Characterizing Communication Strategies to Open the Door to Difficult Conversations in Pediatric Serious Illness

Key Message : This prospective, longitudinal study identified and characterized ‘open door’ moments in serious illness discussions, in which pediatric oncologists, children with advanced cancer, and caregivers each played an active role in creating opportunities to segue discussion from scan results towards prognosis and goals of care .

Abstract: Context: Most children with serious illness and their caregivers want to receive honest, direct information about prognosis, yet clinicians often avoid or soften prognostic disclosure (1-5).


Objective: To characterize communication strategies that enable clinicians to transition from discussing scan results to exploring prognosis and goals of care in advanced childhood cancer.


Methods: In this prospective longitudinal study, serial disease reevaluation discussions between children with advanced cancer, caregivers, and clinicians were audio-recorded for 24 months or until death. Inductive content analysis was used to generate a definition for dialogue that facilitated a transition (i.e., ‘open door’ moment) into discussion about prognosis and goals of care. Transcripts were deductively coded to identify and describe open door communication, including who initiated the dialogue and types of approaches used.


Results: Forty-nine encounters comprising >21 hours of dialogue were recorded between 17 patients/families and their teams. Open door moments encompassed statements or questions that prompted exploration of advancing illness, prognosis, and non-curative goals of care. A total of 154 open door segments occurred in 78% of encounters (n=38). Oncologists initiated open door moments more often (82.5%) than patients (3.9%) or caregivers (13.6%). Six communication strategies comprised open door communication: 1) recognition of suffering; 2) assessment of prognostic understanding; 3) exploration of quality-of-life goals; 4) promotion of agency; 5) reduction of urgency; 6) acknowledgement of incurable disease. Following an open door moment, patients/caregivers more often stepped through the door (i.e., engaged in dialogue about prognosis and goals of care) when oncologists used patient/caregiver responses to guide their next questions, rather than pivoting to describe treatment options, which often resulted in closing the door.


Conclusion: These findings describe actionable strategies to support clinicians in the difficult task of ‘opening the door’ into conversations about prognosis and goals of care, which will inform future communication skills training initiatives.

References: 1. Kaye EC, Stall M, Woods C, et al. Prognostic Communication Between Oncologists and Parents of Children With Advanced Cancer. Pediatrics 2021;147:e2020044503.
2. Porter AS, Woods C, Stall M, et al. Mismatch between Pediatric Oncologists' Private and Parent-Facing Prognostic Communication: Communication Patterns Used to Soften Prognostic Disclosure. J Palliat Med 2023;26:210-219.
3. Porter AS, Woods C, Stall M, et al. Oncologist approaches to communicating uncertain disease status in pediatric cancer: a qualitative study. BMC Cancer 2022;22:1109.
4. Heijsters FACJ, van Eick MD, van Nassau F, et al. What Parents of Children Born with a Cleft Lip and/or Palate Want to Know About the Care for their Child. Cleft Palate Craniofac J. 2025;62:853-862.
5. Boss RD, Lemmon ME, Arnold RM, Donohue PK. Communicating prognosis with parents of critically ill infants: direct observation of clinician behaviors. J Perinatol. 2017;37:1224-1229.