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Sixty consecutive evaluable children with recurrent primary tumors of the central nervous system were treated with a regimen of vincristine, nitrogen mustard, procarbazine, and prednisone over a 12-year period. Tumor types included medulloblastoma (19), brain-stem glioma (16), astrocytoma (13), and a miscellaneous glioma (12). Responses and sustained survivals were achieved. Responses were highly dependent on tumor type. Disease progression was halted in 73% of the children with medulloblastoma, and three have survived in complete remission for more than 10 years from the start of therapy with vincristine, nitrogen mustard, procarbazine, and prednisone. Two of four patients with anaplastic glioma, are long-term survivors. In contrast, less than one third of children with brain-stem gliomas responded. Toxicity consisted mainly of neutropenia, thrombocytopenia, infections, and rarely a procarbazine rash.

The results of treatment of infants with medulloblastoma using surgery and chemotherapy, without the use of radiation therapy, are reported. Both survival and outcome, in terms of growth, neurologic deficit, and intelligence are compared with the same parameters in children treated conventionally. Although preliminary, our results suggest that chemotherapy combined with surgery is a valid option for the treatment of infants with this type of neoplasm.

Intracranial tuberculoma has become a rare cause of space-occupying intracranial lesions in childhood, but it must still be considered in the differential diagnosis. Tuberculosis remains a significant disease in developing countries and in the United States, and tuberculoma is a well known presentation of childhood tuberculosis. This diagnosis must be considered especially in persons traveling or living in developing countries and in immigrants from third-world areas. We report three cases of tuberculoma in children seen during one year at our institutions to illustrate the need for continued suspicion. We summarize the clinical presentation and current treatment recommendations and review the available literature.

Physicians should work with pediatric patients and their parents in deciding courses of treatment, especially when the patients are very ill. Ethics committees may be consulted in cases of disagreement. The patient-centered "best interest" standard should guide the decision making of professionals, patients and parents. Determining the benefit versus the burden of a potential treatment may also help in making a treatment decision, although it may be difficult to decide what is the patient's best interest in some cases. Physicians are advised not to label certain treatment options as futile in their opinion. They may refer patients to other doctors who may be more willing to try riskier treatments. Pediatric patients should be involved in decisions about their treatment to the extent they can understand. Physicians treating older children and adolescents should respect their requests for confidentiality and their autonomy., Background. Much has been written about the care of the hopelessly ill adult, but there is little guidance for pediatric health care professionals in the management of children who are critically or terminally ill. Methods. Through a 3-day meeting in Tarrytown, NY, attended by a group of pediatricians and others directly involved in these issues, a principled approach was developed for the treatment of, and health care decision-making for, children who are gravely ill. Results. The group agreed that the needs and interests of the child must be the central focus of any treatment plan and that the child should be involved to as great extent possible, consistent with developmental maturity, in the decision-making process. Quality of future life should be viewed as being relevant in all decisions. Parents are believed to be the natural guardians of children and ought to have great latitude in making decisions for them. However, parental discretion is not absolute and professionals must maintain an independent obligation to protect the child's interests. Conclusions. Decision-making should be collaborative among patient, Parents, and professionals. When conflict arises, consultation and ethics committees may assist in resolution. When cure or restoration of function is no longer possible, or reasonable, promotion of comfort becomes the primary goal of management. Optimal use of pain medication and compassionate concern for the physical, psychological, and spiritual well-being of the child and family should be the primary focus of the professionals caring for the dying child. Pediatrics 1994; 94:433-439; decision-making, quality of life, parental discretion, adolescent autonomy, end of life in children.

The increased awareness of the rights of dying patients has been translated into new laws; a patient's right to refuse medical treatment has been upheld in numerous court decisions. Popular attitudes about the rights of dying patients have changed, often in advance of the attitudes of health care providers, legislators, and the courts. Physicians must have timely discussions with patients about life-sustaining treatment and terminal care, and become familiar with patients' personal values and wishes, documenting them as they document information about medical history. Dying at home can provide the opportunity for quiet, privacy, dignity, and family closeness that may make death easier for the patient and provide consolation for the bereaved. Home care should be guided by the physician and implemented with the help of well-trained personnel from hospice units that now serve many communities. Care of the dying demands constant adjustment to pain control, fear and suffering. If pain cannot be controlled with the commonly used analgesic drugs more potent narcotics should be prescribed. Even as death approaches, and curative techniques are not required, sensitivity and responsibility to the patient and their family, are needed. With compassionate care patients will be less likely to commit suicide which differs from euthanasia in that the act of bringing on death is performed by the patient, not the physician. The physician who considers aiding a patient's suicide must determine first that the patient is indeed beyond all help and not suffering from a treatable depression, common in those with terminal illnesses. Even though suicide itself is not illegal, helping a person commit suicide is a crime in many states. No physician has ever been prosecuted in the U.S. for prescribing pills in order to help a patient commit suicide. Euthanasia, is being widely discussed in the U.S., but the prospect of criminal prosecution deters even the strongest physician advocates of this practice.

Focuses on the opinion of the author on the normalization program for the death process in the children suffering from chronic diseases. Decription of the stages of passages for the patients from the role of a healthy person to that of an acknowledged patient; Importance of the child health care professionals; Need for examination of the concept of patient autonomy.