**Acknowledgements**

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

with difficult decision-making.

**11. Audit, quality assurance and follow-up**

improved upon and inform local research.

palliative care.

patient needs.

the team.

caregivers.

compassion.

practices in the PICU.

**12. Conclusions**

of patients and their families.

As aforementioned, routine meetings between the family and the interdisciplinary team should provide the family with consistent communication about the child's clinical condition and agree upon treatment goals. All team members are provided with an opportunity to discuss the patient and support the medical team and family

A focus on audit and quality improvement is key to the delivery of high-quality

It is important that the institution recognises the need to educate care providers regarding palliative care practices. Education may take place in the form of multidisciplinary teaching sessions, provision of online resources or provision of funding for staff to gain additional qualifications such as a diploma or masters in

Development of an integrated care pathway for palliative care in PICU will provide guidance for staff. All members of the multidisciplinary team should have input in the creation of such a document. It should function as a guide in the delivery of palliative care but recognise the importance of individual

As aforementioned, in our institution we meet with bereaved parents in the months following a child's death. We also have an ethical duty to support our staff who can be left with a profound emotional impact from caring for a dying child. A helpful means of debriefing is the 'Schwartz Round', where the multidisciplinary team can discuss the emotional impact of their work [63]. This enables staff to support each other and can strengthen relationships within

Palliative care in PICU can be a complex process. Paediatric patients may require palliative care for a variety of reasons and interventions should be tailored to each specific patient. The goals of care are to enhance quality of life and relieve suffering

Ideally the patient, family and multidisciplinary team will form a shared plan to guide their palliative care journey. Regular family conferences should take place to continue this collaborative process and build relationships between the family and

Processes such as redirection of care, withdrawal of life-sustaining therapies

As not all children will have an advance care plan, the PICU team need to be equipped to deliver end of life care and guidance should be in place to facilitate this. Regular audit of outcomes should guide quality improvement in palliative care

and organ donation should be approached by the team with sensitivity and

palliative care in PICU. There are many evidence-based guidelines [62] which specify standards for provision of a comprehensive paediatric palliative care service. Undertaking audit against such guidelines is essential to gauge whether care is adequate and also provides the impetus to develop local quality improvement plans. Another simple means of assessing a unit's performance is to conduct surveys amongst both the PICU staff and parents. This will identify areas that need to be

**24**

No external funds were sought or obtained for the preparation of this manuscript.
