• Mithya Lewis-Newby, Jonna D Clark, Warwick W Butt, Karen Dryden-Palmer, Christopher S Parshuram, and Robert D Truog.
• Divisions of Pediatric Critical Care Medicine and Pediatric Bioethics, Department of Pediatrics, University of Washington, Seattle, WA.
• Pediatr Crit Care Me. 2018 Aug 1; 19 (8S Suppl 2): S33-S40.

ObjectivesTo examine the circumstance of death in the PICU in the setting of ongoing curative or life-prolonging goals.Data SourcesMultidisciplinary author group, international expert opinion, and use of current literature.Data SynthesisWe describe three common clinical scenarios when curative or life-prolonging goals of care are pursued despite a high likelihood of death. We explore the challenges to providing high-quality end-of-life care in this setting. We describe possible perspectives of families and ICU clinicians facing these circumstances to aid in our understanding of these complex deaths. Finally, we offer suggestions of how PICU clinicians might improve the care of children at the end of life in this setting.ConclusionsMerging curative interventions and optimal end-of-life care is possible, important, and can be enabled when clinicians use creativity, explore possibilities, remain open minded, and maintain flexibility in the provision of critical care medicine. When faced with real and perceived barriers in providing optimal end-of-life care, particularly when curative goals of care are prioritized despite a very poor prognosis, tensions and conflict may arise. Through an intentional exploration of self and others' perspectives, values, and goals, and working toward finding commonality in order to align with each other, conflict in end-of-life care may lessen, allowing the central focus to remain on providing optimal support for the dying child and their family.

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