Symptom control in a seriously ill child — long-case communication station

Long-case communication and management station: a 9-year-old with relapsed metastatic sarcoma and escalating pain, breathlessness, nausea and agitation. The candidate must conduct a goals-of-care conversation, design a stepwise symptom-control plan with weight-based morphine, manage opioid-induced neurotoxicity by rotation, match an antiemetic to the emetic pathway, exclude reversible causes of delirium before sedating, prescribe an anticipatory box for home, and explain the proportionate use of palliative sedation and the doctrine of double effect.

long-case communication and symptom management station4 min readVerification in progress

Prompt

A 9-year-old boy with relapsed metastatic sarcoma is admitted with worsening pain (back and pelvis), breathlessness, nausea and new agitation. He is on a stable oral morphine regimen totalling 40 mg per 24 hours with paracetamol and ibuprofen. The parents are frightened and want to take him home. You are the paediatric registrar asked to assess and manage his symptoms, conduct the goals-of-care conversation with the family, and design a home-discharge symptom plan.

Candidate instructions

You have 20 minutes. You are the paediatric registrar. You will: ^[1]

Take a focused symptom history and assess each of pain, breathlessness, nausea and agitation, using the parents as informants and the child's self-report where possible.
Conduct a goals-of-care conversation with the parents, anchoring the symptom plan in what matters to the child and family.
Design a stepwise symptom-control plan covering the WHO two-step ladder, breakthrough dosing, opioid rotation if there is neurotoxicity, antiemetic matching, and the management of agitation with exclusion of reversible causes.
Construct the anticipatory (just-in-case) prescribing plan for home discharge and explain the subcutaneous route and syringe driver.
Explain when and how you would use proportionate palliative sedation, and the ethical justification. ^[1]

A paediatric palliative care specialist is available for advice on opioid rotation, methadone and refractory-symptom management. ^[1]

References4Show

[1]van Teunenbroek KC, Mulder RL, Ahout IML, et al A Dutch paediatric palliative care guideline: a systematic review and evidence-based recommendations for symptom treatment. BMC Palliat Care, 2024.PMID 38481215
[2]Zernikow B, Michel E, Craig F, Anderson BJ Pediatric palliative care: use of opioids for the management of pain. Paediatr Drugs, 2009.PMID 19301934
[5]Chen Y, Jiang J, Peng W, Zhang C Palliative sedation for children at end of life: a retrospective cohort study. BMC Palliat Care, 2022.PMID 35473555
[9]Hui D, Bohlke K, Bao T, et al Management of Dyspnea in Advanced Cancer: ASCO Guideline. J Clin Oncol, 2021.PMID 33617290

Symptom control in a seriously ill child — long-case communication station

long-case communication and symptom management station4 min readVerification in progress

Candidate instructions

You have 20 minutes. You are the paediatric registrar. You will: ^[1]

Take a focused symptom history and assess each of pain, breathlessness, nausea and agitation, using the parents as informants and the child's self-report where possible.

Conduct a goals-of-care conversation with the parents, anchoring the symptom plan in what matters to the child and family.

Design a stepwise symptom-control plan covering the WHO two-step ladder, breakthrough dosing, opioid rotation if there is neurotoxicity, antiemetic matching, and the management of agitation with exclusion of reversible causes.

Construct the anticipatory (just-in-case) prescribing plan for home discharge and explain the subcutaneous route and syringe driver.

Explain when and how you would use proportionate palliative sedation, and the ethical justification. ^[1]

A paediatric palliative care specialist is available for advice on opioid rotation, methadone and refractory-symptom management. ^[1]

References4Show

[1]van Teunenbroek KC, Mulder RL, Ahout IML, et al A Dutch paediatric palliative care guideline: a systematic review and evidence-based recommendations for symptom treatment. BMC Palliat Care, 2024.PMID 38481215
[2]Zernikow B, Michel E, Craig F, Anderson BJ Pediatric palliative care: use of opioids for the management of pain. Paediatr Drugs, 2009.PMID 19301934
[5]Chen Y, Jiang J, Peng W, Zhang C Palliative sedation for children at end of life: a retrospective cohort study. BMC Palliat Care, 2022.PMID 35473555
[9]Hui D, Bohlke K, Bao T, et al Management of Dyspnea in Advanced Cancer: ASCO Guideline. J Clin Oncol, 2021.PMID 33617290