this difficult milestone requires a multidisciplinary decision involving the patient , whenever possible , the family , relatives , friends and the entire team of carers . stopping curative therapy will depend on medical considerations such as patient viability , futility of further aggressive therapy , and the exhaustion of all reasonable , potentially curative options . ready for the transition ( with appropriate , sensitive discussion in the older child ) . the importance of family acceptance of palliation versus cure can not be stressed enough and requires frank discussion , often over several hours . finally , but equally important , the acceptance of carers must never be overlooked and the personal view of each individual should be actively explored . ultimately , a unified team decision is required to avoid conflict that will only add to the distress of the child and his / her family . the transition to palliation in critically ill children does not involve a special set of medical ethics . indeed , the appropriate application of basic principles provides the platform on which difficult issues can be discussed and ethically acceptable decisions taken . hence , carers should strive toward beneficence ( essentially , in this context , do what is in the patient 's best interest ) whilst respecting the patient 's autonomy within the confines of his / her competence . all issues should be aired realistically , honestly and sympathetically , with due consideration for the patient's / family 's views , beliefs and wishes . as highlighted in part i of this series , for medical decisions to be ethically acceptable , they should be based on all the facts and points of view , free of bias and emotional overtones , and consistent from one patient to another . despite this ideal , often an accurate prediction of outcome ( and time - scales ) may be difficult in critically ill children , especially . prolongation of life through palliative care raises the issue of quality of life , an extremely subjective issue dependent on personality , inherent expectations ( realistic or otherwise ) , cultural background , religious beliefs and pressure from third parties . nevertheless , the caring team have a primary duty to maintain the quality of life at all times of , firstly , the child and , secondly , that of the family . in addition , they must present an honest assessment of the medical condition with realistic goals and argue toward the reasonableness , or otherwise , of continuing support . in practice , this can not be done without taking account of available resources , although healthcare  rationing in the terminally ill child can be very difficult . moreover , these problems are made doubly difficult in children unable to grasp the complex issues involved and , therefore , can not participate in the decision process and depend on third parties , usually their immediate family members . in the vast majority of cases , the latter correctly decides what is right for their child and for them as a family , and the role of the caring team is essentially to support and facilitate their decisions . rarely family members may , knowingly or unwittingly , hold strong views that may be biased by their own fears / beliefs and may not be in their child 's interest . at this point the caring professionals may be required to gently redress any misguided views to ensure that the child is not put through any unnecessary suffering . once a decision for palliative and not curative care is taken , the unified focus should be toward support , quality and not quantity of life . toward the later stages of palliative care respect must be shown for the wishes of the patient , the family and carers in the light of their background , culture and creed . throughout the dying process , great attention must be paid to the child and his family 's needs , both physical and emotional . whenever possible , decisions relating to where to die ? , with whom ? and how ? should be planned with the family . every effort should be made to enroll all support services ( e.g. hospice movement , social workers , friends , etc ) in order to fulfill the child 's and the family 's wishes . certainly in the majority of expected deaths ( e.g. cancer relapse ) this is eminently feasible , but it is extremely difficult with sudden , unexpected deaths ( e.g. post - accidental ) . the fact that each child will die only once and that this is invariably a major event for loved ones should form the basis for a modus operandi that strives to ensure that death is as  acceptable as possible . a concerted drive to respect the patient 's and family 's wishes , to ensure quality time , and  humanize the dying process can help enormously in allowing loved ones to  let go with resigned acceptance. in this regard , the spiritual needs of the family must be taken into consideration , and a conscious effort made to ask the family if they would like the appropriate religious counselor to attend . finally , it is entirely appropriate to decide , together with the family , against active resuscitation and the initiation of further extraordinary ( but futile ) measures . indeed , there is little to compare death after a frantic resuscitative attempt without family or friends , with the peaceful death of a child in his / her mother 's arms quietly surrounded by loved ones . for critically ill children , cure should not be pursued at all costs and there may come a time when cure is impossible and palliative care is in the child 's best interest . certainly , appropriate supportive care should continue at all times and must include the child 's family and friends . acceptance of death is very important , particularly for the child 's family , and can only be achieved after sympathetic , often prolonged and repeated discussion with loved ones . quality time for both family and their dying child and , ultimately , strive for one overriding goal : namely , to safeguard the child 's right to die with dignity .
despite the application of robust ethical principles , complex issues in child care commonly result in ethical dilemmas with no clear answers . 
 this is especially so in those  life and death decisions relating to continuing curative therapy or opting for palliative care . 
 as with many situations in paediatrics , these decisions are complicated by difficulties in establishing clear prognostic outcomes both in terms of disease progression and timescales , the child 's reliance on third parties , and appropriate use of resources . 
 great efforts are required to ensure family members are fully informed of the evolving clinical situation relating to their child , and helping them to accept the inevitability of death . 
 whenever possible , they should be encouraged to plan for their child 's death in a manner that is most appropriate for them as an individual family . 
 this article will explore the ethical principles which offer guidance in these situations , and strives toward : i ) establishing the acceptance of death by the child and family , ii ) ensuring  quality time for both family and their dying child and , iii ) safeguarding the child 's right to die with dignity .