Complementary alternative medicine (CAM) usage and physicians' attitude was evaluated by interviewing all 100 pediatric cancer patients' parents and adolescents seen in the last half of 2003 at Meyer Children's Hospital in Israel. Sixty-one percent of the patients used CAM, an average of 3 different treatments per patient. CAM use was higher: among parents having previous CAM experience (85% vs. 51%, P=0.001) and higher education (79% vs. 50%, P=0.024), and in nonreligious families (71% vs. 50%). Jews and Arabs had similar CAM use rates as with different types of therapies. Socioeconomic status does not affect the rate of CAM use (P=0.9) but does affect the type of treatments used: patients of the higher socioeconomic level mainly used chemi-biological remedies and homeopathy (24% and 28% of interviewees; P=0.002). Middle or lower socioeconomic patients mostly used traditional Arab treatments (32% and 54%, respectively; P=0.012). Only 36% discussed it with their physicians, and most discussions were initiated by parents (79%). Beneficial effect was reported by 69% of CAM users. Most interviewees were interested in getting CAM information and availability in the hospital. Most pediatric cancer patients, regardless of their ethnic origin, use CAM without informing their physicians. Physicians should be aware and know more about it, to be advisors for better integrated care.

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Despite progress in the treatment of pediatric cancer, approximately 25% of these children will die of the disease. The last period of life is characterized by profound physical and psychological suffering, both of the children and their loved ones. Adequate alleviation of this suffering becomes the priority in the management of these patients. The authors retrospectively evaluated the indications, incidence, and characteristics of palliative sedation (PS) in 19 children with brain tumors (BT) and 18 with sarcomas (S) at the end of life. Twelve of the 18 S patients received PS, as did 13 of the 19 BT patients. Indications for initiation of PS for those with BT were seizures and/or pain, for those with S were pain and/or respiratory insufficiency. It was concluded that PS may be the only efficacious and safe treatment for the alleviation of suffering in these children at the end of life, despite differing indications.

The goal of this study was to evaluate the frequency and timing of "do not resuscitate" (DNR) orders among pediatric oncology patients with progressive solid tumors. A retrospective evaluation of the medical charts of 36 patients who died in our department over the last 4 years was made. There were 21 males and 15 females with a mean age of 10 years (range, 1-22 years). Fourteen patients had brain tumors, 12 had sarcomas, 5 had lymphomas, 4 had neuroblastomas, and 1 suffered from hepatocellular carcinoma. A DNR order was registered in the medical charts of 22 (61%) patients. The DNR was ordered within less than 24 h of death in 5 patients. Median time from DNR order until death was 5 days (range, 0.25-82 days). Place of death was home for 5 (14%) patients, 3 of whom had DNR orders; pediatric oncology ward for 28 (78%), 19 of whom had DNR orders); ICU for 3 (8%), none with a DNR order. Mean time from last day of anticancer treatment until death was 63 days in the group with DNR orders and 56.5 days in the group without DNR orders (p = NS). The study showed that (1) DNR orders were written in only about half the charts of patients with progressive cancer; (2) in several cases, DNR orders were given close to death; and (3) advanced discussion of DNR with parents is needed to reduce parental and medical staff stress accompanying the death of a child and optimizing management of the terminal phase of the disease.