palliative medicine-powerpoint presentation

Palliative medicine

1. What Is Palliative Medicine? Palliative medicine is a medical subspecialty focused on improving the quality of life for patients with serious, life-threatening illnesses and their families. According to the World Health Organization (WHO), palliative care aims to prevent and relieve suffering through early identification, assessment, and treatment of physical, psychosocial, and spiritual issues. Unlike hospice care, palliative care can be provided alongside curative treatments at any age or stage of illness

2. Palliative care is typically delivered by an interprofessional team, while palliative medicine refers specifically to the role of physicians in managing symptoms and guiding treatment decisions. Care is categorized into primary (basic symptom management and communication about goals of care) and specialist levels (handling complex symptoms and conflicts about treatment).

3. HISTORY The term palliative originates from Latin, meaning "to clothe," symbolizing the relief or "covering" of symptoms like pain. Modern palliative medicine emerged from the hospice movement led by Dr. Cicely Saunders in the late 1960s and was introduced in the U.S. during the 1970s. Initially focused on end-of-life care, the field has expanded to include support for all patients with serious illnesses, emphasizing relief from suffering regardless of prognosis. In response to growing demand, academic medical centers began establishing inpatient palliative care teams. Hospice and palliative medicine became an officially recognized subspecialty in 2006, with board certification starting in 2008. Physicians from ten specialties, including anesthesiology, are eligible to pursue this field.

4. Why Palliative Medicine Is Needed Palliative medicine is increasingly necessary due to the aging population and advances in healthcare that have led to more people living with chronic and serious illnesses. A significant portion of Medicare spending (13–25%) is directed toward patients nearing the end of life, many of whom would benefit from palliative care due to complex needs, repeated hospitalizations, and limited life expectancy. Patients with serious illnesses often suffer from pain, anxiety, depression, and breathing difficulties, while families struggle with similar emotional burdens and poor communication from healthcare providers. Palliative care addresses these issues through symptom management, goal setting, and clear communication.

5. Relevance to Anesthesiologists: As more elderly and seriously ill patients undergo surgery, anesthesiologists must understand and apply palliative care principles. Their expertise in managing pain and critical care makes them valuable contributors to palliative care teams. With growing responsibilities in perioperative care, anesthesiologists are expected to engage In discussions about patient goals and symptom relief. Palliative Care Teams & Delivery: Palliative care is ideally delivered by interprofessional teams—including doctors, nurses, social workers, and chaplains—tailored to the patient’s needs. In the U.S., the field has grown rapidly, with 85% of hospitals with 50+ beds offering programs by 2022. However, access still varies by region; rural and south-central states lag behind urban and northeastern areas. Care is provided in hospitals, homes, and outpatient clinics, though community-based services are not yet widely available.

6. When to Involve Palliative Care Specialists: While all clinicians should have basic palliative care knowledge, specialist consultation is appropriate for patients with life-limiting or life-threatening conditions (e.g., metastatic cancer, sepsis, cirrhosis) and one or more additional indicators—such as frequent hospitalizations, ICU stays >7 days, or declining function. Hospitals are encouraged to establish their own criteria to identify patients who may benefit from consultation, often related to complex symptom management, decision-making, or emotional support.

7. Palliative Care in the ICU (Especially SICU): There are three models of ICU palliative care integration: Consultative (specialists advise primary team) Integrative (ICU team provides basic palliative care) Hybrid (a blend, sometimes with specialists involved in daily ICU rounds) Hybrid models have shown potential benefits like more efficient resource use, though the best model depends on hospital culture and resources. Quality improvement efforts —like screening tools, early family meetings, and structured interventions—have increased palliative consultations but show mixed outcomes, reflecting the complexity of ICU care and decision-making.

8. Challenges in Surgical ICUs (SICU): Palliative integration in SICUs faces barriers like: Limited surgeon/anesthesiologist training in palliative care ICU culture differences and physician reluctance A focus on rescue efforts rather than long-term outcomes These cultural and educational gaps often delay or prevent appropriate palliative discussions, particularly regarding quality of life or end-of-life care.

