Background: In the US, 55,000 children die annually, mostly in intensive care units and rarely receiving palliative care. Barriers to palliative care for children have not been well studied.Methods: Our goal was to describe providers' perspectives on barriers to optimal end-of-life care for children. With IRB approval, we surveyed pediatric providers in a children's hospital using a confidential questionnaire asking demographics, practice characteristics, and perceptions of specified barriers to palliatve care for chidren (as Likert scales). We compared perceptions across settings, medical acuities, and children's ages using non-parametric statistics. Results: Of 229 questionnaires, 22% were conpleted by physicians, 49% by nurses. 65% of providers work in intensive care. 31% of deaths occurred in patients aged <2 months. The most frequently perceived barriers were uncertain prognosis, acceptance of fatal prognosis, time and staffing constraints, language and cultural differences, and family preference for more aggressive treatment. More non-ICU providers than ICU providers reported time constraints (p=0.001) and staff shortages (p=0.003) as barriers. Non-ICU providers more frequently perceived parent discomfort with withholding/withdrawing hydration or nutrition than ICU providers (p=0.01). Non-ICU providers more frequently preferred more aggressive life-support than parents thought approriate (p=0.009).Conclusions: Providers report more barriers to end-of-life care in non-intensive settings than in intensive settings. This may relate to higher patient loads, limited resources, or lack of organizational support for providers in less acute hospital wards where death is a less comon event. Non-intensivists may not experience the burden of interventions that intensivists witness and may advocate for more aggressive treatment than family members think appropriate. These differences in perceptions of barriers to care may help identify ways to improve end-of-life care for patients as well as ways in which to support pediatric providers as they care for dying children.