Paeds · pain-palliative-and-end-of-life-care
Withholding and withdrawing life-sustaining treatment
Also known as Limitation of life-sustaining treatment in children · Withdrawal of intensive care in paediatrics · Best-interests decisions at the end of life · RCPCH framework for limiting treatment · Shared decision-making for life support in children
Fellowship guide to withholding and withdrawing life-sustaining treatment in children. Covers the ethical equivalence of withholding and withdrawing, the best-interests standard, parental authority and the zone of parental discretion, the RCPCH framework categories for limiting treatment, shared decision-making and documentation, escalation to clinical ethics and the court when disagreement persists, conscientious objection, and ANZ, UK and North American regional practice differences. Built for RACP, RCPCH/MRCPCH, ABP/ACGME and RCPSC examination.
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Red flags
- A persistent disagreement between the clinical team and the family about limiting life-sustaining treatment is not resolved by repeating the same conversation: escalate early to senior clinicians, the clinical ethics service and, when required, the court, rather than allowing conflict to harden at the bedside.
- Withholding and withdrawing life-sustaining treatment are ethically equivalent; the clinician who is comfortable not starting ventilation but refuses to stop it after a trial of therapy is applying an inconsistent standard that harms the child.
- A decision to limit treatment never means the withdrawal of care: symptom control, presence, dignity and family support intensify as disease-directed life support is reduced.
- Do not ask a parent to make the decision alone. Shared decision-making places the recommendation with the clinical team and the values with the family, so that the parent is not left carrying the whole moral weight of stopping treatment.
- When the child is an adolescent with capacity, their voice is sought and documented; excluding a capable young person from the goals-of-care conversation is a professional failure.
Life stages
Care settings
Clinical exam formats
Board mappings
- Clinical Sciences — Ethics and professionalism
- Clinical Practice — Communication
- Current 2026 PREP curriculum — Learning Objective 1.4.1: Communicate effectively and compassionately with children, young people and families including goals-of-care and end-of-life conversations
- Current 2026 PREP curriculum — Learning Objective 2.3.1: Recognise and manage the child with a life-limiting condition, including palliative care and end-of-life decisions
- Renewed curriculum for first-year trainees from 2027 — Learning goal 5: Ethical practice and end-of-life care
- Clinical Applications
- Medical Sciences
- Professional Qualities
- Long Cases
- Short Cases
- Communication stations
- 1. Professional values and behaviours
- 4. Professional skills and knowledge: Patient management
- 5. Communication
- 9. Leadership and team working
- Applied Knowledge in Practice (AKP)
- Theory and Science (TAS)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics Content Outline — Universal Task 8: Ethics and Professionalism
- General Pediatrics Content Outline — Universal Task 5: Communication
- Patient Care 5: Patient Management
- Interpersonal and Communication Skills 1
- Professionalism 1: Professional Conduct and Ethical Principles
- Systems-Based Practice 2
- Medical Expert
- Communicator
- Collaborator
- Professional
- Pediatrics: Palliative and end-of-life care
Overview & Definition
A six-month-old infant with severe hypoxic-ischaemic encephalopathy remains ventilator-dependent after a catastrophic out-of-hospital arrest. The intensive-care team judges that continued invasive support is not in the child's best interests; the parents ask that "everything be done". The fellowship task is to move from this scene to a safe, ethical, documented plan that puts the child first while holding the family. [1] [2] [3]
Withholding and withdrawing life-sustaining treatment in children are ethically equivalent acts governed by the best-interests standard, shared decision-making with the family, the RCPCH framework categories for limiting treatment, clear documentation, and early escalation to ethics and the court when disagreement persists; care, symptom control and family support intensify as life support is limited. [1] [2] [3]
This page is written so a candidate can answer examiner questions across definition, ethics, communication, documentation and escalation without reaching for another source. Regional frameworks differ in language, but the bedside sequence is stable: stabilise comfort, explore understanding, make a recommendation, share the decision, document, and escalate early when disagreement persists. [1] [2] [3] [4]
References8ShowHide
- [1]Larcher V et al. Making decisions to limit treatment in life-limiting and life-threatening conditions in children: a framework for practice. Arch Dis Child, 2015.PMID 25802250
- [2]Himelstein BP et al. Pediatric palliative care. N Engl J Med, 2004.PMID 15103002
- [3]Dworetz AR et al. Withholding or withdrawing life-sustaining treatment in extremely low gestational age neonates. Arch Dis Child Fetal Neonatal Ed, 2021.PMID 33082153
- [4]Gillam L et al. How Could Parents' Reasons Shift a Refusal of Treatment into the Zone of Parental Discretion?. Am J Bioeth, 2025.PMID 41108243
- [5]Vemuri S et al. Conceptualising paediatric advance care planning: a qualitative phenomenological study of paediatricians caring for children with life-limiting conditions in Australia. BMJ Open, 2022.PMID 35577468
- [6]Horridge KA et al. Advance Care Planning: practicalities, legalities, complexities and controversies. Arch Dis Child, 2015.PMID 25275088
- [7]Papadatou D et al. Home or hospital as the place of end-of-life care and death: A grounded theory study of parents' decision-making. Palliat Med, 2021.PMID 33307990
- [8]Moynihan KM et al. Epidemiology of childhood death in Australian and New Zealand intensive care units. Intensive Care Med, 2019.PMID 31270578