND",    (0,3), (-1,3), WHITE),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#bfdbfe")),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 7),
    ("RIGHTPADDING",  (0,0), (-1,-1), 7),
]))
story.append(types_tbl)
story.append(sp(3))

# ---------- 3. THREE CORE ELEMENTS ----------
story.append(section_heading("THREE CORE ELEMENTS OF INFORMED CONSENT", "3"))
story.append(sp(2))
story.append(B("All three must be present simultaneously for consent to be legally and ethically valid:"))
story.append(sp(2))

elem_data = [
    [Paragraph("<b><font color='white'>Element</font></b>", h3),
     Paragraph("<b><font color='white'>Requirements</font></b>", h3)],
    [Paragraph("<b>1. DISCLOSURE</b>", body),
     Paragraph("Nature of anaesthetic technique (GA/regional/sedation) · Alternatives with pros and cons · "
               "Risks and benefits · Material risks specific to the patient · Consequences of refusal · "
               "Standard: 'Reasonable person standard' - what information would a reasonable patient need?", body)],
    [Paragraph("<b>2. VOLUNTARINESS</b>", body),
     Paragraph("Decision made freely, without coercion, undue influence, fraud, or misrepresentation. "
               "No consent obtained under threat, duress, or compulsion is valid.", body)],
    [Paragraph("<b>3. DECISIONAL CAPACITY</b>", body),
     Paragraph("(a) Understand - comprehend information given\n"
               "(b) Appreciate - apply it to their own situation\n"
               "(c) Reason - rationally weigh options\n"
               "(d) Communicate - express a stable, consistent choice\n\n"
               "Note: 'Capacity' = clinical determination; 'Competency' = legal determination (court)", body)],
]

elem_tbl = Table(elem_data, colWidths=[W*0.22, W*0.78])
elem_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), TABLE_HEAD),
    ("BACKGROUND",    (0,1), (-1,1), WHITE),
    ("BACKGROUND",    (0,2), (-1,2), TABLE_ALT),
    ("BACKGROUND",    (0,3), (-1,3), WHITE),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#bfdbfe")),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("TOPPADDING",    (0,0), (-1,-1), 6),
    ("BOTTOMPADDING", (0,0), (-1,-1), 6),
    ("LEFTPADDING",   (0,0), (-1,-1), 7),
    ("RIGHTPADDING",  (0,0), (-1,-1), 7),
]))
story.append(elem_tbl)
story.append(sp(3))

# ---------- 4. PROCESS IN ANAESTHESIA ----------
story.append(section_heading("THE INFORMED CONSENT PROCESS IN ANAESTHESIA", "4"))
story.append(sp(2))
story.append(B("The anaesthesiologist must conduct the consent discussion during the preoperative visit and document it. "
               "Steps include:"))
story.append(sp(2))

steps = [
    ("<b>1. Identity confirmation</b>", "Patient name, DOB, procedure site verified"),
    ("<b>2. Anaesthetic plan explained</b>", "Technique (GA/spinal/epidural/nerve block), airway management, monitoring"),
    ("<b>3. Risks disclosed</b>", "See risk table below"),
    ("<b>4. Alternatives discussed</b>", "GA vs. regional vs. sedation; advantages and disadvantages of each"),
    ("<b>5. Questions answered</b>", "Patient given adequate time; not rushed or coerced"),
    ("<b>6. Understanding confirmed</b>", "In patient's own language; patient can explain back key points"),
    ("<b>7. Signature and documentation</b>", "Signed form + narrative note in preoperative record"),
]

step_rows = [[Paragraph(f"<b><font color='white'>Step</font></b>", h3),
              Paragraph(f"<b><font color='white'>Action</font></b>", h3),
              Paragraph(f"<b><font color='white'>Detail</font></b>", h3)]]
for i, (s, d) in enumerate(steps):
    bg = WHITE if i % 2 == 0 else TABLE_ALT
    step_rows.append([
        Paragraph(str(i+1), body),
        Paragraph(s, body),
        Paragraph(d, body),
    ])

step_tbl = Table(step_rows, colWidths=[W*0.07, W*0.32, W*0.61])
step_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), TABLE_HEAD),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, TABLE_ALT]),
    ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#bfdbfe")),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("ALIGN",         (0,0), (0,-1), "CENTER"),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 6),
    ("RIGHTPADDING",  (0,0), (-1,-1), 6),
]))
story.append(step_tbl)
story.append(sp(3))