9. Trigger Criteria in the SICU: Trigger criteria (predefined patient risk factors like multiorgan failure, prolonged ICU stay, or multiple admissions) help proactively identify patients who might benefit from palliative care. While they improve early conversations and decision-making (e.g., earlier DNR orders), no universal criteria exist, and hospital-specific, data-driven triggers are recommended. Some challenges with trigger use include: Concerns about overburdening palliative care teams Workflow disruptions Clinician ambivalence or resistance Need for stakeholder buy-in

10. Post–Intensive Care Syndrome (PICS): PICS includes lasting cognitive, psychological, and physical impairments in ICU survivors. Family members can also suffer emotional trauma (PICS-F). High rates of depression, anxiety, PTSD, and disability are reported post-ICU. Post-ICU recovery programs and clinics have emerged, particularly after COVID-19. The focus on recovery and meaningful outcomes closely aligns with palliative care principles.

11. Outpatient Palliative Care Purpose: Offers symptom management and psychosocial support after hospital discharge. Effectiveness: A 2010 study showed patients with metastatic lung cancer receiving early palliative care had: Better quality of life, Less depression Lived 2.7 months longer despite less aggressive treatment Recommendations: ASCO advises palliative care for all advanced cancer patients. Benefits: Improved quality of life and depression Reduced aggressive end-of-life care More advanced care planning Lower hospitalizations and increased satisfaction

12. Hospice Care vs. Palliative Care Palliative Care: For any stage of serious illness, can be concurrent with curative treatment. Hospice Care (U.S. definition): For patients with a <6-month prognosis Often initiated after curative treatment stops Focus: comfort, dignity, family support

13. Hospice Care in the U.S. Eligibility: Certified by two physicians; prognosis <6 months. Coverage: Medicare covers ~80%; includes visits from nurses, aides, chaplains, social workers, and bereavement counseling. Utilization: Median stay: 18 days Common diagnoses: Cancer (30%), heart disease (18%), dementia (15%), COPD (11%) Many are referred late, sometimes within last 3 days of life Outcomes: Reduced symptom burden High family satisfaction Potential cost savings with appropriate timing and duration

14. Anesthesiologists and Palliative Care Anesthesiologists, especially in critical care and pain management, play a key role in: Aligning care with patient goals Assisting with hospice eligibility Managing pain and symptoms

15. Surgery in Seriously Ill Patients Palliative Surgery : Aimed at symptom relief, not cure. Outcomes improving with better patient selection and shared decision-making. Studies show: 2004: 29% morbidity, 11% mortality 2011: 20% morbidity, 4% mortality Improved outcomes attributed to better communication and alignment with patient goals.

16. Communicating Surgical Risk Challenges: Patients may not fully understand the risks Surgeons often frame surgery as obligatory Best Case/Worst Case Tool: Helps visualize treatment options and outcomes Encourages informed, values-based decisions Validates non-surgical options as legitimate care

17. Preoperative Considerations Decision-Making Capacity : Must be assessed, as it may fluctuate. DNR Orders : Must be reviewed and discussed. If suspended during surgery, a clear plan should be made for reinstating it postoperatively. Surrogate Decision-Maker : Should be designated in case complications arise. Comprehensive Evaluation : Assess disease burden, cognitive and functional status, medications (e.g., chemotherapy, opioids), metastases, and wounds. Opioid Use : High-dose opioid therapy is common—manage pain accordingly (see pain management guidelines).

18. Intraoperative Concerns Communicate Resuscitation Status : All providers should be informed. Special Considerations : Frailty, geriatric syndromes PONV (postoperative nausea and vomiting) prophylaxis Fragile skin, bones, and muscles Hematologic Issues : Conditions like thrombocytopenia or neutropenia may limit regional/neuraxial anesthesia use.

19. Anesthetic Choice in Cancer Patients Cancer Recurrence & Anesthesia: Some studies suggest regional anesthesia may reduce mortality, but meta-analyses and large trials show no consistent effect on recurrence. Trials in breast, lung, abdominal, and thoracic surgery show no benefit of regional vs general anesthesia on cancer outcomes. Some in vivo/in vitro studies suggest systemic anesthetics may affect tumor biology differently, but clinical relevance is unclear. Postoperative Course Standard Care is Typically Adequate, but: Monitor for higher risks of pain, delirium, nausea, and vomiting. Communicate any care limitations and when to return to baseline care preferences (e.g., DNR status).

20. Communication and Advance Care Planning in Serious Illness Effective communication about care goals and treatment preferences significantly improves outcomes for seriously ill patients. Benefits include better quality of life, less aggressive treatment at the end of life, care aligned with patient values, and earlier hospice involvement. The American College of Physicians emphasizes early, relationship-based communication as a high-value, low-cost intervention. Advance Care Planning (ACP) The 1991 Patient Self-Determination Act requires informing patients about advance directives and institutional policies. However, real-world challenges include changing patient preferences and inadequate communication. Meaningful ACP involves ongoing conversations to update care goals as illness progresses.

