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Perinatal palliative care (PNPC) is a holistic multidisciplinary model of care for both baby and family in the event of a perinatal diagnosis of a life-limiting condition. It aims to provide optimal symptom control and end-of-life care to the baby as well as specialized support to families from diagnosis through to birth, death, and bereavement. This chapter aims to address the challenging clinical, ethical, and practical issues specific to perinatal palliative care. It describes antenatal life-limiting diagnoses, the role of anticipatory bereavement care, a palliative care approach to pregnancy, and outlines the complex planning and models of care required to optimally provide for the baby, mother, and family throughout. This chapter ultimately aims to provide management strategies to guide multidisciplinary teams (MDT) to deliver high-quality PNPC to the family as a whole.

Background Oxycodone/naloxone has a reported equivalent analgesic effect to oxycodone due to insufficient naloxone reaching systemic circulation to affect analgesia. Naloxone plasma concentrations can increase in some, e.g. patients with hepatic or renal impairment. Case presentation A 75 year-old male with prostate and lung carcinoma was admitted for palliative radiotherapy. Admission analgesia included oxycodone/naloxone 70/35 mg bd, pregabalin 100 mg bd and oxynorm 20 mg prn. Management Day 3: Multiple breakthroughs required for severe pain. Oxycodone/naloxone changed to oxycodone 90 mg bd (maximum licensed dose of oxycodone/naloxone exceeded). Pregabalin increased to 150 mg bd. Day 4: Respiratory infection diagnosed and treated with intravenous antibiotics. Mild myoclonus but no other signs of toxicity. Pain ongoing. Day 5: Sudden deterioration with respiratory depression (respiratory rate - 6, oxygen saturations -60%). Rapid response to naloxone 40micrograms intravenously. Opioids and pregabalin discontinued. Multiple further naloxone doses required for recurrent respiratory depression. Continuous subcutaneous infusion (CSCI) of 1.5 mg naloxone commenced. Day 6: Naloxone infusion discontinued when pain recurred. CSCI of oxycodone 30mg/24hours commenced and subsequently rotated to hydromorphone 4mg/24hours due to mild opioid toxicity. Radiotherapy completed and patient discharged home on hydromorphone and gabapentin. Discussion Given the timing, and despite normal renal and liver function, we believe the oxycodone/naloxone to oxycodone switch contributed to the severity of opioid toxicity in this case. Other possible factors include infection and titration of pregabalin. When repeated naloxone doses are required for toxicity, a continuous intravenous infusion often necessitates transfer to an acute hospital and may be avoided by administering a CSCI of naloxone. To the best of the authors’ knowledge, this is the first case report of naloxone administered via CSCI for opioid toxicity. Conclusion When switching preparations of oxycodone, specific patient factors and intra- and inter-patient variability should be considered and patients monitored carefully. CSCIs of naloxone for opioid toxicity should be considered if intravenous administration is not feasible.

This paper reports the findings from a Delphi Study undertaken to identify the research priorities in children's palliative care in Ireland. Palliative care for children is a small and highly specialised field of healthcare that focuses on improving the quality of life of children living with, or dying from, a life-limiting condition. Ideally, support for children requiring palliative care begins at the time of diagnosis, which for many children with life-limiting conditions can be from birth. There is a notable overlap between the needs of children requiring palliative care and those with disabilities and other complex care needs, resulting in care being provided by a range of voluntary and statutory agencies. As a new specialty, there is a need to develop an evidence-based approach to providing children's palliative care. In order to do this in a systematic way, identification of the research priorities in children's palliative care within Ireland is required.