# Risks sub-table
story.append(sub_heading("Key Risks to Disclose (Barash, 9e — Complication Rates)"))
story.append(sp(1))

risk_data = [
    [Paragraph("<b><font color='white'>Risk</font></b>", h3),
     Paragraph("<b><font color='white'>Approximate Incidence</font></b>", h3),
     Paragraph("<b><font color='white'>Notes</font></b>", h3)],
    ["PONV", "20-30% (GA)", "Higher in females, non-smokers, h/o motion sickness"],
    ["Sore throat / hoarseness", "50-90% (intubation)", "Usually self-limiting"],
    ["Awareness under GA", "1.2-1.5 / 1,000", "Higher risk: cardiac surgery, obstetric GA, emergency cases"],
    ["Dental damage", "~1 / 4,500", "Esp. with laryngoscopy, difficult airway"],
    ["Ulnar neuropathy", "47 / 10,000", "Positioning-related; Warner et al. 1995"],
    ["Peripheral nerve injury (block)", "18 / 10,000 (>5 days)", "Ultrasound guidance reduces risk"],
    ["Postoperative visual loss", "Rare; higher in prone spine surgery", "Discuss in high-risk patients (Miller's, 10e)"],
    ["Anaphylaxis", "1 / 10,000 - 1 / 20,000", "Neuromuscular blocking agents most common trigger"],
    ["Malignant hyperthermia", "1 / 50,000", "Genetic susceptibility; succinylcholine / volatile agents"],
    ["Death", "<1 / 100,000 (elective, ASA I-II)", "Higher in emergency, high-risk patients"],
]

for r in risk_data:
    if isinstance(r[0], str):
        r[0] = Paragraph(r[0], body)
        r[1] = Paragraph(r[1], body)
        r[2] = Paragraph(r[2], body)

risk_tbl = Table(risk_data, colWidths=[W*0.25, W*0.30, W*0.45])
risk_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), TABLE_HEAD),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, TABLE_ALT]),
    ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#bfdbfe")),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 6),
    ("RIGHTPADDING",  (0,0), (-1,-1), 6),
]))
story.append(risk_tbl)
story.append(sp(3))

# ---------- 5. WRITTEN CONSENT ----------
story.append(section_heading("WRITTEN CONSENT — SPECIFIC REQUIREMENTS", "5"))
story.append(sp(2))
story.append(B("A valid written anaesthesia consent form must contain ALL of the following:"))
story.append(sp(2))

written_items = [
    "Patient's full name and date of birth",
    "Name of the procedure and <b>type of anaesthesia planned</b>",
    "Name of the anaesthesiologist (wherever possible)",
    "Statement that risks, benefits, and alternatives have been <b>explained and understood</b>",
    "<b>Specific consent to administration of general anaesthesia</b> — separate from the surgical consent",
    "Statement that the patient had opportunity to ask questions",
    "<b>Patient's signature</b> (or guardian/proxy if incapacitated)",
    "<b>Witness signature</b> — to prevent allegations of forgery or coercion",
    "Date and time of consent",
]
for item in written_items:
    story.append(bp(item))
story.append(sp(2))

story.append(info_box("Legal Rules for Written Consent (Essentials of Forensic Medicine, 2026)", [
    "Should refer to ONE SPECIFIC procedure — not blanket permission given on hospital admission",
    "Must be witnessed by a disinterested third party present at the time of signing",
    "Must be taken BEFORE the procedure, not at the last moment or while patient is premedicated",
    "Should be an ONGOING PROCESS extending over time — not a one-time event",
    "Wording must confirm patient has been informed of the nature of the procedure before signing",
    "Morgan & Mikhail, 7e: Some centers include anaesthesia consent within surgical consent; others use a SEPARATE anaesthesia consent form",
]))
story.append(sp(3))