21. SUPPORT Study Findings The SUPPORT study (1995) revealed major gaps in end-of-life care: Nearly half of patients who declined CPR lacked a DNR order. Physicians often didn’t know patient wishes. While documentation improved with interventions, only a minority of patients spoke with doctors, and physician awareness of directives remained low. Challenges to Effective ACP Barriers include poor timing, ineffective communication, and physician-patient misunderstandings. For example, many patients with incurable cancer believe treatments like chemotherapy may cure them. Delays in end-of-life discussions often result in choices being made during crises rather than proactively.

22. Surgical Context Advance directives are often overlooked before high-risk surgeries. Many surgeons may avoid operating on patients who wish to limit life-sustaining care. Yet, patients desire clearer preoperative information about: Surgical necessity vs. alternatives Recovery expectations Advance directives

23. Communication Skills Training for Physicians Communication about serious topics (e.g., code status, DNR, death) deeply affects patient and family perceptions. Though increasingly taught in medical school, communication skills are often poorly retained. Many physicians, especially trainees, feel unprepared for delivering bad news. Only a small percentage of surgical and internal medicine residents feel adequately trained in palliative care. Despite this, residents often lead these critical discussions, highlighting the need for better training.

24. Discrepancies in Self-Assessment vs. Reality Physicians often overestimate their communication abilities. For example, while most surgeons feel confident discussing prognosis, other healthcare team members and patients rate their communication poorly. Miscommunication is common; physicians may misunderstand patients’ wishes or fail to clearly explain prognosis. Emotional topics are often avoided, and conversations are dominated by technical details rather than empathy.

25. The “Surgical Contract” and Cultural Influences Surgical patients often believe surgery will fully “fix” their issue—risks of functional or cognitive decline are rarely emphasized. Surgeons may feel an implicit “contract” to sustain life at all costs after surgery (a “covenantal” ethic). Preoperative discussions often center on technical success rather than long-term quality of life or complications.

26. Systemic and Cultural Barriers to Palliative Care Aggressive postoperative care is influenced by: “Fix-it” mentality. “Clinical momentum” (cascading interventions). ICU and surgical culture prioritizing rescue and intensive treatment. Systemic constraints (e.g., ICU strain, bed availability, staffing) also limit nuanced decision-making and palliative care use.

27. Opportunities for Improvement Enhancing empathic communication in training can improve palliative care conversations. Preoperative palliative care interventions—especially in high-risk surgeries—may align care with patient goals. Ongoing research and structured programs aim to address these challenges and integrate palliative care more effectively.

28. What Families Value in End-of-Life Communication Top priorities: Trust in physicians and honest, clear communication. Satisfaction increases when families are involved in decision-making. Use of simple language , clear prognosis sharing, and involvement in care planning are critical. Empathy and emotional support during discussions are highly valued.

29. Information Preferences and Cultural Sensitivity Preferences vary based on personal, cultural, and family dynamics. Physicians should ask open-ended questions like: “How much would you like to know?” Some patients may prefer less information and designate a surrogate decision-maker. Avoid assumptions based on race or ethnicity— individualize communication .

30. Spirituality at the End of Life Spirituality often becomes more significant during serious illness. Patients want providers to acknowledge spiritual needs, even if not religious. Asking questions like “Is religion or spirituality important in your life?” can guide care. Understanding spiritual beliefs helps align medical care with patient values.

31. Communication Frameworks & Family Meetings Effective communication frameworks include elements like: Setting up the conversation Assessing understanding Sharing prognosis Discussing goals and fears Documenting and communicating outcomes Family meetings in ICU , especially within 72 hours, can reduce length of stay and improve satisfaction. Frameworks like VALUE (Value, Acknowledge, Listen, Understand, Elicit questions) foster empathy and support.

32. Challenges and Future Directions Barriers: Time, clinical demands, perception that meetings are only for big decisions, COVID-19 restrictions. Risks of single meetings: Some studies show increased family stress; emphasize ongoing dialogue . Emerging focus on: ICU survivorship and follow-up care Post-ICU clinics Resources for grieving families Goal: Support both patients and families before, during, and after critical illness.

