Symptom control in serious paediatric illness — formative SAQs

SAQ 1 — Breathlessness, secretions and palliative sedation in a dying child (10 marks, 15 minutes)

Stem: A 7-year-old with a progressive brainstem glioma is in the last days of life. He becomes increasingly breathless with audible gurgling secretions, and his parents are frightened. He is unconscious and on no regular opioid. Outline the assessment and the stepwise pharmacological and non-pharmacological management of his breathlessness and secretions, and explain when and how you would use palliative sedation. [9]

Model answer (structured as marked): [1]

Assessment and goals of care (2 marks)

• Confirm this is refractory end-of-life symptom distress: assess work of breathing, oxygenation, the work of the family, and review reversible causes (pleural effusion, pneumothorax, aspiration) against the burden of transfer.
• Anchor the plan in a goals-of-care conversation with the parents: the intent is comfort, the child is not distressed by the secretions himself, and the family's distress is a treatment target too. [1]

Breathlessness — non-drug and drug management (3 marks)

• Position upright and forward; airflow on the face (fan or open window); parent presence and calm.
• Give oxygen only if the child is hypoxaemic and finds it relieves the choking sensation — not simply for a "low number", and tubing may add to distress.
• Give a low-dose opioid: morphine 0.05 to 0.1 mg/kg subcutaneously or intravenously, repeated after 15 to 30 minutes, or a small regular dose. Explain to the parents that opioids relieve the sensation of breathlessness centrally and may not change the saturation — the number was never the target. [9]

Noisy respiratory secretions (death rattle) (2 marks)

• Reassure the parents that the child is unconscious and not distressed by the sound; reposition on the side; provide gentle mouth care; reduce non-essential hydration that worsens secretions.
• Give an anticholinergic: glycopyrronium 4 to 10 mcg/kg/24h subcutaneously (preferred, as it does not cross the blood-brain barrier and is less deliriogenic), or hyoscine hydrobromide 10 to 20 mcg/kg subcutaneously if sedation is wanted. Avoid repeated blind suctioning, which traumatises the child and rarely helps. [11]

Palliative sedation — when and how (3 marks)

• Indication: a refractory symptom (severe pain, breathlessness, agitation or convulsions) that has not responded to escalating specialist-guided treatment.
• Drug: subcutaneous midazolam infusion started at 0.05 to 0.1 mg/kg/hour (30 to 60 mcg/kg/h) and titrated upward to the minimum sedation that relieves the symptom; add levomepromazine if midazolam alone is insufficient.
• Consent and ethics: the goals conversation (ideally held earlier) documents the intent — relief of a refractory symptom, not the ending of life; proportionate sedation is justified by the doctrine of double effect and is ethically distinct from euthanasia. [5]