Practices and attitudes of physicians regarding palliative sedation in children: a cross-sectional survey

Pediatric palliative sedation is clinically complex and ethically sensitive, particularly due to developmental differences, parental involvement, and concerns about life-shortening. Despite its importance, empirical evidence remains limited and pediatric-specific guidelines are scarce internationally, leading to variability in practice. This study examines sedation practices and attitudes, including goals and considerations, and variation by experience, training, and clinical setting. This study reports secondary analyses of Belgian data from an international cross-sectional online survey in physicians, exploring sedation practices, physicians' attitudes and three case vignettes. Descriptive and comparative analyses were performed. The survey was completed by 127 physicians. Midazolam (94%) and morphine (78%) were most commonly used, often in combination (72%). Multidisciplinary consultation was common (78%). Decision-making was almost always in consultation with parents (96%), with competent children consulted beforehand in 73%. Alleviating the child's suffering was the primary goal (97%), though 32% aimed to induce unconsciousness either sometimes or often, and a (co-)intention to hasten death was reported by 35% of physicians sometimes and by 15% often, totaling 50% reporting this intention at least occasionally. About 26% had difficulty distinguishing it from euthanasia. Although experts deemed the vignettes suitable for sedation, only 56% of physicians would initiate it. In the vignettes, physicians with prior sedation experience, who most often worked in academic hospitals, were more likely to choose midazolam for induction, to discontinue artificial hydration and nutrition, and to escalate sedation during gasping, and were less often uncertain which drug to start. These subgroup differences were consistent but exploratory. Conclusion: Pediatric palliative sedation in Belgium shows substantial variability associated with clinician experience, training, and clinical setting. Physicians working in academic hospitals were more likely to adhere to guidelines and seem to initiate treatment in a more holistic approach. These findings emphasize the need for expertise, multidisciplinary collaboration, and clear guidance in pediatric end-of-life care. What is Known? • Pediatric palliative sedation is clinically complex and ethically sensitive, and the lack of robust evidence and pediatric-specific guidelines contributes to variability in clinical practice. What is New? • Even when experts deemed the clinical case vignette suitable for sedation, only 56% of physicians would initiate it, and key management choices were associated with prior sedation experience rather than at random. Future research could explore the benefit of structural training and guidance in this complex patient population.