33. Starting Family Meetings Many physicians find it challenging to begin family meetings. Common strategies include: Introducing team and family members. Asking about the family’s understanding of the situation (e.g., “What have you been told about your dad’s condition?”). Clarifying the purpose of the meeting. Several structured communication tools can assist, including: VitalTalk TeamTalk Best Case/Worst Case Ask-Tell-Ask

34. VALUE Framework for End-of-Life Conferences A communication strategy designed to promote empathy and engagement: Value – Appreciate what the family shares (e.g., “Thank you for helping me understand...”). Acknowledge – Recognize and validate emotions (e.g., “This is often a sad time...”). Listen – Actively and silently listen, allowing the family space to speak. Understand – Learn about the patient as a person (e.g., “What kind of person was your father?”). Elicit – Invite questions from family members (e.g., “Do you have any questions?”).

35. SPIKES Protocol for Breaking Bad News A six-step method designed to guide difficult conversations: Setting – Choose a quiet, private space. Perception – Gauge what the family understands so far. Invitation – Ask how much information they want. Knowledge – Provide facts using simple, clear language. Empathy – Validate emotions (e.g., “I wish things were different.”). Sequelae – Plan the next steps and follow-up meetings.

36. NURSE Framework for Responding to Emotion A tool to respond compassionately to emotional reactions, including anger: Name – Identify the emotion being expressed (e.g., “It seems like you’re angry.”). Understand – Show empathy (e.g., “I can’t imagine how hard this must be.”). Respect – Acknowledge the person’s strength (e.g., “You’ve done so much for your mom.”). Support – Offer help (e.g., “I want to help.”). Explore – Ask for elaboration on the emotion (e.g., “What was frustrating today?”).

37. Requests for Nondisclosure Some families may request that diagnoses be withheld from the patient. Cultural expectations vary widely. In the U.S., open disclosure is now more standard. There are no clear guidelines, but expert opinion recommends: Empathetically exploring the family’s reasons. Asking the patient directly about their preferences for receiving medical information (e.g., “Would you prefer to hear about your health yourself or have a family member do so?”).

38. Time-Limited Trials Used when outcomes of an intervention are uncertain. Involves setting a defined period to assess the benefit of a treatment. Benefits: Decreased ICU length of stay. Improved quality of family meetings. Reduced intensity and duration of interventions (e.g., ventilation). Also useful when families have high or uncertain expectations of survival, serving as a bridge to palliative or end-of-life care.

39. Outcomes of Cardiopulmonary Resuscitation (CPR) CPR, introduced in the 1960s, has improved with time. In-hospital cardiac arrest : ~50% survive initial CPR. ~25% survive to discharge. Better outcomes with shockable rhythms (37%) vs. PEA (12%) or asystole (11%) . Time to defibrillation is critical. Surgical patients : 85% of arrests are postoperative. They may have better survival rates. ~50% have moderate-severe neurologic deficits post-CPR; 60% survive at 1 year. OR/PACU arrest is rare (5.6 per 10,000) but carries 58% mortality.

40. Postoperative cardiac arrest : 71% 30-day mortality. Therapeutic hypothermia (33°C) doesn’t consistently improve outcomes compared to normothermia. Gender and racial disparities exist: Women: worse cognitive/functional/psychiatric outcomes. Black patients: higher mortality and worse neurologic outcomes vs. White patients.

41. Resuscitation Status Discussions Discussing code status is complex and should reflect patient goals (e.g., life prolongation vs. quality of life). No universally best approach for these discussions. Alternatives like “Allow Natural Death” vs. “DNR” showed no clear preference. VitalTalk and REMAP (Reframe, Expect emotion, Map, Align, Plan) offer structured communication tools. Perioperative Limitations on Treatment Guidelines from the ASA and ACS emphasize ethical considerations in perioperative DNR decisions.

42. Prognosis Clinicians often overestimate survival , particularly in terminal or hospice patients. Example: In hospice, 63% of physician predictions were overly optimistic. ICU physicians tend to be overly pessimistic , yet still more accurate than scoring systems in short-term mortality predictions. Agreement between providers (e.g., nurses and physicians) improves prognostic accuracy. Nurses often more pessimistic and more likely to recommend withdrawal, even when patients survive. Despite uncertainty, most families want prognostic estimates , even if rough. Useful communication strategy: offer time-range categories (e.g., days to weeks) and clarify uncertainty.

43. Disease Trajectories Most patients at the end of life follow one of four functional trajectories: Sudden extreme disability or death Stable function followed by rapid decline (e.g., cancer) Waxing and waning decline (e.g., heart failure, COPD) Slow steady decline from already low function (e.g., dementia) These models help clinicians discuss prognoses, especially in unpredictable conditions.