# ---------- 6. SPECIAL SITUATIONS ----------
story.append(section_heading("SPECIAL SITUATIONS", "6"))
story.append(sp(2))

specials = [
    ("Paediatric Patients", [
        "Parental or guardian consent is required for all minors",
        "Children with sufficient understanding may provide ASSENT (ethical, but not legally binding consent)",
        "Emergency treatment proceeds under implied consent even without parental consent if life-threatening",
        "Reference: Barash, 9e — 'Informed consent in pediatric anesthesia: a narrative review' (Anesth Analg 2018)",
    ]),
    ("Emergency Situations — Implied Consent", [
        "When life-threatening emergency exists and patient is unconscious or incapacitated",
        "IMPLIED CONSENT applies: a reasonable person would consent to emergency treatment",
        "Anaesthesiologist must DOCUMENT: nature of the emergency and that consent could not be obtained",
        "Once stabilized, formal consent must be obtained for further non-emergency interventions",
        "Tintinalli's EM: 'Render needed emergency treatment when consent cannot be obtained in a timely fashion due to the nature of the illness'",
    ]),
    ("Patients Who Lack Capacity", [
        "Identify a SURROGATE DECISION-MAKER: spouse, next of kin, legal guardian, healthcare proxy",
        "Follow state/national law for hierarchy of surrogates",
        "In absence of surrogate: document and proceed in patient's best interest if surgery is urgent",
        "Advance directives and healthcare powers of attorney take precedence when available",
    ]),
    ("Refusal of Consent", [
        "A competent adult has the ABSOLUTE RIGHT to refuse anaesthesia or surgery",
        "Even if refusal leads to serious harm or death — this right cannot be overridden",
        "Document clearly: INFORMED REFUSAL signed by patient (acknowledging consequences)",
        "Patient's decision must be witnessed and noted in medical record",
    ]),
    ("Therapeutic Privilege", [
        "Exception to full disclosure when disclosure itself would cause serious psychological harm",
        "E.g., a severely neurotic or psychotic patient who may decompensate if given frightening risk details",
        "Must be: Documented with full reasoning · Supported by consultant opinion · Used sparingly",
        "Doctor should note intention and reasons in patient's record (Essentials of Forensic Medicine, 2026)",
    ]),
    ("Waiver of Information", [
        "Patient explicitly chooses NOT to receive detailed risk information",
        "This waiver itself must be clearly documented in the medical record",
        "The physician need not give information to those who waive their rights (Forensic Medicine, 2026)",
    ]),
]

for title, items in specials:
    story.append(sub_heading(title))
    for item in items:
        story.append(bp(item))
    story.append(sp(1))

story.append(sp(2))

# ---------- 7. LEGAL ASPECTS ----------
story.append(section_heading("LEGAL AND MEDICOLEGAL ASPECTS", "7"))
story.append(sp(2))

legal_items = [
    "Performing anaesthesia without valid consent = <b>civil battery</b> + possible criminal liability",
    "Indian Law: <b>Section 350, IPC / Section 129, BNS</b> — unlawful force on a person",
    "Section 25, BNS: A person >18 years may give valid consent to an act that may cause harm",
    "Failure to obtain valid consent = ground for <b>medical negligence</b> and professional misconduct before the Medical Council",
    "<b>Paternalism</b> (withholding information to manipulate patient choice) is a violation of patient autonomy and is actionable",
    "Parikh's Forensic Medicine: 'For anaesthesia, <b>separate consent</b> should be obtained'",
    "If the anaesthetic plan must change significantly <b>after</b> premedication or induction, the reasons must be documented (Barash, 9e)",
    "JCAHO / Joint Commission requires an immediate <b>preanesthetic re-evaluation</b> to confirm patient status has not changed",
]
for item in legal_items:
    story.append(bp(item))
story.append(sp(3))

