In pediatric medicine, clinical decision-making rarely occurs in a vacuum. While pediatricians are trained to recommend evidence-based care, parents and caregivers may approach treatment decisions from a place of hope, fear, and deep emotional investment — especially when a child’s condition is life-threatening. These perspectives don’t always align.
Tension can develop when families request aggressive or life-sustaining interventions that clinicians believe are nonbeneficial treatments. In these situations, the challenge is not just medical — it’s ethical, communicative, and deeply human.
New guidance from the American Academy of Pediatrics (AAP) provides a structured approach to resolving these conflicts. These recommendations emphasize transparency, shared goals, and thoughtful escalation when consensus cannot be reached.
As these situations become more common in high-acuity care settings, providers are being called not only to deliver care but to navigate some of the most difficult conversations in medicine.
Ways to navigate and resolve disputes related to parental requests for potentially nonbeneficial treatment are addressed in a clinical report and accompanying technical report issued by the American Academy of Pediatrics and published online March 23 in Pediatrics.
Deena Levine, M.D., from St. Jude Children’s Research Hospital in Memphis, Tennessee, and colleagues provide practice guidance for pediatricians and other physicians for resolving disputes when parents (or surrogate decision-makers for children) request interventions that are not medically recommended and are considered to be potentially nonbeneficial, focusing on life-threatening situations.
According to the authors, it is ethically appropriate to forgo physiologically futile interventions and illegal interventions, irrespective of patient or parent requests. Physicians have a moral obligation not to offer such interventions. Formulating a goal-concordant treatment plan by first identifying patient or parent goals can prevent intractable conflict and is an essential step toward patient- and family-centered care. Gathering additional information and engaging relevant parties may be helpful if parents continue to request treatment that the medical team believes to be nonbeneficial. A clear process of resolution should be established, starting with obtaining a second opinion to help clarify misunderstandings and help parents and physicians to find common ground. Transfer to another institution should be considered.
“If a systematic and transparent approach does not result in resolution of the disagreement or transfer to an alternate location for care, there is uncertainty or even low-level potential for benefit of a persistently requested therapy, and there is no significant risk of harm to the patient, it is reasonable to consider the emotional burden to the family of unilaterally withholding or withdrawing medical interventions and consider continuing to provide ongoing life-sustaining medical treatment,” the authors write.
Treatment disagreements are rarely about the intervention alone. For families, the requests for continued or aggressive care are often driven by a desire to preserve hope, maintain control, or avoid the emotional weight of loss. Cultural values, spiritual beliefs, and prior healthcare experiences can also shape how families interpret provider recommendations.
For some families — such as those from historically marginalized communities — these moments may also be influenced by mistrust in the healthcare system. Concerns about provider bias, undertreatment, or not being fully heard can make it difficult to accept recommendations to limit care.
AAP’s new guidance reinforces a key point: many conflicts in the exam room can be prevented — or at least descalated — through early, intentional communication.
Rather than immediately focusing on whether to provide a treatment, clinicians are encouraged to first explore the family’s goals. Do they hope for more time? A chance at recovery, no matter how small? Or reassurance that everything possible has been done?
By reframing the conversation around goals rather than specific interventions, providers can often identify areas of alignment and reduce the likelihood of entrenched disagreement.
When disagreements on nonbeneficial treatments persist, the AAP report outlines a stepwise approach that prioritizes clarity and collaboration.
This includes:
This structured approach can help shift the situation from a potentially adversarial situation to a more transparent and ethically grounded one.
The guidance makes it clear that providers are not obligated to provide interventions that could be futile, harmful, or outside the bounds of legal or ethical practice.
But how these limits are communicated is critical. Delivering abrupt refusals or poorly explaining decisions can deepen the mistrust and escalate conflict with patients’ families. A transparent, stepwise process allows families to feel heard — even when the final decision is not what they had hoped for.
For Black patients and other underserved populations, these conversations may carry additional weight. Historical inequities in the healthcare system have contributed to ongoing disparities in trust, communication, and outcomes.
Labeling a treatment as “nonbeneficial” can be particularly sensitive for these communities. Without a clear explanation, it can be perceived as dismissive or biased.
This is why culturally responsive communication is so important. Providers must ensure that families understand not only what is being recommended, but why. They should also know that those recommendations are not only grounded in science but also in the patient’s best interests — not assumptions or systemic bias.
Conflicts over pediatric treatment decisions are among the most challenging situations providers face. The sit at the intersection of medicine, ethics, and emotion — where there are rarely easy solutions.
The latest guidance from the AAP on nonbeneficial treatments offers a structured framework not just for resolving disputes, but for approaching them with greater clarity, empathy, and structure. By prioritizing communication, transparency, and shared goals, providers can better navigate these difficult moments without compromising clinical integrity.
Ultimately, the goal is not just to reach a decision but to ensure that families feel heard, respected, and supported throughout the process. By doing so, providers can help transform conflict into collaboration, even in the most complex cases.
One author disclosed ties to Chiesi USA.
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