Paediatric Palliative Care – Clinical Fellowship

I About The Programme
II Assessment and Evaluation
III Target Audience and Eligibility Requirements
IV Other Information
 

I About The Programme

Name of Programme

Clinical Fellowship in Paediatric Care

Overview

The KKH Women’s and Children's Hospital ranks among the best specialized hospitals for paediatrics in Asia-Pacific. It is also the first medical institution outside of North America to be recognized as a ChildKind Hospital by ChildKind International, highlighting excellence in pain management and education.

The KKH Paediatric Palliative Care (PPC) service was established to deliver both clinical excellence and academic achievement. The PPC team serves KKH’s cancer service as well as managing non-cancer patients referred from the range of specialties including the children’s and neonatal ICUs, cardiology, neurology, etc.

The KKH PPC service partners closely with the community palliative care service HCA Hospice’s Star PALS team to deliver holistic, individualized and continuous care to the patient and family wherever they wish to be cared for.

HCA Star PALS (Paediatric Advanced Life Support) is Singapore’s only paediatric palliative home care service. The service supports children and young persons with life-limiting conditions through a multidisciplinary team comprising doctors, nurses, social workers, and allied health professionals.

With a strong emphasis on holistic, patient-centred and family-focused care, HCA Star PALS delivers medical, psychosocial and emotional support to patients and their families in their preferred place of care—often the home. The team works closely with KKH and other hospitals to ensure continuity of care across settings, journeying with families throughout the end-of-life chapter and empowering them to navigate complex medical journeys with dignity and hope.

This Fellowship programme is delivered jointly between KKH and HCA Star PALS.

This fellowship programme offers fellows with the opportunity to be acquainted with palliative care to patients with wide-ranging pathologies, both in the hospital and community settings. Within KKH, fellows will participate in inpatient ward rounds, multi-disciplinary team (MDT) meetings and outpatient clinics. With the HCA Star PALS team, there are opportunities to attend home visits and work alongside a multi-disciplinary, community team. Fellows can also learn how clinical governance, risk management and team organization apply in the community setting.

Aim of Programme

This comprehensive fellowship programme in Paediatric Palliative Care aims to develop the knowledge, skills and attitudes for a paediatrician or paediatric specialist, with a special interest in palliative care.

Duration of Programme

6 months

Learning Outcomes

• Deliver paediatric palliative care as a paediatric clinician with a special interest in this specialty.
• This takes into account the patient’s bio-psychosocio-spiritual needs and engages the multi-disciplinary team in supporting the child and family who are facing a life-limiting illness.

Content Areas

The programme covers the following areas:

a. Introduction to paediatric palliative care (PPC)

• Understand the role of PPC approach and services in the care of a patient with life-limiting illness
• Identify opportunities where PPC may benefit patients
• Demonstrate foundational skills in person‐centered care, a bio-psychosocial-spiritual model of care
• Engage in team-based delivery of PPC

b. Pain assessment and management

• Describe basic pain physiology and appreciate the prevalence of nociceptive and neuropathic pain in the PPC context
• Recognise and assess pain across different age groups and cognitive abilities (verbal/non-verbal) using appropriate pain assessment tools
• Distinguish between acute and chronic pain syndromes
• Apply the WHO approach to pain management in patients with chronic and advanced disease
• Understand and use common pharmacological agents (including opioids) to manage pain in a palliative setting
• Understand and deploy non-pharmacological measures as part of multi-modal analgesia

c. Symptom management (beyond pain management)

