Goals of Care: medically complex child
5m 29s encounter
This is an unedited encounter from ClinicalSim. Review the same recording, transcript, and feedback report the learner received.
The scenario
Your role
You are the gen peds resident leading a goals of care meeting for Eli Thompson. Your attending is there, but is encouraging you to lead this.
Eli Thompson is a 7-year-old boy with severe cerebral palsy, chronic lung disease, epilepsy, and G-tube dependence, admitted with recurrent respiratory failure requiring BiPAP support. Over the past year, Eli has had six PICU admissions for respiratory decompensation.
His mother, Monica Thompson, is increasingly exhausted. She worries that Eli is 'suffering more than living,' but feels guilty questioning aggressive interventions. The palliative care team has recommended a goals-of-care discussion to clarify family priorities and discuss future escalation decisions.
Monica is the decision-maker.
Objectives
- Understand Monica's experience and Eli's quality of life
- Validate Monica's exhaustion and guilt explicitly before discussing prognosis
- Communicate Eli's illness trajectory honestly
- Avoid recommending a specific care plan until Monica's values have been articulated and reflected
- Close with a clear next step and statement of continued support
Listen to the recording
Hear the full 5m 29s encounter
▶Transcript23
Thanks for meeting with me. It's just been so much recently. Maybe too much.
Yeah, Monica, you and Eli have been through so much, and I really would love to hear about what life has been like for you.
It's… hard to even describe. This is our sixth time in the PICU this year. I feel like I live between hospital rooms and packing bags.
And Eli… he's so tired. I'm so tired. I don't even know what day it is anymore, honestly.
Yeah. I mean, it's hard to keep track of it all, especially when we're back and forth so much.
Yeah. And people keep asking me how I'm doing, and I don't… I don't have an answer anymore. I just watch him.
I watch his breathing, I watch the monitors. I try to catch his little smile when it happens. That smile is… it's everything.
Yes. I mean, it sounds like you are Eli's expert, and, you know, I can't help but wonder how you feel like he's doing now.
Honestly? I don't know if he's… living, or if he's just enduring. And I feel so guilty even saying that out loud.
Like, what kind of mother thinks that? But the smiles are fewer now. He winces more.
And I just… I keep wondering if we're doing this for him or for us.
Wow, that feels very brave of you to say out loud, um, a- and to share with me.
Thank you. I've been carrying that for a long time. I haven't said it to anyone, not even to my husband.
I keep thinking if I say it, I'm giving up on him. And I'm not. I love him so much.
I just… don't want him to hurt anymore.
Hmm. When you look at him, do you feel like he's hurting now?
Yeah. I do. Not all the time, but… more than before.
When they suction him, when they move him, even sometimes when it's quiet, he gets this look. And I know that look. He's uncomfortable.
And the smiles I used to see every day… I might see one this week, if I'm lucky.
Wow. I, I can, uh, hear in your voice the sadness and maybe some grief, um, that's coming with how you're noticing Eli's changing body.
Yeah. It's like I'm losing him a little at a time. And everyone keeps talking about the next thing, the next treatment, the next procedure… and I nod, because that's what I've always done.
But inside, I'm just… I'm grieving. I've been grieving. And I didn't even have a word for it until just now.
Well, it seems like you've been really thoughtful about Eli's life, and it seems like you've made decisions that, um, you know, really promote longevity and comfort. And, and now you're seeing how his body's changing, and it feels like maybe, um, I don't know, maybe we're shifting a little bit more towards advocating for comfort.
Yeah. I think… I think that's where I am. I just didn't know if I was allowed to say it.
I don't want him to suffer so I can have more time. That doesn't feel like love anymore, that feels like… me being scared to let go. And he deserves better than that from me.
I mean, you've always been his advocate and you'll continue to be his advocate, and we will support you no matter what.
Thank you. That… that means more than you know. I've been so afraid the team would think I was giving up on him.
But I'm not. I'm just trying to love him the way he needs now, not the way I need.
