Ethical approach to pain management in pediatric patients in a terminal situation: A systematic review.

Objective: Pediatric palliative care aims to provide a professional, scientific, and compassionate response to the needs of terminally ill pediatric patients, with pain management being one of its fundamental pillars. This systematic review analyzes the ethical aspects involved in the management of pain in pediatric patients at the end of life, using the core principles of clinical bioethics: autonomy, beneficence, non-maleficence, and justice as a framework.

Materials and methods: A systematic review was conducted following the guidelines of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Original qualitative or quantitative studies published between 2010 and 2024 in English or Spanish were included, provided they addressed pain management in pediatric palliative care from an ethical perspective. The databases consulted were PubMed, Scopus, and Web of Science. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT).

Results: A total of 18 studies met the inclusion criteria. Autonomy was addressed in a limited manner, often through indirect participation of the child via their caregivers. The principles of beneficence and non-maleficence were compromised by the underuse of analgesics due to fear of adverse effects, delays in referral to palliative care, and the continuation of futile treatments. The principle of justice was reflected in structural barriers, unequal access to opioids, and limited availability of specialized care, particularly in resource-limited settings.

Conclusions: Bioethical principles are present in the management of terminal pediatric pain, but their application remains inconsistent. There is a clear need to enhance professional training, implement standardized clinical protocols, and promote effective communication with families.