Palliative care in cancer

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Target exams

Red flags

• A child with high-risk, relapsed or refractory cancer is referred to the paediatric palliative care team at the diagnosis of the high-risk disease, not only when curative treatment has failed, because the parallel concurrent model improves symptom control and the family's quality of life
• Uncontrolled pain in a child with cancer is a medical emergency that is escalated up the World Health Organization analgesic ladder without delay, and the fear of opioids must never deny a child adequate analgesia
• The goals-of-care and advance care planning conversation is opened early, before the acute deterioration, and is revisited at every turning point, because the conversation deferred to the last hours is the conversation that fails the family
• A child at the end of life with cancer who develops new respiratory distress, agitation or secretions is assessed and treated with anticipatory medicines, and the family is prepared and supported rather than reassured that nothing can be done
• The siblings and the parents are bereavement-risk assessed before and after the death, because complicated grief in siblings of a child who died of cancer is common and is reduced by structured support

Life stages

Care settings

Clinical exam formats

Board mappings

• Recognises that a child with high-risk, relapsed or refractory cancer is referred to the paediatric palliative care team early, at the diagnosis of the high-risk disease, and not only when curative treatment has failed
• Names the World Health Organization consensus definition of palliative care as the active total care of the child with a life-limiting illness and the family
• Applies the World Health Organization analgesic ladder to the child with cancer pain and escalates without delay when the pain is uncontrolled
• Coordinates the parallel concurrent model in which disease-directed and palliative care run together through the multidisciplinary team, the symptom control, the advance care planning and the bereavement follow-up
• Leads the goals-of-care and the advance care planning conversation with the child and the family, using honest prognostic communication and the documented plan
• Synthesises the symptom assessment and the anticipatory prescribing into a care plan that carries the child and the family through the last days of life and into the bereavement support
• The World Health Organization definition of palliative care is the active total care of the child with a life-limiting illness and the family, and it runs concurrently with disease-directed therapy, not only after it fails
• Cancer pain is escalated up the World Health Organization analgesic ladder, from the non-opioid to the opioid, and the fear of opioids must never deny a child adequate analgesia
• The symptoms at the end of life in childhood cancer are pain, fatigue, dyspnoea, nausea and agitation, and the family is prepared and supported through the last days
• Counsels an adolescent with relapsed cancer and the family on the integration of palliative care with ongoing disease-directed therapy, the prognosis, and the goals of care
• Builds the multidisciplinary plan that runs paediatric oncology, palliative care, psychology, social work, chaplaincy, child life and the family through the symptom control, the advance care planning and the bereavement
• Synthesises the long-case child who died of cancer into a bereavement and sibling-support plan that addresses complicated grief and the family's longer-term needs
• Level 1: Recognition that palliative care is introduced early in high-risk childhood cancer and runs in parallel with curative treatment
• Level 2: Application of the World Health Organization analgesic ladder and the symptom-assessment tools, and the structured goals-of-care conversation
• Level 3: Coordination of the integrated palliative pathway from diagnosis through the last days of life and into the bereavement follow-up
• The World Health Organization consensus definition of palliative care and the parallel concurrent model in paediatric oncology
• The World Health Organization analgesic ladder and the principles of opioid prescribing for cancer pain in children
• The symptom burden at the end of life in childhood cancer and the principles of anticipatory prescribing and the last-days-of-life care
• Communication station: open the goals-of-care and the advance care planning conversation with an adolescent with relapsed cancer and the family
• History and planning station: assess and plan the symptom control for a child with advanced cancer across the physical, the psychological, the social and the spiritual dimensions
• Bereavement station: assess the bereavement risk of the parents and the siblings of a child who died of cancer and build the follow-up support
• General Pediatrics Content Outline - the integration of palliative care in the child with high-risk or relapsed cancer
• General Pediatrics Content Outline - the World Health Organization analgesic ladder and the safe opioid prescribing for cancer pain
• General Pediatrics Content Outline - Universal Task 4: the goals-of-care conversation and the coordination of the end-of-life care
• Patient Care 4: Clinical Reasoning - the recognition of the child who needs integrated palliative care alongside cancer therapy
• Patient Care 5: Patient Management - the symptom control, the advance care planning and the anticipatory prescribing for the child with advanced cancer
• Interpersonal and Communication Skills 1: the honest prognostic communication and the goals-of-care conversation with the child and the family
• Systems-Based Practice 2: the coordination of the multidisciplinary palliative pathway and the bereavement follow-up
• Medical Expert - the symptom assessment and the management of pain, dyspnoea and agitation in advanced childhood cancer
• Communicator - the goals-of-care and advance care planning conversation with the family
• Pediatrics: Palliative care applied domain