Pediatric Palliative Care Flashcards

1
Q

Should children be told about family illnesses?

A

Yes—children are capable of understanding
Yes—their imaginations are often worse than reality
Yes—parents regret not telling children, but rarely regret telling

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2
Q

How to comfort infants around death

A

They can sense tension and stress in caregivers

Ensure ongoing familiarity (e.g. recordings of voices, clothing)

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3
Q

How do 2-6yo children view death? (6)

A
  • Death is reversible
  • Death won’t happen to them
  • Magical thinking about causing/reversing death
  • Compare death to sleep
  • Death can become part of play
  • Anxiety that they caused death (e.g. by wanting someone to go away)
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4
Q

How to support 2-6yo children? (3)

A
  • Explain death in a concrete way (e.g. no breathing, no heartbeat)
  • Emphasise permanency of death
  • Dispel idea that child could be to blame (guilt ++)
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5
Q

How do 7-12yo children view death? (3)

A
  • Aware of finality of death
  • Aware they can die
  • As they age, understand illness better (vs. external causes)
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6
Q

How do adolescents view death? (2)

A
  • Intellectually aware they could die
  • Emotionally, death is distant–may lead to risky behaviour
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7
Q

How to support adolescents? (3)

A
  • Ensure that they have a supportive peer circle
  • Ensure that supportive peers are themselves supported
  • Discuss the future that will never be
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8
Q

How does one best discuss illness/death with a child? (10)

A
  1. Match how family usually discusses things (observe, ask)
  • E.g. “how have you discussed difficult topics in past?”
  1. Ask family how they would like it to be shared. Offer to be there.
  • Family must be the ones to do the talking
  • They will be having these conversations long after you are no longer there
  1. Honesty without cruelty
  2. Check in with child about how much info they want
  3. Explore beliefs w. Family and child
  4. Watch to your own beliefs and how they can contrast w. Patients’
  5. Reflect on likely responses from child
  6. Focus support on what pt/family say is important to them.
  7. Clarify child’s understanding without it feeling like a test

Mnemonic: US THI BBRIC (figure this out later)

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9
Q

How might you clarify understanding after explaining something to a child?

A

E.g. “we’ve talked a lot–what do you remember most?”
E.g. “what might you tell a friend at school if they ask?”

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10
Q

List 6 practical tips for speaking with children in palliative care

A
  • It is OK to cry so long as child does not feel need to comfort
  • Explain that it’s sad so it’s normal to cry
  • Provide toys/play options for child
  • Talk with child about their favourite toys/shows etc. to put at ease
  • “I don’t know but I’ll find out” is an acceptable answer
  • play/grief is a normal mixture for young children
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11
Q

Common Qs:
“What is death?

A
  • Emphasise difference from sleep
  • Explain the physical changes
  • No heartbeat, no breathing
  • No eating or drinking
  • No playing or waking up
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12
Q

Common Q’s:
Death vs. Sleep

A
  • Acknowledge that it looks similar
  • Emphasise that it’s different from sleep
  • It’s permanent
  • It won’t happen to them if they fall asleep
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13
Q

Common Q’s:
What happened to them?

A
  • Honesty!!!
  • No cliches/idiomatic language
  • Explain death, permanency, and cause as able
  • Explain (if true) that this is not going to happen to them
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14
Q

How to prepare child for death of a loved one (6)

A
  1. Allow them to do small helpful things
  2. If able, have a support person who is not grieving (e.g. volunteer)
  3. Explain what they may see in the room (like medical equipment)
  4. Explain what a dead person looks like
  5. Reassure they can still interact with their dead loved one at the end
  6. Follow children’s lead in what they need/want
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15
Q

How do you talk to a
sick child about death? (7)

A
  • Honesty does not remove hope
  • Earlier conversations allow more time to process
  • Reassure children they are supported
  • Reassure children they will not be forgotten
  • Frank language helps makes fears concrete and :. manageable
  • Create physical and social memories
  • Address the future that might not be
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16
Q

What age can kids use 1-10 scales?

A

7-8 year developmental age

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17
Q

What scale is best 4-8yo?

A

FPS-R

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18
Q

How do you use FPS-R?

A

Introduce using words child uses for pain (e.g. “hurt” or “ouchies”)
Explain “no pain” to “most pain”
Do not use emotional words
Faces are not supposed to represent how the child will look (i.e. this is a self-report scale)

19
Q

How does Peds pain mx
differ from adults’?

