Dilemmas and difficulties involving end-of-life decisions and palliative care in children.

This review discusses the main dilemmas and difficulties related to end-of-life decision's in children with terminal and irreversible diseases and propose a rational sequence for delivering palliative care to this patients' group. The Medline and Lilacs databases were searched using the terms 'end of life', 'palliative care', 'death' and 'terminal disease' for articles published in recent years. The most relevant articles and those enrolling pediatric patients were selected and compared to previous authors' studies in this field. The current Brazilian Medical Ethics Code (2010) was analyzed regarding end-oflife practices and palliative care for terminal patients. Lack of knowledge, insufficient specific training, and legal concerns are the main reasons why end-of-life decisions in terminal children are based on medical opinion with scarce family participation. The current Brazilian Medical Ethics Code (2010) fully supports end-of-life decisions made consensually with active family participation. Honest dialogue with the family regarding diagnostic, prognostic, therapeutic and palliative care measures should be established gradually to identify the best strategy to meet the child's end-of-life needs. Treatment focused on the child's welfare combined with the family's participation is the basis for successful palliative care of children with terminal diseases.