• Understand and implement pharmacological and non-pharmacological management strategies for common symptoms including dyspnea, delirium, anorexia, constipation, seizures, nausea, and vomiting, anxiety, insomnia, depression

d. Communicating with children and families facing life-limiting illness

• Understand and implement family-centred care
• Identify key end-of-life issues that require sensitive communication, such as managing patient’s and family’s expectations regarding prognosis, managing uncertainty
• Develop a communication model for managing challenging conversations
• Develop a communication model for initiating advance care planning
• Recognise and seek support for, or develop strategies for specific situations such as profound parental denial, mutual pretense, parental request to withhold information from the child

e. Maintaining quality of life

• Understand the social determinants influencing a patient’s sense of self, and quality of life
• Engage the multi-disciplinary team to provide multi-dimensional support to enhance the patient’s and family’s quality of life.

f. End of life care in children

• Recognise the clinical signs of when a child is approaching the end of his/her life
• Appreciate the role and challenges of prognostication in PPC
• Demonstrate basic skills and attitudes in advance care planning / goals of care discussions with families (and if appropriate, with patients)
• Analyze challenges in caring for the imminently dying patient
• Demonstrate basic knowledge and skills in symptom management planning for the terminal phase of illness
• Appreciate and access support for the psycho-emotional and spiritual needs of the dying child and their family during the terminal phase of illness

g. Psychological support and spiritual care

• Recognise psychological and spiritual distress in the patient and family and how to access support
• Appreciate culture-specific priorities in a multi-faith, multi-belief society like Singapore
• How to facilitate legacy building and memory making

h. Grief and bereavement in families

• Support anticipatory grief in patient, family and the medical team
• Addressing the family’s grief and bereavement needs
• Recognise and seek support for complicated grief in family members
• Address the misconceptions of grief
• Identify family-centered strategies to address grief

i. Self-care for healthcare professionals

• Recognise the importance of self-care as a core tenant of being a PPC provider
• Appreciate and develop own professional identity
• Examine own triggers for stress, burnout, and compassion fatigue  
• Develop a self-care plan to encourage personal growth and resilience

Training Methods

Method of Supervision:
In the hospital setting at KKH, the Fellow will be supervised by an SMC-approved supervisor from the KKH Paediatric Palliative Care service, for all clinical contacts.

The Fellow will have the opportunity to:

• Directly observe the different members of the teams in clinical settings (inpatient, outpatient)
• Assist or carry out under supervision, the assessment of the child and family’s physical, psychosocial and spiritual needs
• Observe and assist the team in formulating management plans and engage the wider MDT to support the patient and family
• Observe, participate in and contribute to quality improvement (QI), training, service development

In the community setting with the HCA Star PALS team, the Fellow will have the opportunity to do the following in the pediatric and adult home hospice teams:

• Directly observe the different members of the team by participating in joint home visits 
• Assist or carry out under supervision, the assessment of the child and family’s physical, psychosocial and spiritual needs
• Observe and assist the team in formulating management plans and engage the wider MDT to support the patient and family
• Learn how to conduct goals-of-care discussions in the home environment, including advance care planning
• Observe and contribute to bereavement support activities and legacy-building interventions

Team of Experts

II Assessment and Evaluation

Fellows will need to demonstrate their proficiency level based on the following  competencies:

1) Patient Care

• Manage patients in appropriately and safely at a level expected of a paediatrician with a special interest in Palliative Care
• Demonstrates appropriate technical skills and when to seek advice and expertise of senior or specialist colleagues
• Possess situational awareness as the patient’s condition changes and responds appropriately

2) Medical Knowledge

• Possess appropriate level of general paediatric knowledge
• Demonstrates logical and analytical thought processes in decision making
• Is motivated and seeks opportunities to update and broaden knowledge in area of Palliative Medicine.

3) Practice-Based Learning and Improvement

• Continuous self-directed learning on top of the education programme.
• Reads up and familiarises oneself for the upcoming clinical work.
• Asks/seeks knowledge and guidance from seniors or specialists appropriately.
• Copes well in stressful clinical situations.

4) Interpersonal and Communication Skills

• Collegial and respectful of colleagues.
• Can communicate effectively and empathetically with the patient and family.
• Interacts effectively with colleagues and fellow healthcare professionals.

