SickKids inaugural palliative research symposium - keynotes by Dr Adam Rapoport and Kim Widger

SickKids inaugural paediatric palliative research symposium began with keynotes from palliative care doctor Dr Adam Rapoport and palliative researcher Kim Widger.

Adam showing exciting growth in palliative research over a decade from a Pub Med search showing 10 results for "paediatric palliative care" in 1990 and 80 in 2008; "paediatric oncology" however displays 1500 studies. Palliative studies are still largely descriptive and observational and there is a "need to design quantitative studies."

An ethical challenge to palliative research posed by Research Ethics Boards (REBs) is their view that palliative children are "particularly vulnerable". Three criteria hold sway: in so far as research posed a "minimal risk" to the subjects, REBs continue to have grave concerns about negatively impacting parents psychologically and adding to their traumatic experience. In terms of the "benefit" to the subjects, since there is little medical benefit, research can be seen to satisfy altruistic needs, help create meaning and legacy building and be both challenging and rewarding. The third, generation of "generalizeable knowledge", offers the strongest argument however the REB wants to see only a "minor increase over minimal risk" to subjects.

REBs try to protect children and families from "unreasonable risk" and may presume that (ethical) risks to palliative children in a proposed study are the same as non-palliative children. REBs may deny choice to palliative parents and children to participate.

REBs are extremely concerned about parental informed consent and lack of child autonomy to refuse to join a study. Also some parents do not wish that their child know they are dying. It is important that parents know they can decline or drop out at any time with no consequences. Pamela Hinds shows parents were as comfortable declining palliative research as non-palliative research.

Kim Widger started with the virtual impossibility of fully randomized controlled trials, the gold standard of medical research. Getting the minimum 40 participants group in a new model and old model cohort would be logistically difficult and ethically problematic for the relationship based discipline to deny half the group advanced palliative care. More feasible may be not randomized but quasi- experimental using two hospitals with different care models. They also are descriptive or use expert opinion about standards and norms of practise.

As to what research can measure, we look beyond health status (as all eventually die) to quality of death, quality of life, family health status, location of death and patient and family satisfaction: sometimes families describe horrible deaths but are satisfied with the care.

With children, the planning of care appears more important to families than the location of death.

Research creatively uses children drawing and mapping with a color pain scale and use of parents as proxy for their children based on the amount of time spent with them.

Research is complicated by the small numbers traversing a large number of disease groupings. Researchers must consider the best time and manner to communicate with parents and allow it to be easy to withdraw, which can compromise a study or instrument development's validity. Parents want choice as to whether they participate and the manner and they want reassurance their feedback gets back to caregivers.

Kim concluded by calling for sharing of evidence we do have, working as a team with parents, seeing the joys and rewards that come from the effort and addressing the "appalling representation" ethnographically due to expense and difficulty of finding research assistants, also pointing to a need for more international teams.


Adam Rapoport joined the Max and Beatrice Wolfe Children’s Centre, a part of the Temmy Latner Centre for Palliative Care, as the pediatric palliative care consultant in June 2009. He also works as a general pediatric hospitalist at the Hospital for Sick Children in Toronto, where he spends most of his time providing care to children with chronic complex conditions. After completing his final year of pediatric residency as Chief Resident, Adam entered into an Academic General Pediatric Fellowship. During his fellowship he obtained a Masters of Health Sciences in Bioethics at the University of Toronto and pursued further clinical training in the field of pediatric palliative care. His academic work focuses on the intersection of his 3 primary interests: pediatrics, palliative care and ethics. Adam and his wife Mia are kept very busy by their 2 daughters, Lilah (22 months) and Chloe (5 months)…and they love every minute of it!

Kimberley Widger began her PhD studies in September 2006 at the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto. She is supported in her studies with a Fellowship from the Canadian Institutes for Health Research. Prior to moving to Toronto, Kimberley was as a Clinical Nurse Specialist with the Pediatric Palliative Care Service at the IWK Health Centre and an Adjunct Professor at the Dalhousie University School of Nursing in Halifax, NS. She is a member of the Canadian Hospice Palliative Care Nursing Examination Committee and is on the executive of the Canadian Network of Palliative Care for Children. In her doctoral research she is developing an instrument to measure the quality of care provided to dying children and their families from the perspective of bereaved parents. Kim and her husband Mike are also kept busy with their two children, Rebecca (6 years) and Ryan (4 years).

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