The decision to forgo life-sustaining treatment (LST) is frequently made for children dying in paediatric intensive care units (PICU). Many studies have been published on this issue. They show important international differences in end-of-life (EOL) practices among countries not only in PICU but also in adult and neonatal intensive care units. This variability applies to all aspects of EOL, such as the frequency of limitations of LST, the decision-making process and the implementation of the decision. For instance, children from northern European countries more often die after a decision to forgo LST, whereas children from southern European countries more often die after cardiopulmonary resuscitation failure. The decision-making process and the respective contributions of the decision-makers also differ among countries. In north America the parents appear to be the main decision-makers. Conversely, in Europe and south America doctors still play a dominant role in the decision. Several hypotheses have been suggested to explain this variability, including the influence exerted by religion, culture, race, legal and professional backgrounds and social factors. Understanding worldwide differences about EOL issues is important because it is a way of improving EOL care.