Goals of Care in Progressive Osteosarcoma
8m 4s 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 pediatric hematology-oncology clinician caring for Maya Patel, an 11 year old female with metastatic osteosarcoma of the left distal femur, who is admitted to the heme/onc inpatient unit with dyspnea.
Fourteen months ago Maya was diagnosed with osteosarcoma of the distal femur with pulmonary metastases, and she completed multimodal therapy with MAP (high-dose methotrexate, doxorubicin and cisplatin) and surgical resection/reconstruction in addition to bilateral thoracotomies for her pulmonary disease. Routine imaging six months after the end of therapy showed relapsed disease in in her spine and lungs for which she and dad opted to pursue IV ifosfamide and etoposide.
It is now weeks later and she has presented to the ER with new respiratory distress. Imaging obtained on admission shows a further increase in the number of pulmonary metastases plus a new moderate-sized left pleural effusion. She was admitted to the inpatient hematology-oncology unit, on low flow nasal cannula. She is comfortable appearing but tachypneic, and she says she feels short of breath.
You are meeting Ravi, Maya's father, in a family conference room down the hall from Maya's room. Maya is not present. Ravi has already asked the bedside nurse when a chest tube can be placed.
He has also asked the team not to tell Maya that her scans are worse.
Objectives
- Deliver a clear headline that Maya's disease has progressed on ifosfamide and etoposide.
- Make room for Ravi's emotion and responses throughout the conversation.
- Explore the family's values and use this to make recommendations around how to manage her dyspnea (ie not intervening vs. offering a single large-volume thoracentesis vs. chest tube placement.)
- Respond to Ravi's request that Maya not be told, and advocate for developmentally appropriate inclusion of Maya in this conversation.
- Introduce the idea of concurrent palliative and hospice care and the benefits this may provide.
Listen to the recording
Hear the 8m 4s recording
The recording ends while the father asks how to talk with Maya about the worsening scans. The feedback covers the conversation up to that point.
▶Transcript37
They said you wanted to talk to me about the fluid.
Hi, Mr. Patel. This is Dr. Doyle. Um, you may remember I'm Maya's, um, oncologist, coming in to give you an update.
Yeah, I remember. Okay, so when are you putting the tube in? She is working to breathe in there, you can see it.
The fluid is on the left, you told me that. Take it out, she breathes.
Um, Ravi, I just... It seems like you have a pretty good understanding of what's going on right now, but can you tell me a little bit more about what you think is going on with the fluid and her underlying cancer?
Okay, so the chemo, the ifosfamide and the etoposide, it's been four weeks. There is fluid on the left side, that's what's making her breathe like that. You drain it, she's off the oxygen, she can talk, she can eat.
That's what I understand. The scan last week was worse, you said something changed, but the fluid is the thing right now. So when can you put the tube in?
Hmm. Yeah. So, Ravi, um, I, I have some hard news.
Is it okay if we, we talk about something that might be a little bit difficult to hear?
...Just say it.
Okay. Um, so I think we're in a different place with Maya's cancer now. Um, the-- This fluid on her lungs, the effusion, is a sign that her latest treatment has, has not worked and her cancer is progressing.
... Priya... she was on the ventilator. At the end. I was there.
You're not putting my daughter on a ventilator.
Oh, is Priya your wife?
Yeah. Three years ago. Cancer.
She was in the ICU, they put her on the ventilator, and... that's how it ended. I was in the room. So no. Not Maya.
That is not happening to her.
Oh.Okay. That's actually really important information for us to know, Ravi, and I really imp- appreciate you sharing, sharing that story with me.
Okay. So ...
And...
...you ...
I'm sorry.
Go ahead.
Ravi, can you, um, explain that again? What did you mean by that?
What do you mean, explain it again? My wife died on a ventilator. In the ICU.
Three years ago. I was sitting right there when they, when they turned things off. And now you're telling me Maya's cancer is growing.
So in my head, that's where this goes. And I'm telling you, that is not where we're going. Not with her.
Mm.
So what are you telling me? That the chemo didn't work.
Mm. Yeah, I know this is so difficult to hear, and especially difficult with what you've been through in the past with your wife. Um, we, we really wanna support you through what, what is, wha- what's coming next.
Okay. So what is coming next. Because I have been reading.
There's regorafenib, it's a pill, I have the page right here on my phone. Why is she not on that? And what about the tube, for the fluid.
She still can't breathe. That part hasn't changed.
Yeah. So we do need to do something to make Maya more comfortable at this point, um, and I'd like to make a recommendation at this time based on what you've told me about what you value for Maya and how difficult it was seeing your wife connected to a breathing machine.
Okay. Go ahead.
So, there is a procedure that we could do to remove fluid from the lung and hopefully make her more comfortable with just the oxygen that she's on right now.
Okay. So a tube. When?
We, we could do that sometime today after talking to the surgeons. But, Ravi, I, I do, I do wanna let you know that that's not going to change the underlying process, um, and that she's, she's dying from her cancer at this point.
