Approximately 25% of children with cancer die of their disease. Early in the course of a patient's illness, it is often impossible to determine whether the disease will be cured with cancer-directed treatment. When potentially curative therapy is no longer an option, the patient, family, and oncology team face enormous medical, psychological, and spiritual challenges. Optimal palliative care requires willingness on the part of the physician and caregiver team to engage the patient and family in discussions of their hopes and fears and to provide solace and support for emotional and physical pain. Using the comments of a child in the terminal phase of acute leukemia, his mother, and his physician, we describe opportunities and important lessons often revealed only when families and their caregivers face the end of a child's life. A broad-minded assessment of the patient's and family's physical, emotional, and spiritual needs and clarification of realistic goals and hopes not only improves the clinical care that the patient receives but also contributes to the sense of satisfaction and meaning that the physician can gain from the experience of caring for children at the end of life.