The outlook for survival of mechanically ventilated children with a variety of chronic respiratory disorders has improved to an extent that forces reexamination of traditional views of what is in these children's best interest with respect to medical care. In the ICU setting, this kind of situation represents a major dilemma in current pediatric medical practice since both alternatives (prolonged mechanical ventilation versus withholding/withdrawing) imply an unfavorable outcome. Because the survival and quality of life for children receiving long-term assisted ventilation are not highly discouraging, increasing numbers of pediatric patients are not being managed at home with life-support technology. This article reviews medical data on the survival of children managed with mechanical ventilation and discusses some of the key ethical issues pertaining to decisions about withholding/withdrawing assisted ventilation in infants and children. In addition, we suggest the following guidelines and procedures that might be useful in dealing with the prolonged mechanical ventilation dilemma in pediatric medical practice: (1) obtain the correct facts on prognosis (good ethics start with good facts); (2) avoid irreversible decisions under uncertainty; (3) remember that withdrawing treatment is ethically preferable to withholding; (4) resolve disagreements with the use of outside consultation; (5) include the entire family in the decision-making process; (6) remember that consent is a process, not an event, and requires regular discussions with the family; (7) one physician must be identified as the primary provider and communicator.