# ---------- 8. SHARED DECISION MAKING ----------
story.append(section_heading("SHARED DECISION MAKING (SDM) — CONTEMPORARY MODEL", "8"))
story.append(sp(2))
story.append(B("SDM is an enhanced, modern form of informed consent applicable in elective situations "
               "when multiple anaesthetic options exist. It is supported by Barash, 9e and is increasingly "
               "mandated by quality standards."))
story.append(sp(2))

sdm_data = [
    [Paragraph("<b><font color='white'>Component</font></b>", h3),
     Paragraph("<b><font color='white'>Description</font></b>", h3)],
    ["Evidence-based information", "Shared using educational materials ('decision aids')"],
    ["Patient preferences elicited", "What matters most to the patient? (pain, mobility, nausea, awareness)"],
    ["Values explored", "Cultural, religious, and personal values that influence choice"],
    ["Collaborative decision", "All parties satisfied with understanding before a decision is made"],
    ["Documentation", "SDM process documented in the preoperative note"],
]
for r in sdm_data:
    if isinstance(r[0], str):
        r[0] = Paragraph(r[0], body)
        r[1] = Paragraph(r[1], body)

sdm_tbl = Table(sdm_data, colWidths=[W*0.35, W*0.65])
sdm_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), TABLE_HEAD),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, TABLE_ALT]),
    ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#bfdbfe")),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 7),
    ("RIGHTPADDING",  (0,0), (-1,-1), 7),
]))
story.append(sdm_tbl)
story.append(sp(3))

# ---------- 9. DOCUMENTATION ----------
story.append(section_heading("DOCUMENTATION IN ANAESTHESIA", "9"))
story.append(sp(2))
story.append(B("The preoperative anaesthesia note (Morgan & Mikhail, 7e) must include:"))
story.append(sp(2))

doc_items = [
    "Anaesthetic plan: GA / regional / sedation; whether invasive monitoring planned",
    "Statement that informed consent discussion occurred with the patient (or guardian)",
    "Narrative: 'the plan, alternative plans, their advantages/disadvantages including relative risks were presented, understood, and accepted by the patient'",
    "Some centres: consent for anaesthesia within surgical consent; others use a <b>separate signed anaesthesia consent form</b>",
    "JCAHO: Immediate <b>preanesthetic re-evaluation</b> required to confirm no status change since consent was obtained",
    "Any intraoperative change in anaesthetic plan must be <b>documented with reasons</b>",
    "Good records provide strong medicolegal defense; sloppy/incomplete records are damaging in litigation (Barash, 9e)",
]
for item in doc_items:
    story.append(bp(item))
story.append(sp(3))

# ---------- 10. VALIDITY CRITERIA ----------
story.append(section_heading("VALIDITY CRITERIA FOR CONSENT", "10"))
story.append(sp(2))

validity_data = [
    [Paragraph("<b><font color='white'>Criterion</font></b>", h3),
     Paragraph("<b><font color='white'>Meaning</font></b>", h3)],
    ["FREE", "No coercion, undue influence, fraud, or misrepresentation"],
    ["VOLUNTARY", "Patient's own decision, not pressured"],
    ["INFORMED", "Based on adequate disclosure of risks, benefits, and alternatives"],
    ["INTELLIGENT", "From a competent, understanding patient with decisional capacity"],
    ["DIRECT", "Personally given by the patient (or valid proxy)"],
    ["SPECIFIC", "To a defined, named procedure — not blanket permission"],
    ["CONTEMPORANEOUS", "Given before the procedure, not retrospectively"],
    ["WITNESSED", "Signed in the presence of a disinterested third party"],
]
for r in validity_data:
    if isinstance(r[0], str):
        r[0] = Paragraph(f"<b>{r[0]}</b>", body)
        r[1] = Paragraph(r[1], body)

