Paeds · professional-practice-and-evidence
Best-interests decisions and treatment limitation
Also known as Best-interests standard in paediatrics · Limitation of life-sustaining treatment in children · Withholding and withdrawing treatment · Goals-of-care and treatment-limitation decisions · Medical futility in children · DNACPR and Allow Natural Death decisions · End-of-life decision-making for children
Fellowship-level approach to best-interests decisions and treatment limitation in paediatrics: the best-interests balance of benefits against burdens, the zone of parental discretion, futility, withholding and withdrawing life-sustaining treatment, goals-of-care conversations, DNACPR/Allow Natural Death, ethics consultation and the courts, paediatric palliative care, and regional differences across ANZ, UK, US and Canada.
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Red flags
- Equating the emotional weight of withdrawing treatment with a moral difference from withholding it
- Declaring futility unilaterally without a second senior clinician, the team and ethics input
- Treating an isolated DNACPR order as a complete limitation plan when the rest of care is unaddressed
- Conflating brain death with a treatment-limitation decision
- Continuing invasive treatment past the point of benefit because no one raised limitation early
- Excluding the child or young person from a conversation that concerns them directly
- Using a family member as interpreter for a high-stakes limitation meeting
- Unilateral clinician withdrawal of treatment the family still wants
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Ethics and professional practice
- Current 2026 PREP curriculum — Learning Objective 1.2.1: Communicate with a child or young person in a way which is appropriate to the position of that child within their own culture
- Current 2026 PREP curriculum — Learning Objective 1.2.2: Communicate with parents or carers
- Renewed curriculum for first-year trainees from 2027 — Learning goal 12: Communication with patients, families, and health professionals
- Renewed curriculum for first-year trainees from 2027 — Learning goal 9: Clinical assessment and management – child safety and maltreatment
- Professional practice: best-interests decisions, treatment limitation and end-of-life care for children and young people
- Clinical Applications
- Ethics and law in paediatric practice
- Long Cases
- Short Cases
- Communication stations
- 2. Professional skills and knowledge: Communication
- 4. Professional skills and knowledge: Patient management
- 1. Professional values and behaviours
- 9. Safeguarding vulnerable children
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Ethics, consent and law
- Communication
- History
- Clinical
- General Pediatrics Content Outline — Domain 23: Ethics
- General Pediatrics Content Outline — Domain 1: Preventive Pediatrics/Well-Child Care
- General Pediatrics EPA 10: Leading Interprofessional Teams to Provide Collaborative, Family-Centered Care
- Ethics of treatment limitation, futility and end-of-life care in children
- Professionalism 1: Professional Behavior and Ethical Principles
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Patient Care 4: Clinical Reasoning
- Systems-Based Practice: legal and ethical dimensions of end-of-life care
- Professional
- Communicator
- Pediatrics: Core EPA #10 — Leading discussions with patients, families and/or other health care professionals in emotionally charged situations
- Best-interests decisions and limitation of life-sustaining treatment in paediatrics
Overview & Definition
Picture a seven-year-old with a progressive neurodegenerative disease back in PICU for the third time this winter, now ventilated and not weaning. The team believes intensive care can no longer help her. Your job is not to decide alone, and it is not to walk away. It is to work out, with the family, what is now in this child's best interests. [1]
Four terms do most of the work. The best-interests standard is the test for a child who cannot decide for themselves: it balances the benefits of a treatment against its burdens from the child's point of view. Life-sustaining treatment (LST) is any treatment that prolongs life without curing the underlying condition — ventilation, CPR, artificially delivered nutrition and hydration, cardioactive drugs. Withholding means never starting a treatment; withdrawing means stopping one already begun, and the two are morally equivalent. [4] [1]
Limitation of treatment is the umbrella term for deciding not to start, or to stop, life-sustaining interventions judged no longer beneficial. Futility describes a treatment that cannot achieve its physiological goal. And a goals-of-care order documents what the team will and will not offer, and what comfort will be provided — it is far more than a single resuscitation decision. [1] [4]
[1] [4]References12ShowHide
- [1]Larcher V, Craig F, Bhogal K, Wilkinson D, Brierley J 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]Diekema DS Parental refusals of medical treatment: the harm principle as threshold for state intervention. Theor Med Bioeth, 2004.PMID 15637945
- [3]Diekema DS Revisiting the best interest standard: uses and misuses. J Clin Ethics, 2011.PMID 21837884
- [4]Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med, 2008.PMID 18431285
- [5]Wilkinson D The window of opportunity for treatment withdrawal. Arch Pediatr Adolesc Med, 2011.PMID 21383270
- [6]Wilkinson D In Favour of Medical Dissensus: Why We Should Agree to Disagree About End-of-Life Decisions. Bioethics, 2016.PMID 25908398
- [7]Kon AA, Davidson JE, Morrison W, Danis M, White DB Shared Decision Making in ICUs: An American College of Critical Care Medicine and American Thoracic Society Policy Statement. Crit Care Med, 2016.PMID 26509317
- [8]Garros D, Rosychuk RJ, Cox PN Circumstances surrounding end of life in a pediatric intensive care unit. Pediatrics, 2003.PMID 14595079
- [9]Himelstein BP Palliative care for infants, children, adolescents, and their families. J Palliat Med, 2006.PMID 16430356
- [10]Morrison W, Clark JD, Lewis-Newby M, et al. Titrating Clinician Directiveness in Serious Pediatric Illness. Pediatrics, 2018.PMID 30385625
- [11]Barry A, Prentice T, Wilkinson D End-of-life care over four decades in a quaternary neonatal intensive care unit. J Paediatr Child Health, 2023.PMID 36495233
- [12]Freckelton I, McGregor S Refusal of potentially life-saving treatment for minors: The emerging international consensus by courts. J Law Med, 2016.PMID 30136557