Goals-of-care conversations and advance care planning for children — branching viva

Stem

You are running goals-of-care encounters across a serious-illness paediatric service. The examiner will challenge the structure, the evidence, the prognostic disclosure and the limits of the conversation in disagreement and emergency. [1] [2]

Branch 1 — Definitions and structure

Examiner: Define a goals-of-care conversation, and distinguish it from advance care planning and from a resuscitation order. [1]

Strong answer: A goals-of-care conversation is the ongoing, structured discussion that aligns medical treatments with the child's and family's values, priorities and hoped-for outcomes. Advance care planning is the broader proactive process that surrounds that conversation and documents it for a child with serious or life-limiting illness. A resuscitation order is a portable medical order that flows from the agreed goals-of-care frame. They build on each other; they are not synonyms. [1] [9]

Examiner: Walk me through the Serious Illness Conversation Guide. [2]

Strong answer: Set up — warn the family and ask permission. Assess — elicit what they know, how much they want to know, and what matters most. Share — give honest prognosis in plain language. Align — connect values to what the team can offer and name the goals-of-care frame. Plan — agree and document the frame, treatments wanted and not wanted, resuscitation status, preferred place of care, and a review date. [2]

Branch 2 — Adolescent oncology evidence

Examiner: A 15-year-old with relapsed leukaemia. What evidence supports structured advance care planning here? [3]

Strong answer: The Lyon programme of family-centred advance care planning for teens with cancer, tested in randomised trials, raised and sustained adolescent-family congruence on end-of-life treatment preferences, improved family positive caregiving appraisals, and supported adolescent preparedness and quality of life. The key point is that ACP is defensible with trial evidence in paediatrics, not just expert opinion. [3] [4] [5]

Examiner: How do you capture her voice directly? [11]

Strong answer: Invite her into the conversation at her developmental level and use an age-appropriate tool such as Voicing My CHOiCES so her preferences are recorded in her own words, alongside her parents' involvement and her evolving capacity for autonomous decision-making. [11]

Branch 3 — Complex chronic child with no plan

Examiner: A technology-dependent 7-year-old with severe neurodisability, repeated admissions, no documented plan. Parents say they want everything. [8]

Strong answer: Recognise the gap as the trigger and schedule a structured meeting now. Interpret "want everything" as most often fear of abandonment: reassure you will not leave them and separate comfort from giving up, then explore the child's values and baseline quality of life and weigh each intervention's burden against its realistic benefit. Anchor the plan in the child's best interests and document the agreed goals-of-care frame. [1] [8]

Examiner: How do you make sure the plan survives the next admission? [12]

Strong answer: Document the frame, values, agreed and declined treatments, resuscitation status, preferred place of care and death, and surrogates. Disseminate it across every setting, summarise it for the family and primary care, convert it to a portable order that retrieval and emergency services can find, and set a review date. An undiscoverable plan is no plan at a crisis. [1] [12]

Branch 4 — PICU and disagreement

Examiner: A critically ill child who will not recover. The family insists on full escalation against the team's advice. [9]

Strong answer: Run the structured conversation — assess, share honest prognosis, align, plan — and lean on palliative care. Reassure that comfort is not abandonment. If the disagreement is irreconcilable or life-sustaining treatment is contested, escalate to clinical ethics, a second opinion, and where necessary the local legal pathway, while keeping the relationship intact and documenting everything including the family's view. [1] [9]

Branch 5 — Emergency limit

Examiner: A child arrests with no prior goals-of-care plan. Does the conversation apply now? [1]

Strong answer: Life-sustaining treatment proceeds under implied consent. You do not run a structured meeting during an active resuscitation and you do not withhold treatment for want of a plan. You stabilise the child and then convene the goals-of-care conversation with the family and senior team the same day to decide what should happen at the next deterioration. [1] [9]

Examiner extras

• ACP does not cause depression, remove hope, or hasten death — a defensible viva point. [8]
• Three goals-of-care frames are fluid, not terminal: curative, complex chronic, comfort. [1]
• The most common reason for delay is the fear that naming dying harms the child — the evidence says otherwise. [8] [11]