val_tbl = Table(validity_data, colWidths=[W*0.22, W*0.78])
val_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), TABLE_HEAD),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, TABLE_ALT]),
    ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#bfdbfe")),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ("TOPPADDING",    (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",   (0,0), (-1,-1), 7),
    ("RIGHTPADDING",  (0,0), (-1,-1), 7),
]))
story.append(val_tbl)
story.append(sp(3))

# ---------- MNEMONIC ----------
story.append(sub_heading("Quick Exam Mnemonic — Valid Consent: \"FiVDiSCW\""))
story.append(sp(1))

mnemo_data = [
    ["F", "Free — no coercion"],
    ["i", "Informed — adequate disclosure"],
    ["V", "Voluntary — patient's own decision"],
    ["D", "Decisional Capacity — competent patient"],
    ["i", "Intelligent — understands information"],
    ["S", "Specific — to a named procedure"],
    ["C", "Contemporaneous — before the procedure"],
    ["W", "Witnessed — signed in presence of witness"],
]

mnemo_rows = [[Paragraph(f"<b><font color='white'>Letter</font></b>", h3),
               Paragraph(f"<b><font color='white'>Stands for</font></b>", h3)]]
for letter, meaning in mnemo_data:
    mnemo_rows.append([
        Paragraph(f"<b><font color='{MID_BLUE.hexval()}'>{letter}</font></b>", h2),
        Paragraph(meaning, body)
    ])

mnemo_tbl = Table(mnemo_rows, colWidths=[W*0.12, W*0.88])
mnemo_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), TABLE_HEAD),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, TABLE_ALT]),
    ("GRID",          (0,0), (-1,-1), 0.5, colors.HexColor("#bfdbfe")),
    ("ALIGN",         (0,0), (0,-1), "CENTER"),
    ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 8),
    ("RIGHTPADDING",  (0,0), (-1,-1), 8),
]))
story.append(mnemo_tbl)
story.append(sp(3))

# ---------- REFERENCES ----------
story.append(hr())
story.append(sp(2))
story.append(sub_heading("REFERENCES"))
story.append(sp(1))

refs = [
    "Miller's Anesthesia, 10e (Miller) — Ischemic optic neuropathy, ION-specific consent, postoperative visual loss",
    "Morgan and Mikhail's Clinical Anesthesiology, 7e — Preoperative note, documentation of informed consent",
    "Barash, Cullen, Stoelting's Clinical Anesthesia, 9e — Informed consent process, shared decision making, record keeping, complication rates",
    "Kaplan & Sadock's Comprehensive Textbook of Psychiatry — Three components of informed consent; four components of decisional capacity",
    "The Essentials of Forensic Medicine and Toxicology, 36e (2026) — Types of consent, written consent rules, legal status in India",
    "Parikh's Textbook of Medical Jurisprudence, Forensic Medicine and Toxicology — Separate anaesthetic consent; medicolegal obligations",
    "Tintinalli's Emergency Medicine, 9e — Documentation of consent, exceptions to informed consent, implied consent in emergencies",
    "Bailey and Love's Short Practice of Surgery, 28e — Implied consent and confidentiality",
    "Sabiston Textbook of Surgery, 21e — Informed consent process and disclosure standards",
    "P C Dikshit's Textbook of Forensic Medicine and Toxicology — Separate anaesthesia consent requirement",
]
for r in refs:
    story.append(Paragraph(f"• {r}", ref_style))

story.append(sp(4))
story.append(hr())
story.append(Paragraph("Generated by Orris Medical AI · For educational use only · Always verify with current institutional guidelines", footer_style))

# ── BUILD PDF ────────────────────────────────────────────────────
doc.build(story)
print(f"PDF saved: {OUTPUT}")