44. Prognostic Tools Tools like ePrognosis are more accurate when considering patient factors (e.g., functional status) rather than just diagnosis. Median survival of 6 months is associated with specific symptoms in both cancer and non-cancer illnesses . ICU-based prognostic tools exist but are more useful in research. Prognostic factors for non-cancer illnesses: CHF : Poor prognosis with hospitalization, hypotension, low EF Dementia : Poor prognosis with infections, immobility, difficulty eating COPD : BODE index and prolonged ventilation predict poor outcomes Liver disease : MELD score, encephalopathy, and renal issues worsen prognosis Kidney disease : Poor long-term outcomes, especially post-dialysis withdrawal Frailty : Strong predictor of poor outcomes and mortality

45. Symptom Management Routes of Drug Delivery Subcutaneous route is preferred near end of life due to ease and safety. Transmucosal, sublingual, rectal, and neuraxial routes are also used. Pain Management Cancer Pain : Most managed via the WHO Cancer Pain Ladder ; 60–90% of advanced cancer patients experience severe pain. Bone Pain : Common in metastatic cancers; managed with radiotherapy, steroids, NSAIDs, and sometimes surgery or interventional techniques. Neuropathic Pain : Often needs specific agents (e.g., TCAs, SNRIs, gabapentinoids ) over opioids; methadone may help due to NMDA antagonism.

46. Pain in the ICU ICU pain is common but under-assessed due to sedation, intubation, or delirium. Validated tools include: Behavioral Pain Scale Critical Care Pain Observation Tool Pain management has improved post-SUPPORT trial, though challenges remain. AI may assist in the future through facial/body expression monitoring.

47. Opioid Use Common at end of life; 70% of patients received opioids in their last week. Fears of hastening death are generally unsupported by research. Properly titrated opioids are considered safe and do not usually require invoking the doctrine of double effect. Opioid use is declining in the cancer population due to the opioid epidemic, raising concerns of undertreatment.

48. Interventional Pain Management 10–20% of cancer patients have pain unresponsive to standard opioid therapy. Interventional methods (e.g., celiac plexus blocks, intrathecal analgesia) can provide significant relief. Neuraxial analgesia reduces pain and opioid side effects and may improve survival. Nausea and Vomiting Common and distressing; often treated similarly to perioperative nausea. For chemotherapy/radiation: 5-HT3 antagonists, dexamethasone, NK1 antagonists, olanzapine. In other cases, treatment is less evidence-based; often includes scheduled antiemetics.

49. Bowel Obstruction Poor surgical outcomes in terminal patients; non-surgical options preferred. Management includes NG tubes, stents, venting gastrostomy, antiemetics, octreotide, and corticosteroids. Artificial Hydration and Nutrition Often considered due to fear of "starvation" but may not benefit dying patients. Can cause complications (e.g., edema, diarrhea). Should be evaluated as a medical intervention with risks and benefits discussed.

50. Dyspnea Subjective and highly distressing; common even without cardiopulmonary disease. Managed through cause reversal or symptom control (e.g., opioids, fans). Oxygen not always beneficial; low-dose opioids are safe and effective. Acupuncture and benzodiazepines show potential benefit.

51. Depression and Anxiety Prevalence at end of life: depression (5–30%), anxiety (7–13%). Rapid screening tools are available. SSRIs/MAOIs for patients with longer prognosis; methylphenidate for shorter life expectancy. Delirium Affects 28–90% of terminally ill patients; incidence increases near death. Often reversible, especially in younger or less impaired patients. Management should align with goals of care; unnecessary tests can be avoided in terminal stages.

52. Grief vs. Depression in Terminally Ill Patients Characteristic Normal Grief Depression Nature of response Adaptive Maladaptive Focus of distress Specific loss, not pervasive Affects all aspects of life Symptom pattern Comes in waves, improves over time Constant, unrelenting Mood Sadness, dysphoria Persistent depression, flat affect Pleasure & interests Retained interest; reduced due to decline Anhedonia, no pleasure in any activity Hope Episodic loss, may retain future hope Persistent hopelessness Self-worth Maintained, though may feel helpless Feelings of worthlessness Guilt Regret over specific events Excessive, global guilt Suicidal thoughts Passive, fleeting Active preoccupation with death

53. Delirium in Palliative Care Causes : Metabolic disturbances, organ failure, medications, infections, brain pathology, hypoxia, withdrawal, hematologic conditions. Hypoactive delirium is more common than often appreciated. Assessment : Goals of care Medication review Metabolic & infection workup (labs, imaging) Consider EEG, ABG, CT/MRI if needed Treatment : Nonpharmacologic approaches are first-line (reorientation, sleep hygiene, family visits, sensory aids). Antipsychotics may be used (typical or atypical). Palliative sedation may be required for terminal delirium.