...she's dying. Okay. So the tube ... does it even help?
If, if it's the cancer, and not just the fluid. Does taking the fluid out ... does she actually breathe better?
Yes. I think that there is a good chance that taking off the fluid right now will help her be more comfortable. And that might be our goal at this point, is to make Maya as comfortable as possible with the time she has remaining, um, lip smack and, and to be able to, to spend time with you.
Yeah. Okay. So ... if we do this.
The, the drainage. Is it a tube that stays in, or...? Because I don't want, I don't want another thing.
Another thing attached to her. She has had so many things.
That's a really good question. Um, so that is an option to have a tube that stays in, but there's also another option, which is to briefly put a needle in, take out the fluid so that she's immediately more comfortable, um, and, and see where, where that gets us for the moment.
Okay. So you go in once, you take the fluid off, and we see. And if it helps ... she breathes easier, she can talk, she can, I don't know, sit up, eat something ... then we know the fluid was doing it.
And if it doesn't help ... ...then it's the cancer in the lungs, not the fluid. That's what you're telling me.
That is what I'm telling you. And if it is the cancer in her lungs or it temporarily works and the fluid reaccumulates, we do have medications that we can give Maya to, to make her more comfortable and to make her feel less hungry for air.
Okay. Okay. Let's do the, the needle one.
The one time. And see. ...she's going to ask me what it's for. She's not stupid.
She's eleven, she's been doing this a year, she counts the procedures out loud. She told me last week she was tired of getting poked. And I changed the subject.
I ... I didn't know what to say to her.
Okay. Mm. Yeah, that, that's so difficult, um, for you as a parent, and I'm sure for, for Maya as well.
Um, you and I can come up with a plan together to, to talk to her about this next procedure and, and what might be coming in the near future.
Yeah. I don't ... I don't want her to know the scans are worse. I know you probably think she should.
But I'm, I'm scared if she hears that, she stops trying. She's been fighting for a year. If she thinks it's not working ... ...but I don't know how to sit there and not say it either.
So. What would you, what would you actually say to her.
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: The learner handled a very difficult pediatric goals-of-care conversation with honesty and warmth. The reframe and the plain-language disclosure that Maya is dying were courageous and clear, and the planning step adapted intelligently to the father's fear of another device attached to his daughter, demonstrated in Learner said: "there's also another option, which is to briefly put a needle in, take out the fluid so that she's immediately more comfortable".
- Priority gaps: The middle of REMAP was thin: the learner relied on the father to volunteer his values rather than actively mapping them, and never synthesized and confirmed those values before recommending. At the most emotionally charged moment: the disclosure of his wife's ventilator death: the learner asked him to repeat the story rather than staying with the feeling, which briefly ruptured the connection.
- Top action items
- Ask an explicit mapping question about what matters most and what the father fears before recommending.
- Synthesize the values you hear and confirm them out loud before pivoting to a plan.
- When emotion peaks, name it and pause rather than requesting more information.
- Close loops you open: return to the father's question about what to tell Maya with concrete language.
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
Elliott L, Loeb DM, Trucco M. Management of pediatric bone sarcomas. Curr Opin Pediatr. Published online December 8, 2025. doi:10.1097/MOP.0000000000001516
Hiraga H, Machida R, Kawai A, et al. Methotrexate, doxorubicin, and cisplatin versus methotrexate, doxorubicin, and cisplatin + ifosfamide in poor responders to preoperative chemotherapy for newly diagnosed high-grade osteosarcoma (JCOG0905): a multicenter, open-label, randomized trial. J Clin Oncol. 2025;43(16):1867-1876. doi:10.1200/JCO.24.01158
Baxter JS, Montiel Equihua C, Molenaar JJ, et al. Paediatric therapeutic development workshop on osteosarcoma. Br J Cancer. Published online August 18, 2026. doi:10.1038/s41416-026-03145-7
Wessel KM, Janeway KA, Davis LE, et al. Considerations for clinical trial design in relapsed and refractory osteosarcoma: an FDA symposium. Clin Cancer Res. Published online March 2, 2026. doi:10.1158/1078-0432.CCR-25-3421
Meltzer PS, Helman LJ. New horizons in the treatment of osteosarcoma. N Engl J Med. 2021;385(22):2066-2076. doi:10.1056/NEJMra2103423
Gaspar N, Hung GY, Strauss SJ, et al. Lenvatinib plus ifosfamide and etoposide in children and young adults with relapsed osteosarcoma: a phase 2 randomized clinical trial (OLIE/ITCC-082). JAMA Oncol. 2024;10(12):1645-1654. doi:10.1001/jamaoncol.2024.4381
Kempf-Bielack B, Bielack SS, Jürgens H, et al. Osteosarcoma relapse after combined modality therapy: an analysis of unselected patients in the Cooperative Osteosarcoma Study Group (COSS). J Clin Oncol. 2005;23(3):559-568. doi:10.1200/JCO.2005.04.063
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