Pediatric palliative care in the United States remains the poor step-sibling of adult palliative care and pediatric palliative care in other developed countries. Multiple factors contribute to this situation, including dramatic reductions in morbidity and mortality due to childhood cancer and prematurity, as well as substantial life-prolongation associated with many chronic diseases affecting children. However, those phenomena affect care in all “first world” countries. In the U.S., pediatric palliative care inevitably does not pay for itself, a problem for profit-oriented medical systems. Americans in and outside of the health care system must overcome their unrealistic wish that modern medicine cure all childhood diseases and appreciate that palliative care services help improve quality of life and build trust prior to the need for expertise in end-of-life care. Pediatric palliative care in the U.S. should follow the model developed by Ann Goldman in England at the end of the last century, integrating palliative teams into the initial care of children diagnosed with life-threatening disorders.