**2. The application of palliative care in pediatric patients**

The word "palliative" comes from the Latin terms "pallium" (which represents the dress or overcoat of ancient Roma) and "palliation" (which means "to cloak or cover"); in medicine, the concept of cloaking or covering has been employed not to "hide" but to "protect" the person, in a vision of protective care [2].

Pediatric oncology represents a huge success in the story of medicine, with an overall survival rate of 80%. Recently, many progress has been made in pediatric palliative protocols, incorporating multidisciplinary support in physical, emotional, spiritual, mental, social, and financial aspects, highlighting the significance of comprehensive palliative care teams and management programs [3, 4]. Recent medical advances in South Africa have demonstrated that effective multidisciplinary palliative care involving children's families and communities can be implemented successfully

even in resource-limited settings, usually through voluntary and unstructured forms of activities and participations [5–7].

The Wayne State University School of Medicine established the first hospitalbased palliative care consult service in the United States in 1985 at Detroit Receiving Hospital; Dr. Declan Walsh established the first palliative medicine program in the United States in 1987 at the Cleveland Clinic Cleveland, Ohio: it was the first wideranging integrated program designated as a WHO international demonstration project and accredited by the European Society of Medical Oncology. Following it, several other programs were established, including the Palliative Care Program at the Medical College of Wisconsin (1993), the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center (1996), and The Lilian and Benjamin Hertzberg Palliative Care Institute at Mount Sinai School of Medicine (1997). Since then, there has been a considerable increase in the number of hospital-based palliative care programs, which now number over 1400. Currently, 80% of US hospitals with more than 300 beds have a palliative care program [8].

Palliative care was not available for children for many decades, and only a few pediatric patients have recently benefited from a dedicated palliative care service [3, 9]. It can be used in a variety of fields, including:


The role of surgery in palliative care is to achieve the best quality of life for cancer patients for as long as possible; surgeons may participate in oncological management in a variety of ways, including obtaining correct and representative biopsies to confirm histological diagnosis, positioning central venous catheters for short- or long-term use and nutritional devices, and performing curative or tumor-debulking surgeries (reducing symptoms caused by tumor compression on adjacent structures) [10]. Furthermore, based on clinical aspects and tumor peculiarities, each patient must have a unique, tailored management plan. "How far is too far?", "What is far enough?", and "How far is not far enough?" are among the numerous questions that remain for surgical management of palliative care patients. Ethical conflict is vital, especially when choosing on tumor debulking and removal of malignant metastases in palliative patients: each decision must be founded on the child's and family's values and rights, as well as the beliefs, duties, and rights of all parties involved [11].

Moreover, Kassam A. et al. found that adolescents and young adults with cancer (particularly hematological disorders) have a greater rate of intensive care at the endof-life stage than adults in a recent publication (40.6% vs. 22.4%) [12]. Oncological kids die in hospitals over half of the time (and nearly half of them in intensive care units),

compared to only 25% of adults who die in hospitals. Furthermore, pediatric patients dying of oncological disease usually suffer greatly in their final weeks of life: according to parental reports, 89% of these children have at least one debilitating symptom, particularly weariness, discomfort, or dyspnea, till the end of their lives [13, 14].

These findings may reflect professionals' discomfort and lack of experience with advanced care planning discussions, deferred conversations about end-of-life (in order to protect younger patients), and caregiver pressure to continue treatments (even if they are ineffective) at the end of their child's life [15, 16]. It may be challenging for the surgeon to pick the appropriate care for their patients in this highly emotional and demanding scenario.

The American College of Surgeons [17] issued a statement on the values of palliative care in August 2005, which was based on the following principles:


Pain, bleeding, intestinal or urinary obstruction, malnutrition, lack of vascular access, fluid collections, intracranial hypertension, respiratory distress, infections, and selective intra-tumoral therapies are just a few of the conditions that may necessitate surgical intervention in oncological patients.
