Ethics, End-of-Life Care, Professionalism, and Systems of Care
Decision-making
Parents or guardians provide surrogate consent using the best-interests standard, while children should give assent when developmentally able, generally from about 7-13 years. Parental authority is not absolute; clinicians may seek ethics consultation or court involvement when a decision causes serious harm. Withdrawing and withholding life-sustaining treatment are ethically equivalent when the goals of care are the same.
End-of-life care
High-quality palliative care addresses pain, dyspnea, secretions, anxiety, and family support. Discuss organ donation sensitively and separately from the withdrawal conversation when possible. Brain death determination follows institutional protocols with prerequisites met and confounders excluded.
Professionalism and systems
Disclose errors honestly, document carefully, and participate in quality improvement and morbidity and mortality review. Recognize moral distress and burnout. Resource allocation during disasters uses triage criteria applied consistently, not first-come-first-served. Systems of care include regionalized referral, telemedicine, transport teams, and social determinants that shape outcomes.
Traps
Do not equate disagreement with incapacity. Do not present a single option as the only choice when reasonable alternatives exist. Avoid conflating sedation for comfort with intention to hasten death. Cultural and religious beliefs must be explored rather than overridden.
Worked rule
A child with a devastating neurologic injury has a poor prognosis. Hold a structured family meeting, clarify the child's values and the family's goals, explain the option of comfort-focused care, and document consensus. If conflict persists, involve the ethics committee before any unilateral decision.