Cancer in adolescents and young adults (AYAs) is associated with an increased risk for suicidal ideation (SI). There are no reported pediatric oncology cases describing management of SI during end of life. We present a case of a 14-year-old male with relapsed, high-risk B-cell acute lymphoblastic leukemia (B-ALL) who received a haploidentical stem cell transplant (HSCT) and was acutely suicidal at the end of life. We discuss how to navigate acute suicidality in this patient population, the impact of discordant goals of care amongst family members, and potential preventative strategies for similar cases.