Pain, from the disease or interventions, is the most common symptom experienced by critically ill children in PICU (27, 28). Other commonly experienced symptoms are nausea, dyspnea and delirium. There are numerous barriers that may contribute to under-reporting of these symptoms. This includes communication difficulties by PICU patients due to severity of illness, unrecognized delirium, neurocognitive impairment and presence of invasive support such as endotracheal tube. Pain assessment in the pediatric population is also more challenging than in adults because patients of different age groups express pain differently. A wide range of pain rating scales for different age groups and verbal skills are readily available to achieve consistency of pain assessment (29). Initiatives to improve EOL care in PICU should include raising awareness of pain as a vital sign and standardizing guidelines for symptoms management.

The management of distressing EOL symptoms is of upmost importance in PC. Retained memories of unrelieved EOL symptoms have negative impacts on bereaved parents and siblings (30). A high index of suspicion and close monitoring assist with identification of symptoms, which can be quickly followed by aggressive interventions in collaboration with subspecialties like acute pain team and PC team. Early engagement of PC team positively impact patient and family-centered outcomes by facilitating better pain and EOL symptoms management. Alleviation of physical EOL symptoms also enables PC team to form a good rapport and better negotiate domains of psychological and spiritual care with the family and patient.

Effective communication is an essential pillar of good pediatric CC. Parents of PICU patients are often overwhelmed with medical concepts and uncertainties and are required to make high-stake decisions for their child. Many PICU physicians and subspecialists function on a roster basis, making continuity of care challenging (7). In a qualitative study, many parents reported that the sheer number of physicians and the coordination of communication added on to their emotional burden and eroded their confidence as they needed to seek clarifications (31). PC specialists can act as a constant and strengthen the team's ability for effective communication in such instances.

The high stress environment of the PICU may predispose to conflicts between physician-family, among physicians and within family (32). Conflicts compromise quality of care and contributes to physicians' burnout (33). Commonly cited reasons for physician-family conflict are disagreement over care plans and poor communication (32, 34). Sources of conflict among physicians include disagreement in medical decisions such as pain management, lack of leadership and undervaluing each other's role in a multidisciplinary team, all of which fall under the umbrella of poor communication (35). Palliative specialists can help neutralize tension between all parties and redirect the focus toward advocating for the child's best interest.

End of life discussion in PICU is a delicate and challenging process for physicians, with uncertainty around prognosis of many pediatric conditions adding to the complexity of it. Even though communication is one of the core skills of PICU physicians, many are uncomfortable with EOL discussion and may delay these important conversations (36). This delay can result in missed opportunities for identification of emotional issues and negatively impair healing for the family (37). A cross-sectional study of family conferences held in the PICU of Children's National Hospital, United States reported that nearly three quarters of family conferences and 79% of physician speech was medically focused (38). This study also reported that a higher patient-centeredness score was associated with higher patient satisfaction (38). The family-centered model of PC helps forge a beneficial and supportive partnership between families and physicians.

Advanced Care Planning (ACP) aims to facilitate early planning of treatment goals, including EOL care, through professionally facilitated discussions with patients and families (39). Positive impacts of pediatric ACP include higher rating of EOL care in patients, decrease negative emotions in parents and enabling parents to be better informed and certain about their decisions (40, 41). A study on bereaved parents reported that all parents felt that ACP was important even though only 61% of the parents had finalized ACP prior to their child's death (42).

The answer to when, how and who to initiate ACP remains controversial. A study on clinical providers' attitudes on ACP identified unrealistic parent expectations, differences between clinical and patient/parent understanding of prognosis and lack of parent readiness as the top 3 barriers to ACP discussion (43). Despite having clarity of the barriers, 71% of the respondents believed that ACP happened too late in the patient's clinical course (43). Naturally, many physicians feel insecure about discussing ACP as they are worried about burdening families and destroying the therapeutic alliance with parents (44). PC specialists can step in to share this burden and ensure timely discussion of ACP in a sensitive manner. It is, however, important that ACP discussion should not be owned by a particular physician and should be shared by the entire medical care team.

A framework by the Royal College of Pediatrics and Child Health, United Kingdom states that there are three sets of circumstances when withholding, withdrawal or non-escalation of life sustaining interventions (WWNLST) can be considered (i) when life is limited in quantity, (ii) when life is limited in quality, (iii) lack of ability to benefit (45). Transition in goals of care from curative to comfort should be made by clinical teams in partnership, and with the agreement of, the parents and patient. PPC can work together with PICU physicians to identify patients suitable for WWNLST and aid in timely open discussion with the family to achieve consensus. A large single center retrospective study in Spain reported that WWNLST was more frequently facilitated in suitable patients after the development of a PC unit (46).

The practice of WWNLST remains highly variable despite many published recommendations (47, 48). Poorly handled WWNLST can lead to confusion and distress for the patient, family and medical staff. The role of PC is to formulate a carefully thought-out plan, from planning to post withdrawal of care, to ensure a smooth process and an optimal experience for all involved stakeholders.

Compassionate extubation at home (CEAH) is a valuable service that PICU can offer and facilitate. The familiarity and comfort of home help families achieve a higher level of satisfaction and comfort with their child's EOL care (49). Medical staff involved in CEAH also reported it to be valuable despite its complex orchestration (50). Despite being resource intensive and logistically challenging, reports have reaffirmed the feasibility of CEAH in the pediatric population with positive outcomes (51, 52). A recently published framework detailing processes from preparation to follow through acts as a good reference for PICU intensivists in their provision of CEAH as an option of EOL care (53).

The death of a child can lead to long-term adverse effects on parental and siblings' physical and psychological health (54, 55). Data also suggest that bereaved parents have higher mortality rates (56). The goals of bereavement support are to facilitate healing and adjustment of bereaved parents after the death or their child so that they can continue to live normal and meaningful lives, and also to carry out early intervention for individuals at risk of negative bereavement reactions (57). Despite the established benefits, hospitals lack coordinated and standardized bereavement programs (58).

A systematic review identified five key components of pediatric bereavement: (i) acknowledgment of parenthood and child's life; (ii) establishing keepsakes, (iii) follow-up contact, (iv) education and information, and (v) remembrance activities (59). However, only four out of 12 studies reported interventions that commenced before the death of the child, inconsistent with bereavement theories of facilitating the transition of parents toward a new reality (59). A qualitative study conducted in the United States reported that five out of nine bereaved parents experienced feelings of abandonment by the medical team after the death of their child, with some parents verbalizing their wish for follow up meeting or support (57). These highlight the need for improvement and standardization of bereavement care.

An anecdotal report by a PPC physician on primary medical providers after redirection of patient's care plan toward comfort stated “sudden loss of power of prescription” and “assumption that bereavement should be delegated to other team members” as challenges primary providers faced (60). Hence, PC specialists can help to ensure that important components of pediatric bereavements are met and to empower primary physicians in providing bereavement care, reducing the risks of adverse effects associated with the death of a child.

A systematic review of adult controlled trials reported a reduction in relative risk of ICU admission and ICU length of stay by 37 and 26%, respectively, in patients who received PC interventions and ACP discussion (61). A pediatric retrospective study conducted at St.Jude Hospital, United States reported that children who received PC intervention were significantly less likely to die in PICU and to receive invasive treatment (62). These outcomes have important economic implications and reduce the financial burden of some families. Indeed, an adult cohort study demonstrated that patients who received PC incurred significantly lower costs as a result of reduced length of hospital stay and number of investigations performed compared to patients who received usual care (63).