Neonatal palliative care and end-of-life decision-making — OSCE

Objectives

1. Apply the best-interests balance of benefits against burdens to a neonatal end-of-life recommendation. [10]
2. Run an honest, structured goals-of-care conversation with the parents of a newborn using a recognised framework. [1]
3. Avoid the error of an isolated resuscitation decision and build an overall comfort and symptom plan. [11]
4. Identify the escalation pathway to ethics and the courts for a genuine value dispute, and describe the comfort medications that support a planned withdrawal. [10] [4]

Candidate brief

A 12-minute station. An extreme preterm infant with progressive post-haemorrhagic hydrocephalus and cystic periventricular leukomalacia cannot be weaned from ventilation despite maximal support. The treating team, including a second consultant, agrees that intensive care can no longer achieve its goal and that the burdens of escalation now outweigh any benefit. The candidate must meet the parents, who have not yet heard this assessment, and lead the goals-of-care conversation. The nurse asks what the plan is. A professional interpreter is available if needed. [10]

Expected actions

• Set the scene: a private room, no interruptions, both parents present, and confirm who else the family would like included. [1]
• Give a warning shot before sharing the assessment, then share the prognosis honestly in plain language. [1]
• Ask what the parents understand about their baby's condition and what matters most to them and to their baby. [1]
• Explain the best-interests balance: the team has weighed the chance of recovery against the burden the baby is now bearing, and concluded escalation would add suffering without benefit. [10]
• Clarify that stopping disease-directed escalation is not abandoning their baby; comfort care is intensified, and the family stays central. [1] [11]
• Build an overall comfort plan covering escalation, ventilation, resuscitation, symptom relief and feeding — not an isolated resuscitation order. [11]
• Name the comfort medications that would support a planned withdrawal, titrated to the baby's comfort. [4]
• Explore fears and hope honestly; do not treat 'do everything' as a binding instruction. [1]
• Agree a plan you and the family own, and name the review point or time-limited trial if uncertainty remains. [10]
• Document the benefits and burdens analysis, who agreed, what will and will not be offered, and the comfort plan. [10]
• If genuine disagreement remains, name the ethics-consultation and court pathway rather than overriding or capitulating. [10]

Examiner prompts

• "Are you saying we should just let our baby go?" → Reframe redirection as redirecting to comfort and what matters, not giving up. [1] [11]
• "We want you to do everything." → Explore the fear underneath the phrase before treating it as a treatment directive. [1]
• "Isn't stopping worse than never starting?" → Explain that withholding and withdrawing are morally equivalent. [11]

Marking foci

• Applies the best-interests balance of benefits against burdens, not a personal quality-of-life judgement. [10]
• Runs a structured, honest goals-of-care conversation that elicits parental values, using an interpreter where indicated. [1]
• Builds an overall comfort and symptom plan, not an isolated resuscitation order. [11]
• Frames withdrawal as active comfort care, supported by appropriate comfort medications, not abandonment. [4]
• Identifies the ethics and court escalation pathway for a genuine value dispute. [10]