Paediatric palliative care principles and referral — branching viva

Opening question

This 6-year-old with relapsed high-risk neuroblastoma has just been diagnosed, and the oncology team plans further intensive treatment. Tell me why you would refer him to the palliative care team today, what the WHO definition of paediatric palliative care is, and why referring only at end of life is the most common error in this field. [1] [5]

Branch 1 — the parallel-care model and the misconception

You have decided to refer at diagnosis. Explain the parallel-care model to the oncology fellow who worries this means giving up. Tell me how you would correct the misconception that palliative care replaces active treatment, and how you would explain the relationship between the palliative referral and any resuscitation or escalation decision. [2] [4]

Branch 2 — classifying the non-progressive child

Step sideways to a 4-year-old with severe cerebral palsy, non-verbal, admitted for the third time this year with aspiration pneumonia. Classify her under the Together for Short Lives (ACT) framework, give the defining features of that category, name another worked example, and tell me why suffering in this group is the most under-recognised in paediatrics. Now do the same for a boy with Duchenne muscular dystrophy. [10] [5]

Branch 3 — the PaPaS scale and the referral pathway

Describe the Paediatric Palliative Screening Scale (PaPaS) of Bergstraesser: what it scores, what it is for, and its relationship to the ACT categories. Walk me through the full referral and care pathway from identification through bereavement, and tell me who is in the multidisciplinary team. [8] [4]

Branch 4 — the four domains, settings and place of death

Tell me how you would assess this family across the four domains of suffering, why the family is the unit of care, and how you would elicit and support the preferred place of care and death. What does the evidence from Bluebond-Langner tell you about what shapes a family's preferred place of death? [4] [11]

Closing — bereavement follow-through

Six months after a child dies, the family has heard nothing from the team. Tell me why that is a core failure of palliative care, what a bereavement pathway should look like, and how you would close your viva with the single most important principle a general paediatrician should take away from this topic. [4] [11]