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

Candidate instructions

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

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.
2. Conduct a goals-of-care conversation with the parents, anchoring the symptom plan in what matters to the child and family.
3. 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.
4. Construct the anticipatory (just-in-case) prescribing plan for home discharge and explain the subcutaneous route and syringe driver.
5. 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]

Encounter narrative (for the examiner / actor parent)

Parent opening: "He's been getting worse all week. The morphine isn't working like it did, he's sick to his stomach, he can't get his breath, and last night he was restless and picking at things that weren't there. We want to take him home. Can you make him comfortable?" [1]

Worsening prompts (if the candidate stalls):

• The pain is in his back and pelvis, worse on movement, with episodes of sudden sharp breakthrough pain.
• The nausea came on after the morphine was increased, with some early-morning vomiting.
• His breathlessness is worse lying flat and is frightening him.
• The restlessness and picking at things is new and worse at night. [1]

Home prompts (if the candidate avoids the discharge):

• "We have other children. We want him at home with us. What do we need?"
• "If he gets bad in the night, who do we call?" [1]

Marking domains

Domain 1 — Symptom assessment (20%)

• Elicits the temporal pattern, severity and character of each symptom; uses the parents as informants and the child's self-report where possible.
• Distinguishes breakthrough from background pain, opioid-induced from other nausea, and agitation from delirium.
• Seeks reversible causes for each new symptom. [1]

Domain 2 — Goals-of-care communication (20%)

• Opens the conversation about goals and preferences with empathy, without jargon.
• Elicits what matters most to the child and family (alert time, being at home, siblings, avoiding a particular treatment).
• Documents the goals and revisits them as the plan develops. [1]

Domain 3 — Stepwise pharmacological plan (25%)

• Applies the WHO two-step ladder; gives correct weight-based morphine and breakthrough (one-sixth to one-tenth of the 24-hour total).
• Recognises opioid-induced neurotoxicity (myoclonus, allodynia, delirium on a rising dose) and responds by rotation with a 25 to 50 per cent reduction for incomplete cross-tolerance.
• Matches the antiemetic to the emetic pathway; excludes reversible causes of delirium before sedating; manages breathlessness with positioning, airflow, oxygen for hypoxaemia and a low-dose opioid. [2]

Domain 4 — Anticipatory prescribing and the home plan (20%)

• Constructs a just-in-case box covering pain/breathlessness, agitation/seizure, nausea and secretions, with doses by weight and labelled indications.
• Explains the subcutaneous route and syringe driver for the dying child who cannot swallow.
• Arranges a community palliative nurse and a clear escalation pathway. [1]

Domain 5 — Palliative sedation and ethics (15%)

• States the indication (a refractory symptom), the first-line drug (subcutaneous midazolam infusion 0.05 to 0.1 mg/kg/hour titrated) and the consent (the goals conversation).
• Explains the doctrine of double effect and the ethical distinction from euthanasia (proportionate dose to a refractory symptom, not intent to end life). [5]

Model answers to key questions

"The morphine isn't working and he's twitchy and confused." Recognise opioid-induced neurotoxicity from accumulating excitatory morphine metabolites. Do not escalate the same opioid. Rotate to a structurally different opioid (for example oxycodone), calculate the equianalgesic dose (oral morphine 30 mg ≈ oral oxycodone 20 mg), reduce by 25 to 50 per cent for incomplete cross-tolerance, and re-titrate. Exclude other causes of the delirium (hypoxia, hypoglycaemia, sepsis, urinary retention, constipation) in parallel. Seek specialist input for methadone. [2]

"He's breathless and frightened — what will you give him?" Position him upright and forward, put airflow on his face, keep a parent close. Give oxygen if he is hypoxaemic and finds it helps. Give a low-dose opioid (morphine 0.05 to 0.1 mg/kg subcutaneously or intravenously) that acts centrally on the uncomfortable urge to breathe — it may not change the saturation, and that is expected. Add a small benzodiazepine if anxiety is driving the spiral. Look for reversible causes (pleural effusion, anaemia) that might bend to disease-directed treatment. [9]

"What do we need to take him home?" An anticipatory (just-in-case) box with an opioid for pain and breathlessness, midazolam for agitation and seizures, an antiemetic for nausea, and an anticholinergic for secretions — each with the dose by weight and the indication labelled. A subcutaneous syringe driver for his regular analgesic and anxiolytic once he cannot swallow. A community palliative care nurse with a clear plan of what to watch for, when to call and who to call. And a rehearsed response to a breathlessness or seizure episode, practised with you before discharge. [1]

"If he gets really bad and nothing works, what then?" That is the role of palliative sedation: proportionate sedative doses, started with a subcutaneous midazolam infusion at 0.05 to 0.1 mg/kg/hour and titrated to the minimum sedation that relieves the refractory symptom. We would have discussed this earlier as part of the goals of care, so that the intent — relief of a suffering we cannot otherwise reach — is understood and documented. It is not euthanasia: the dose is proportionate to the symptom, the intent is relief, and it is justified by the doctrine of double effect. [5]