54. Bleeding in Palliative Care Causes : Coagulopathies, cancers. Management : Fibrinolytic inhibitors (e.g., tranexamic acid), embolization, or surgery depending on goals. Transfusions based on individualized needs. In exsanguination: Use dark towels, suction, pressure, sedatives (e.g., benzodiazepines, ketamine).

55. The Dying Process Common signs : Fatigue, loss of appetite and consciousness, terminal secretions (“death rattle”), peripheral cyanosis, skin mottling. Respiratory changes: apnea, Cheyne–Stokes, agonal breaths. Neurologic decline: confusion, inability to communicate. Terminal delirium: agitation, purposeless movements, groaning. Rare: “Golden glow” (short burst of energy before death). Death rattle : Caused by secretions the patient can’t clear. Mixed evidence for antimuscarinics (e.g., atropine, scopolamine). Family members may interpret the sound differently.

56. Family Support & Communication Prepare families for physical changes and emotional needs. COVID-19 highlighted the impact of social isolation on grief and bereavement. Recommend: flexible visitation, digital communication, active family engagement.

57. Ethical and Communication Considerations Withdrawal of life support (e.g., ventilators) is ethically acceptable and honors patient autonomy . Important distinction : Withdrawal of life support ≠ Withdrawal of care . Anesthesiologists play a key role in managing pain and anxiety during the process. ICU protocols typically include: Opioids for pain/dyspnea. Benzodiazepines for anxiety/agitation.

58. Challenges and Gaps Studies show that protocolized withdrawal does not always improve provider perception of quality of death. Areas for improvement include: Better documentation of family meetings . Providing emotional and spiritual support to both families and staff. Making space for rituals and involving spiritual advisors if appropriate.

59. Outcomes and Medication Use Time to death varies based on interventions: Stopping ventilation + vasoactives : median 30 minutes. Only vasoactives stopped : 45 minutes. Only extubation (ventilation stopped): 50 minutes. A study found: Morphine dose increased near death (from 5.3 to 10.6 mg/h). Each 1 mg/h increase in morphine delayed death by ~8 minutes . Similarly, benzodiazepines delayed death (~13 minutes per 1 mg/h increase). Longer time to death correlates with higher family satisfaction .

60. Paralytic Medications Paralytics should not be used prior to extubation — they prevent symptom assessment and can cause unrecognized suffering . If already on paralytics: Wait for neuromuscular function to return before extubation . If waiting causes harm or burden, consider reversal agents like sugammadex . Symptom management is critical, but non-symptomatic needs (emotional, spiritual) should not be overlooked. Standardized protocols can improve symptom control and reduce variability in care. Communication with families and support for clinicians are essential throughout the process.

61. Pediatric palliative care supports children with chronic, serious illnesses and can be effective even in resource-limited settings (per WHO). Anesthesiologists are increasingly involved in perioperative planning for pediatric palliative patients. Unlike adult care, developmental stage is a key factor in pediatric care: Children <2 years : No concept of death. Children ~10 years : May ask detailed questions about dying.

62. Patient Characteristics Pediatric palliative care includes a wider range of diagnoses than in adults. Most common: Congenital and neuromuscular disorders. Largest study findings: 1–9 years and 10–18 years age groups each make up ~1/3 of cases. <20% are under 1 year. Children often live longer after palliative consultation than adults. Some pediatric conditions (e.g., severe developmental abnormalities) are rare in adult care . Prognosis and decisions to stop curative treatment are especially challenging . There are unique legal issues in withdrawing or declining treatment for minors.

63. Symptom Management Historically, children’s symptoms near end of life have been poorly managed . Common issues: Pain , fatigue , and dyspnea . Neurologic symptoms are more common in children than adults near end of life. Regional anesthesia can help with pain not managed well by systemic medications. Many pediatric therapies rely on adult data due to limited pediatric-specific research .

64. Pediatric palliative care must be age-appropriate , holistic, and tailored to each child's developmental understanding . Better symptom control , legal clarity, and more pediatric-specific research are needed. Emotional support for families is crucial, as decision-making is often complex and emotionally difficult .