A

It follows the same principles as adult analgesia:

Anticipate pain
Regular + prn meds
Anticipate s/e, esp. Constipation
Po is ideal
Consider adjuvants

20
Q

What ways does pain assessment differ in children? (4)

A
  • Be vigilant not to downplay children’s pain
  • Children often present nonspecifically (e.g. irritability, not eating)
  • They are often nonspecific even when verbal
  • Pain assessments vary by age
  • Pain assessments vary by condition (esp. Developmental ones)
21
Q

What ways does pain mx differ in children? (5)

A
  • IV > subq, as central access usually available
  • Children are less likely to tolerate s/e
  • Be quicker to rotate opioids (d/t #2)
  • Dose mg/kg until 50kg (then use adult)
22
Q

How does infant opioid dosing differ?

A

Calculate mg/kg dose as usual
Then divide by 3 for starter dose
(<6mo)

23
Q

Why does infant dosing
Differ, physiologically? (4)

A

Increased surface > volume ratio
Decreased fat > lean body mass
Decreased glycoproteins
Decreased renal/hepatic clearance

24
Q

Approach to drug routes in Peds

A
  • Po ideal. Children are picky about formulations.
  • No IM.
  • Avoid rectal.
  • IV preferable parenteral route if central access available.
  • Use small-gauge subq sets.
  • Use EMLA before subq insertion.
25
Q

Peds Morphine Doses

A

0.15-0.3mg/kg po
0.05-0.1mg/kg subq/IV

26
Q

Peds Codeine Doses

A

NO BAD DOCTOR

27
Q

Peds HM Doses

A

0.06mg/kg po
0.015mg/kg subq/IV

28
Q

Dyspnea Assessment Peds
(sample Qs)

A

Are you a lot or a little breathless?
Can you show me how breathless you feel? (VAS)
What can’t you do because you are breathless?

29
Q

Name a dyspnea scale validated in middle-school (and older) children.

A

Dalhousie Dyspnea Scale

Validated age 8+
Three measures
1. Activity limitation
2. Sense of difficulty filling lungs
3. Sense of choking

30
Q

List 5 non-pharmacological approaches to dyspnea in pediatrics.

A
  • Fans
  • Treat mechanical causes (e.g. effusions, pneumothoraces)
  • O2 for comfort, not #s
  • Positioning (e.g. bad-side-down with effusion)
  • Allow child to choose position of comfort if able
  • Pleasant scents in room
31
Q

What 3 ways does adequate
pediatric PC support life?

A
  • Reduced symptom burden
  • Allowing ongoing development
  • Maintaining function
32
Q

What situations is it believed that a peds patients’ burden > benefit?

(esp. in re: withdrawal of care)

A

Dying → no coherent function
Neurological damage → no interxn
Patient choice

all of this is predicated on POOR QOL

33
Q

What is the essential role of
palliative care in withdrawal settings?

A

By reducing symptoms, prevents additional burden caused by withdrawing

e.g. dyspnea post-extubation

34
Q

What are 5 appropriate situations to withdraw care per British guidelines?

A
  1. Brain death (expert dx)
  2. Permanent vegetative state (expert dx)
  3. Minimal chance of delaying death
  4. Severe impairment
  5. Unbearable future decline

(in order of clarity)

35
Q

What is an example of severe impairment leading to withdrawal?

A
  1. Resuscitation required at birth leading to respiratory failure and brain damage
  2. Multiple fatal congenital/genetic dz
36
Q

What are examples of an
unbearable future decline?

A
  1. Toxic chemotherapy with low chance of benefit
  2. Dialysis (in some cases)
  3. Organ transplant (in some cases)
37
Q

What odd ethical situation can arise
more often in children?

A

Children with similar conditions receiving different care (e.g. parents opt to withdraw care in one case)

38
Q

What is the role of PPC if patients/families opt for/against treatment in face of irreversible decline?

A

Close involvement in either case

  • symptoms will evolve
  • the child will continue to grow
  • emotional burden will persist
39
Q

What extra harm can ignoring children’s autonomy cause?

A

It can impair normal development

40
Q

What % of nations have any PPC services?

A

35%

41
Q

When are 4 moments that PPC could be introduced to a family?

A
  1. Prenatally at diagnosis of life-limiting illness
  2. Diagnosis in living child
  3. When benefit of disease-modifying treatment flags
  4. When QOL declines
42
Q

Like 5 reasons that PPC is beneficial to patients and families

A
  1. Reduced time in hospital
  2. APC/Future planning
  3. Support for siblings
  4. Advocacy for patient/family wishes
  5. Symptom management
  6. Improved bereavement support
  7. Reduced aggressive EOL measures
43
Q

What % of nations have any PPC services?

A

35%