Hmm. It's really lovely for you to share, and I, I just, I feel really honored to be a part of, um, Eli's care and a part of your team.
Thank you. Really. I think… I'd like to talk more about what comfort could look like for him.
Not today, maybe. I need to talk to my husband first. But soon.
Is that okay?
Absolutely. Um, how about you talk with your husband in the next day or two, and then you and I can talk again? Um, and, and just know that I'm here at any point in time when you're ready.
Okay. That sounds good. I'll talk to him tonight.
And… thank you. For not rushing me. For letting me just… say it.
I haven't felt this heard in a really long time.
No, we're here for you. Thank you for sharing with me. Um, and it sounds like, you know, we're, we're on the same page about, um, making sure that Eli is as comfortable as possible.
Yes. We are. Okay.
I'm gonna go sit with him for a while. Thank you… really.
Feedback
How to read this feedback
Every score is written as value / max, so you can see both the points earned and the points available. A spoken simulation can’t surface everything a real visit would, so when something couldn’t be judged fairly, the feedback labels it instead of holding it against you. Here’s what each label means.
(simulation limitation)The voice/text modality physically can't reveal it
e.g. eye contact, body language, facial affect, physical exam, EHR documentation
(no opportunity)The scenario never created the occasion
e.g. conversation ended before this step; situation never arose
(not applicable)Out of scope for this case
e.g. a domain that doesn't apply here
A not assessable item does not affect the score. The format did not give you a fair chance to show that behavior, so the item is excluded. That is different from “Not demonstrated,” where the moment was there and the skill didn’t come through. Only the second one reflects on how the encounter went.
For competency frameworks with levels, some scenarios can only assess a competency up to a certain level because the higher levels turn on behaviors a single spoken encounter can’t surface. When a scenario’s ceiling is below Level 4, that milestone is still shown for its formative value but is “Not in overall grade” . It doesn’t count toward the overall grade, so a case that can’t fully exercise a competency never reads as a shortfall.
Overall impression
- Strengths — This was a warm, attuned encounter. The learner excelled at respecting the mother — repeatedly and specifically honoring her courage and advocacy in a way that directly dissolved her fear of being judged for "giving up." Naming was tentative and accurate, support was explicit and paired with a concrete follow-up plan, and the learner consistently avoided premature reassurance, letting the mother reach her own words ("I've been grieving... I didn't even have a word for it until just now").
- Priority gaps — The main missed opportunities were in Exploring: several of the mother's most loaded disclosures (guilt, the "for him or for us" conflict) were answered with praise or interpretation rather than an invitation to say more, occasionally moving the learner's framing ahead of the parent's own. Understanding stayed slightly oriented to the care decision rather than fully legitimizing the raw emotion.
- Top action items
- When a parent voices internal conflict or guilt, ask one open exploring question before naming or reassuring.
- Add an explicit normalizing statement for the emotion itself ("any parent would feel torn like this").
- Keep the specific, action-anchored respecting and the concrete non-abandonment plan — these were the strongest parts of the encounter.
Formative use only. This feedback is AI-generated for education and professional development. It is not a clinical judgment or a credentialing determination, and must not be used as the sole basis for any promotion, remediation, credentialing, or other consequential decision. Responsibility for evaluation and personnel decisions stays with the program and its faculty.
References
- Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: a framework for goals of care conversations. J Oncol Pract. 2017;13(10):e844-e850. doi:10.1200/JOP.2016.018796
- Mack JW, Joffe S. Communicating about prognosis: ethical responsibilities of pediatricians and parents. Pediatrics. 2014;133(Suppl 1):S24-S30. doi:10.1542/peds.2013-3608D
- Feudtner C, Womer J, Augustin R, et al. Pediatric palliative care programs in children's hospitals. Pediatrics. 2013;132(6):1063-1070. doi:10.1542/peds.2013-1286
- Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167(5):453-460. doi:10.1001/archinte.167.5.453
- Accreditation Council for Graduate Medical Education; American Board of Pediatrics. Pediatrics Milestones, Version 2. Chicago, IL: ACGME; July 2021.
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