Membership of the Royal College of Paediatrics and Child Health (MRCPCH) Child Protection, Ethics, Communication and Professional Practice Syllabus

Distinguish withholding from withdrawing treatment, and what is the ethical principle regarding them?

Withholding means not starting a treatment; withdrawing means stopping one already begun. Ethically and legally there is no difference between the two — a treatment that may be withheld may also be withdrawn if it is no longer in the child's best interests.

What are the RCPCH-recognised circumstances in which withholding or withdrawing life-sustaining treatment may be ethically and legally justified?

When life is limited in quantity (treatment cannot/will not prolong life or only briefly), when life is limited in quality (e.g. intolerable suffering, no awareness/benefit), or when an informed competent child with life-limiting illness refuses further treatment. The overarching principle is the child's best interests.

What additional safeguards govern research involving children?

Research must be approved by a research ethics committee; involve minimal risk/burden; have a sound scientific basis; obtain informed parental consent plus the child's assent (and the child's consent if competent); allow withdrawal at any time; and only be done in children when it cannot be done in adults to answer the question.

Differentiate 'therapeutic' from 'non-therapeutic' research in children and the level of acceptable risk.

Therapeutic research offers potential direct benefit to the participating child and may justify proportionate risk. Non-therapeutic research offers no direct benefit to the child and is only acceptable if risk/burden is minimal (no more than minimal, e.g. routine blood test) and the knowledge gained is important.

What communication techniques are recommended when breaking bad news to a child and family?

Use a quiet, private setting with adequate time; ensure key people present; warn ('warning shot'); use clear jargon-free language at the appropriate developmental level; allow silences and emotion; check understanding; provide written information and a contact; and arrange follow-up. Frameworks such as SPIKES can structure the conversation.

What are the six steps of the SPIKES protocol for breaking bad news?

Setting up the interview; assessing the patient's Perception; obtaining the patient's Invitation; giving Knowledge/information; addressing Emotions with empathic responses; and Strategy and Summary.

What is the recommended approach to managing a formal complaint from a family?

Acknowledge promptly; listen and apologise where appropriate (apology is not an admission of liability); investigate openly; communicate clearly with a timely written response; offer a meeting; learn from it; and signpost to PALS and the formal NHS complaints procedure / Ombudsman if unresolved.

What principles should guide the use of interpreters in paediatric consultations?

Use a professional trained interpreter rather than family members or children; speak directly to the patient/family (not the interpreter); use short sentences; allow extra time; ensure confidentiality; and be aware that children should never be used to interpret for serious or safeguarding matters.

Define cultural competence in clinical practice.

The ability to deliver effective, respectful care that is responsive to the patient's cultural and language needs — recognising one's own biases, understanding the family's beliefs and values, and adapting care without making stereotyped assumptions.

What are the core principles of effective multidisciplinary team (MDT) working?

Clear shared goals, defined roles and responsibilities, mutual respect, structured communication (e.g. SBAR), shared decision-making, documented plans, effective handover, and the child/family at the centre of the team.

What does the SBAR communication tool stand for?

Situation, Background, Assessment, Recommendation — a structured handover/escalation framework that improves the clarity and safety of clinical communication.

Define paediatric palliative care.

An active and total approach to care, from diagnosis, throughout the child's life and beyond, embracing physical, emotional, social and spiritual elements; focusing on enhancing quality of life for the child and support for the family, including symptom management, respite and bereavement care. It is not limited to end-of-life and can run alongside curative treatment.

What are the four ACT/RCPCH categories of life-limiting and life-threatening conditions in children?

Category 1: life-threatening conditions where curative treatment may fail (e.g. cancer). Category 2: conditions where premature death is inevitable but long periods of intensive treatment prolong good life (e.g. cystic fibrosis, Duchenne). Category 3: progressive conditions without curative options, treatment exclusively palliative (e.g. Batten disease, mucopolysaccharidoses). Category 4: irreversible but non-progressive conditions causing severe disability and vulnerability to health complications (e.g. severe cerebral palsy).

Outline the principles of symptom control in a child with a life-limiting illness.

Anticipate and regularly assess symptoms; treat the underlying cause where possible; use the WHO analgesic ladder; give regular ('by the clock') plus breakthrough doses; choose appropriate routes (oral, subcutaneous, buccal); titrate to effect; and address total pain (physical, psychological, social, spiritual).

How are opioids titrated for breakthrough pain in paediatric palliative care?

The breakthrough (rescue) dose is approximately $\frac{1}{10}$ to $\frac{1}{6}$ of the total daily opioid dose, given as needed. Persistent breakthrough use is used to recalculate and increase the regular background dose.