Aims Prompt communication with all professionals involved in the care of a child who has died is essential. To aid this, Our Lady’s Children’s Hospital Crumlin (OLCHC), has developed a pan departmental algorithm to provide guidance. The ‘When a Child Dies (WACD) Algorithm’ provides a guided checklist for staff to ensure all stakeholders are informed of the death, and that tasks related to the care of the child and family following a death are completed. This research aimed to audit the activation and completion of the WACD algorithms. Methods A retrospective study was conducted in a 324-bed in OLCHC. The deaths of 251 children from 2015–2016 were included. Demographic information, diagnoses, disease status, end of life care, place of death and algorithm completion was investigated. The audit was conducted against standards from current institutional guidelines. Results Of the 251 paediatric deaths audited, 43% died in OLCHC, 11% died in another hospital or hospice, 3% were unaccounted for, and 42% died at home. The most common departments were Cardiology and Haematology/Oncology, accounting for 26.3% and 21.5% of deaths respectively. 17% (43) had the appropriate WACD fully completed, 48% (120) were partially completed and 35% (88) of cases had no WACD forms completed. Conclusions Departments that more commonly encounter paediatric deaths were more consistent in completion of the WACD algorithm. There is a need to disseminate information and knowledge of the algorithms, especially in departments with a low frequency of childhood deaths. This would ensure that primary care teams, GPs, referring hospitals and any other relevant healthcare professionals are informed on the death of their patient. It also ensures that families are met by the on-call team, the chaplain, and that follow-up with their primary consultant is arranged for the family.

Background and aim Palliative Care for Children is defined as ‘an active and total approach to care, from the point of diagnosis or recognition throughout the child’s life, death and beyond’. It is recognised that the prevalence of children with life-limiting conditions (LLC) is increasing. In Ireland the majority of children with LLC are cared for by paediatricians working in hospitals with no direct access to specialist paediatric palliative care(PPC) services. This study was part of a learning needs assessment of paediatrician’s training and experience in PPC. Methods Consultants and Specialist Registrars in Paediatrics were approached by email and asked to complete a questionnaire regarding their learning needs in PPC. The Quality of Care Collaborative for Australia in PPC Project Research Study Group Learning Needs Assessment template was used with permission. The questionnaire included both multiple choice and free-text questions. Quantitative data from the study has been reported elsewhere. Thematic analysis based on the approach of Braun and Clarke (2006) was used to analyse data provided in the free-text answers. Results 114 paediatricians responded to the survey, 72 respondents (63%) provided free-text answers to the question ‘Reflecting on your most recent clinical interactions with children requiring palliative care support. What were the challenges?’ On analysis, three overarching themes emerged, ‘Best interests of the child’, ‘Inadequate training and confidence’ and ‘Co-ordinating care’. ‘Best interests of the child’ referred to the challenges experienced in ensuring that best interests of the child remain at the core of all decisions made when providing palliative care. This overarching theme included two sub-themes ‘Complex communication’ which referred to the challenges in managing parental expectations in increasingly technologically advanced healthcare systems and ‘First do no harm’ referring to the frequent ethical dilemmas that arise in PPC. ‘Inadequate adequate training and confidence’ referred to lack of specific education in complex symptom management and also to lack of familiarity with community based healthcare services. The theme of ‘coordinating care’ encompassed the need to liaise with community services but also the need to provide holistic care to the whole family which may be unfamiliar paediatricians working in an acute hospital setting. Conclusion This study explores the challenges experienced by paediatricians providing palliative care to children with LLCs. The themes provide insight into those experiences and provides valuable direction to support the development of future educational programmes in this important and rapidly evolving paediatric sub-speciality.

ObjectiveTo analyse the referral patterns of perinatal patients referred to a specialist palliative care service (SPCS), their demographics, diagnoses, duration of illness, place of death and symptom profile.DesignA retrospective chart review of all perinatal referrals over a 4-year period to the end of 2015.SettingA consultant-led paediatric SPCS at Our Lady’s Children’s Hospital, Crumlin, Dublin, and the Coombe Women & Infants University Hospital, Dublin.Results83 perinatal referrals were received in a 4-year period. Chromosomal abnormalities accounted for 35% of diagnoses, congenital heart disease 25%, complex neurological abnormalities 11% and renal agenesis 4%. 22 referrals (26.5%) were made antenatally, with 61 (73.5%) postnatally. Of the postnatal referrals, 27 (44%) were asymptomatic on referral. An opioid medication was recommended (regularly or as required) in 46 cases. Symptom control was achieved without dose titration in 43 of these cases (93%). Of 47 deaths in this group referred postnatally, 22 of these (47%) died at home with support from community teams. Discharge home for best supportive care required complex interagency communication and cooperation.ConclusionsPerinatal palliative care requires effective multidisciplinary work, whether delivered in the inpatient setting or in the community. With appropriate support, end-of-life care can be delivered in the community.