5) Professionalism

• Professionalism
• Must be professional in all aspects of patient care and interaction.
• Shows initiative and interest.
• Accepts responsibility and respectful of patient’s needs.
• Demonstrates integrity and ethical behaviour.
• Is collegial and a good team player

6) Systems-Based Practice

• Demonstrates patient safety principles
• Effectively coordinates patient care with other health providers
• Is aware of work processes and workflows within the clinical area
• Identifies ways to improve current systems

Formative assessment:

• Regular evaluation between Clinical Fellow and Supervisor at KKH PPC team and HCA Star PALS team
• Case reflections and log book of competencies achieved
• Regular case presentations at department MDT meetings

Summative assessment:

• Periodical assessment reports as required by Singapore Medical Council
• Review of log book of competencies achieved after 3 months with KKH PPC team and after 3 months with HCA Star PALS

Feedback:

• End-of-training feedback form as required by Singapore Medical Council
• End-of-training feedback session with KKH and HCA Star PALS heads of servicel.

Evaluation Process

The general overall grading system evaluates the fellow’s performance upon completion of the fellowship programme. All fellows will be given a general overall grading status at the end of the fellowship programme based on the grading criteria requirements incorporating the six competencies-based knowledge, skills and performance that fellows must demonstrate throughout the programme.

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Options for fellows who were graded with a (USP) for unsatisfactory performance

• If a fellow shows unsatisfactory performance (USP) during the first 3 months of a posting, a Performance Improvement Programme (PIP) will be developed in collaboration with the fellow.
• The PIP will outline specific goals, expectations, and support measures to address identified areas of concern.
• The fellow will be given the next 3 months to demonstrate improvement based on the agreed-upon plan.
• Progress will be closely monitored and reviewed at regular intervals throughout the improvement period.

III Target Audience and Eligibility Requirements

Target Audience

Fellows working in a general paediatrics, a relevant paediatric specialty (e.g. Paediatric Oncology), or in adult palliative medicine, who have a special interest in Paediatric Palliative Care.

Pre-requisite/Eligibility Requirement(s)

General requirements for Temporary Registration for training (required by SMC):

• A basic medical degree from an accredited medical university or medical school
• Passed the relevant national licensing examination in the country of conferment of basic degree, where applicable
• Evidence of at least 12 months houseman-ship / internship with a certificate of satisfactory completion of houseman-ship or equivalent
• Been registered as a medical practitioner in the country where he/she is currently practicing
• Been certified to be of good standing by the Medical Council or the relevant national authority

Note: The doctor should be in active clinical practice (and been registered as a medical practitioner in the countries of practice) for the 3 years preceding the application for medical registration in Singapore.

In addition to the above criteria, Clinical Fellows must:

• Have a minimum of 3 years working experience as a medical officer (or equivalent)
• Fulfill English Language requirements of SMC if the medium of instruction for the basic medical qualification is not in English
• Preferably have obtained a postgraduate diploma or medical degree in his/her country or overseas
• Be sponsored by (i) the government, or (ii) regional health authority or (iii) an appropriate institution in the home country. For (d)(iii), the doctor must be on current full-time employment (40 hours or more per week) with the sponsoring institution.

As a Clinical Fellow, the doctor will be allowed to be involved in patient care and make entries in patients’ case note, communicate care plans to patients and fellow healthcare professionals, and perform procedures and write prescriptions under direct supervision or Level 1 supervision under SMC’s Supervisory Framework.

Department’s requirement, if any (only for Fellows in this subspecialty):

• Basic medical degree from an accredited medical university or medical school.
• To be training in a specialty where they care for children with life-limiting conditions.

IV Other Information

Number of Training Places

One intake every July

https://www.hca.org.sg/star-pals/

Course Fees

Training Fees: S$3,000.00 per month (excluding GST)

Funding

Preferably self-funded or funded by external sources

Certification

A certificate of completion will be presented to each Fellow at the completion of the programme.