What are first-line approaches to managing excess respiratory secretions ('death rattle') and breathlessness at end of life in children?

Secretions: repositioning, reduce fluids, and antimuscarinics (e.g. hyoscine hydrobromide/butylbromide, glycopyrronium). Breathlessness: reassurance, positioning, a stream of cool air/fan, oxygen if hypoxic, and low-dose opioids ± benzodiazepines for associated anxiety.

What is meant by a child with 'complex needs' and 'technology dependence'?

A child with multiple, often chronic, health needs requiring input from several services, who relies on medical technology to sustain life or function — e.g. long-term ventilation/tracheostomy, gastrostomy/enteral feeding, central venous lines, or home dialysis.

What are key components of a discharge/care plan for a technology-dependent child going home?

Trained and competent carers; emergency/resuscitation and escalation plan; reliable equipment supply and maintenance; community nursing and respite support; clear communication with GP, school and ambulance service; and a named care coordinator.

What characterises a normal grief reaction, and how does it differ in children by developmental stage?

Normal grief includes shock, sadness, anger, guilt, somatic symptoms and gradual adjustment. Young children may have a magical/incomplete understanding of death's permanence; school-age children may personify death and feel responsible; adolescents understand its finality but may show risk-taking or withdrawal.

What bereavement support should be offered to a family after a child's death?

Memory-making (hand/footprints, photographs, lock of hair); spiritual/cultural support; clear information on practical matters (certification, post-mortem, funeral); a follow-up meeting to discuss results; signposting to bereavement services and peer support; and support for siblings and staff.

According to the GMC's 'Duties of a Doctor' / Good Medical Practice, what are the core domains?

Knowledge, skills and performance; safety and quality; communication, partnership and teamwork; and maintaining trust. Make the care of the patient your first concern.

What are the four pillars (principles) of biomedical ethics?

Autonomy (respecting the patient's right to self-determination), Beneficence (acting in the patient's best interest), Non-maleficence (avoiding harm), and Justice (fairness in distribution of resources and treatment).

Define 'human factors' in the context of patient safety.

The study of the interaction between people, equipment, systems and the environment, and how these affect performance and behaviour — used to design systems that reduce error and improve safety, recognising that humans are fallible.

Distinguish 'slips/lapses' from 'mistakes' in human error, and the Swiss cheese model.

Slips and lapses are unintended actions/failures of execution (skill-based). Mistakes are errors in planning/decision (rule- or knowledge-based). Reason's Swiss cheese model shows accidents occur when latent and active failures (holes) in successive defensive layers align.

What is the statutory duty of candour and when is it triggered?

A legal and professional duty to be open and honest with patients (and families) when something goes wrong with care that has caused, or could cause, moderate or greater harm. It requires informing them as soon as practicable, offering an apology, providing a truthful account, and documenting it.

What is the purpose of incident reporting and the 'no-blame'/just culture approach?

To capture near misses and adverse events so systems can be analysed and improved, learning emphasised over individual blame. A 'just culture' holds individuals accountable for wilful or reckless acts but treats honest error as a system-learning opportunity, encouraging open reporting.

What distinguishes a 'never event' from other patient safety incidents?

A serious, largely preventable patient safety incident that should not occur if available preventative measures are implemented (e.g. wrong-site surgery, wrong-route drug administration, misplaced naso/orogastric tube). They are reportable and trigger mandatory investigation.

Name common quality-improvement (QI) tools used in healthcare.

The Plan-Do-Study-Act (PDSA) cycle, driver diagrams, process mapping, fishbone (Ishikawa) cause-and-effect diagrams, run charts/statistical process control (SPC) charts, and the Model for Improvement (aim, measures, changes).

What is reflective practice and why is it required of doctors?

The process of critically analysing one's experiences, decisions and feelings to identify learning and improve future practice. It is a GMC requirement supporting appraisal, revalidation, professional development and patient safety.

List recognised leadership and teamworking behaviours that improve patient safety.

Clear communication and closed-loop confirmation, situational awareness, flattened hierarchy enabling juniors to 'speak up' (graded assertiveness/PACE), shared mental models, effective delegation, structured handover, debriefing, and role clarity within the team.

What is the WHO surgical safety checklist principle being applied when a paediatric team performs a 'team brief' and 'time-out'?

Standardised pre-procedure verification of patient identity, site, procedure, allergies and equipment, plus shared team awareness — reducing reliance on memory and catching errors before harm, a core human-factors safeguard.