Maintenance dialysis is life-sustaining but poorly accessible in low- and middle-income countries (LMICs). There are not enough functional dialysis centres in the public sector, and in the private sector dialysis is prohibitively expensive. This results in the need for (de facto) rationing of public sector dialysis beds or catastrophic out-of-pocket expenditure. Death occurs in the majority of patients from lower socio-economic backgrounds because dialysis cannot be initiated or must be discontinued [1]. Kidney transplantation is even more inaccessible than dialysis due to inadequate transplant centres and high costs [2]. Conservative care is a continuation of medical care without dialysis that focuses on symptom control and end-of-life care. In high-income countries (HICs), conservative care is usually chosen by elderly, frail kidney failure patients or those with multiple serious comorbidities [3]. In LMICs, conservative care is the only treatment option when dialysis or kidney transplant is inaccessible. In high resource settings, shared decision making by patients and nephrologists regarding dialysis versus conservative care would ideally occur before kidney failure has occurred. Unfortunately, in LMICs, chronic kidney disease (CKD) is often diagnosed late when the patient becomes severely ill from advanced symptoms of kidney failure, requiring emergency initiation of dialysis [4]. Kidney failure in children is usually caused by congenital diseases that present differently from that in adults. Late diagnosis and urgent start dialysis is typical [5]. Paediatric dialysis is only provided in a few specialised centres in LMICs. Thus, parents/caregivers must shoulder the burden of medical caregiving and its associated costs. In these difficult circumstances, physicians face several ethical challenges in their struggle to provide the best possible care despite resource limitations [6].