Central venous access devices (CVADs) play an essential role in the care of critically ill children. Significant challenges exist for teams in managing CVADs particularly in a community setting. The authors aimed to assess the experience of general practitioners (GPs) caring for children with CVADs. From 200 CVADs inserted in a pediatric hospital in 2009, 50 patients were randomly selected and 44 GPs were forwarded a questionnaire. Twenty (46%) GPs responded. The main reasons (n = 22) for using CVADs were medication administration (n = 11), nutrition (n = 6), and blood sampling (n = 5). Thirteen (65%) GPs had no education in CVAD management and 14 (70%) were unaware of existing guidelines. Those identified by GPs as having primary responsibility for care of CVADs in the community included hospital/pediatric teams (n = 9), parents (n = 3), GPs (n = 2), public health nurses (n = 1), and palliative care ("home care") teams (n = 1). The main challenges (n = 15) identified by GPs were lack of education (n = 4), line management difficulties (n = 3), infection risk (n = 3), infrequent exposure to CVADs (n = 3), and poor communication (n = 1). GPs felt that these challenges could be addressed through: education (n = 8), increased manpower and community support (n = 1), and improved communication (n = 1). This study highlights the inconsistency and challenges for GPs surrounding CVAD use in children. Further education and support is necessary to assist GPs in their use particularly when providing end-of-life care for children in the community.

Background: Seizures are a common complication in patients with central nervous system (CNS) tumors. Optimal management is unclear with no defined guidelines and pharmacological management poses many controversies. Due to a hypothesized lack of consistency, we aimed to retrospectively review seizure management in patients with high-grade CNS tumors in our institution. Methods: The medical records of patients with high-grade CNS tumors referred to the specialist palliative medicine service in our institution from January-June 2008 were retrospectively reviewed. Seizure incidence, antiepileptic drug (AED) choice, neurology input, medication interactions, and appropriate drug level monitoring were assessed. Results: Twenty-seven patients were included for analysis. Fifteen (56%) were female. The mean age was 58.8 years (range 31-82 years). Three (11%) patients presented with seizures and 8 (30%) developed seizures subsequently. Eight (73% of those with seizures) were on monotherapy AED. Six different agents were used as first-line agents. Phenytoin was the most common AED used (n = 4). Three (27%) patients were on combination AEDs. Five (45.5%) patients had been seen by neurology and 6 (54.5%) had appropriate drug level monitoring performed. Six (55%) patients had potential AED-non-AED interactions. None of the patients had instructions documented in the clinical notes against driving. Conclusion: Seizure management in patients with CNS tumors is not consistent and remains very much a neglected area. Appropriate choice of AED is crucial. Physicians should be aware of potential drug interactions. Ownership and regular follow-up of this group is required to ensure optimum patient management.

nvestigates the career progression of young female Certified Public Accountants in Ireland. Focuses on generation X accountants. A total of 12 male and 12 female accountants were interviewed. All were under the age of 30 and qualified as within the past five years. Aims to examine: whether the young generation of female accountants has encountered the “glass ceiling”; if there is a tendency for male dominance in professional accountancy practices or in industry; whether gender affects one’s ability to network socially; and the ability of the young accountants to balance their home and work lives. This study is particularly relevant, as previous research studies conducted with accountants have focused on older generations. The results of the study show that young female accountants encounter obstacles in their careers because of their gender. The female accountants in this study suggest that male dominance will persist in accountancy practices. Our findings also suggest that an important challenge for managers today is managing generation Xers, who work to live and do not live to work. Finally, the research findings from this study contribute primarily to the extant research on women in the accountancy profession. Also contributes to the corpus of knowledge on women in management, career development, and the development and management of generation X.