What are the Canadian Paediatric Society guidelines for conducting difficult conversations with children, youth, and their families?

Canadian Paediatric Society Guidelines on Difficult Conversations with Children and Families

I was unable to locate specific Canadian Paediatric Society (CPS) guidelines dedicated to conducting difficult conversations with pediatric patients and families in the evidence provided. However, the available evidence from the American Academy of Pediatrics (AAP) and related pediatric literature offers comprehensive guidance that aligns with best practices in pediatric communication.

Core Communication Principles for Difficult Conversations

Establish a Therapeutic Alliance Using the HELP Framework

The HELP mnemonic provides a structured approach to building rapport during challenging discussions: 1

• Hope: Communicate realistic expectations for improvement while reinforcing the child's and family's strengths and assets 1
• Empathy: Listen attentively, acknowledge struggles and distress, and share in the family's emotional experiences 1
• Language and Loyalty: Use the family's own terminology rather than clinical labels, and express your commitment to support them now and in the future 1
• Permission, Partnership, and Plan: Ask permission before exploring sensitive topics, identify barriers to addressing problems, and establish achievable action steps aligned with the family's motivation 1

What NOT to Say During Difficult Conversations

Avoid these common pitfalls that can undermine trust and communication: 1

• Never minimize distress with statements beginning with "at least" (e.g., "at least he isn't in pain anymore") 1
• Do not instruct children to hide emotions (e.g., "You need to be strong; you are the man of the house") 1
• Avoid claiming to know how they feel (e.g., "I know exactly what you are going through") - instead, ask them to share their feelings 1
• Never tell them how they ought to feel (e.g., "You must feel angry") 1
• Avoid comparisons with your own experiences, as this shifts focus away from the child and may be perceived as insulting or may compel the child to comfort you 1

Confidentiality in Difficult Conversations with Adolescents

Establishing Confidentiality Boundaries

Clearly explain the limits of confidentiality before beginning potentially sensitive conversations, as this is a clinical best practice. 1

• Frame discussions in terms of securing additional supports and ensuring safety rather than legal imperatives, which is more patient-centered and intelligible for youth 1
• Limit disclosures to only essential information when breaches are necessary 1
• Before any disclosures to parents, engage the minor adolescent directly and offer as much control over the disclosure process as feasible 1

Balancing Adolescent Autonomy and Parental Involvement

The pediatrician's primary duty is to the adolescent patient, and encounters should be structured to maximize privacy, comfort, and confidentiality consistent with ensuring safety. 1

• Unless significant risks to safety arise or laws require otherwise, respect the adolescent's preferences regarding parental involvement 1
• Many youth desire parental involvement but have difficulty initiating sensitive conversations - health care professionals can provide critical guidance and even mediate these discussions 1
• Attempt to reach common ground with parents by underscoring shared interests in the adolescent's well-being 1

Serious Illness Conversations

Assessing Understanding and Sharing Prognosis

Use a structured approach when discussing serious illness with families: 2

• Seek permission before initiating the conversation 2
• Assess understanding of the child's illness and prognosis 2
• Share prognosis in developmentally appropriate and honest terms 1
• Explore key topics including hopes, fears, strengths, critical abilities, and trade-offs 2
• Formulate clinician recommendations based on the family's values and goals 2

Titrating Clinician Directiveness

The degree of clinician directiveness should vary based on prognostic certainty, the family's desire for guidance, urgency of the decision, relationship strength, team consensus, and the burdens and benefits of therapy. 3

• Directiveness is an important tool that can support families in stressful situations 3
• Consider presenting "default" options and using informed nondissent as strategies when appropriate 3
• Shared decision-making does not mean avoiding guidance - clinicians often have an obligation to provide direction 3

Developmental Considerations

Age-Appropriate Communication

Every child has a right to "open and honest" communication of "age-appropriate information about his or her illness, as well as potential treatments and outcomes, within the context of family decisions." 1

• Children should be given the opportunity to participate in decisions affecting their care according to age, understanding, capacity, and parental support 1
• Use expressive techniques such as picture drawing or engaging children in activities while talking when they appear reluctant to address topics in direct conversation 1
• Be patient with children's repetitive questions, which may reflect attempts to develop more complete understanding as cognitive development progresses 1

Avoiding Literal Misinterpretations

Misinformation or misconceptions can impair children's adjustment, and literal misinterpretations are common among young children. 1

• Do not assume the reasons for children's worries or hesitation - ask what they are thinking about 1
• Provide clear, concrete explanations that avoid euphemisms that may be misunderstood 1

Practical Strategies for Ongoing Support

Communicating Availability and Follow-Up

Communicate your availability to provide support over time, and do not require children or families to reach out to you for such support. 1

• Make the effort to schedule follow-up appointments and reach out by phone or email periodically 1
• Offer practical advice, such as suggestions about how to answer questions posed by peers or how to talk with teachers 1
• Offer appropriate reassurance without minimizing concerns, letting them know that over time you expect they will become better able to cope with their distress 1

Documentation Requirements

Detailed documentation around difficult conversations is essential given the complex implications of resulting decisions. 1

• Provide a clear rendering of the situation, countervailing considerations, risks and benefits considered, and the ultimate decision and plan 1
• Focus documentation on the best interests of the child or adolescent 1

Professional Development in Communication Skills

Role Modeling and the Hidden Curriculum

Students and residents may be more influenced by the "hidden curriculum" (daily behavior of health care professionals) than by formal training in ethics. 1

• When pediatricians behave contrary to ethical standards or keep silent in the face of inappropriate behavior, they reinforce the view that medicine lacks integrity 1
• Personal reflection, small-group discussions, participation in family conferences, and longitudinal experiences with families living with chronic illness are key strategies for nurturing professionalism 1

Self-Care Enables Compassionate Care

Those who have their personal needs met are more supportive of patients' and families' needs, and self-nurturing promotes the ability to show compassion and empathy for others. 1

• Pediatricians must learn to care for themselves in addition to learning how to care for others 1
• Emphasis on stress management is essential for trainees 1