Ethical dilemmas and intervention strategies in doctor-patient-family communication in end-of-life pediatric oncology: a narrative review.
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BACKGROUND AND OBJECTIVE: Communication in end-of-life pediatric oncology involves ethically sensitive exchanges among healthcare providers, children, and families. The main dilemmas include how to disclose prognosis without abandoning hope, how to balance parents' surrogate authority with the child's evolving participation, and how to align treatment decisions with family values, developmental capacity, and the child's best interests. This narrative review clarifies the conceptual scope of these dilemmas, synthesizes evidence on their psychological, institutional, and sociocultural determinants, and summarizes intervention strategies that may support shared decision-making, advance care planning, family-centered care, and goal-concordant care. METHODS: A narrative review was conducted using PubMed/MEDLINE as the core biomedical database, supplemented by citation chasing and searches of Web of Science, Scopus, PsycINFO, CINAHL, Google Scholar, and reference lists of key pediatric palliative care publications. The primary search covered January 1, 2015, to March 31, 2026; seminal pre-2015 literature was retained only when it provided foundational ethical or communication concepts. Search concepts included pediatric oncology, childhood cancer, pediatric tumors, end-of-life care, palliative care, communication, truth-telling, shared decision-making, advance care planning, parental decision-making, child autonomy, and ethical dilemmas. The evidence was synthesized thematically rather than statistically. KEY CONTENT AND FINDINGS: The review identified three interrelated ethical communication domains: truth-telling and protective disclosure; parental surrogate decision-making and the child's developing autonomy; and the timing and manner of prognostic and goal-of-care communication. Across the literature, communication challenges are shaped by clinician moral distress and avoidance, family grief and protective instincts, institutional barriers to early palliative care integration, and diverse cultural, religious, and socioeconomic preferences. Intervention evidence remains heterogeneous and is often derived from qualitative, observational, or small-scale training studies. Nevertheless, structured communication training, multidisciplinary family meetings, early pediatric palliative care involvement, ethics consultation, psychological support, and developmentally appropriate child participation appear clinically promising when implemented with attention to family preferences and local context. CONCLUSIONS: Ethical communication in end-of-life pediatric oncology should be understood as a longitudinal, relational process rather than a single disclosure event. Current evidence supports cautious use of structured communication training, multidisciplinary collaboration, family-centered psychological support, shared decision-making, and advance care planning, but stronger longitudinal and culturally diverse studies are needed. Future work should avoid one-size-fits-all disclosure models and should develop tools that protect children's data, respect developmental capacity, and promote goal-concordant care.