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The quality of relationships between health care professionals (HCPs) and patients is an important factor influencing people's experiences with their health systems. In Pakistan, pediatric oncologists highlight the need for effective communication to support relationships between HCPs and children and families. Existing communication toolkits on the basis of the evidence from high-income countries are ineffective and culturally unsuitable in the context of low- and middle-income countries. Therefore, we aim to describe how characteristics of current pediatric oncology care practices for children with life-threatening illnesses (LTIs) influence their relationships and communication about illness and treatment. A phenomenological qualitative study was conducted. In-depth interviews (N = 60) were conducted with children (8-18 years) with LTI receiving treatment at one of three pediatric oncology units in Karachi, their families, and HCPs. Themes were generated after inductive coding. Five themes were identified, and four key findings are highlighted. First, HCPs valued effective communication. Practices were influenced by the sociocultural environment using a range of approaches, often without formal training, to respond to local needs. Second, families and HCPs were concerned about treatment-related fears, leading to reluctance in sharing illness information with children regardless of age. Third, both groups felt that disclosing diagnosis, involving families and children in treatment plans, and age-appropriate communication would strengthen the therapeutic alliance. Finally, HCPs emphasized the importance of faith and a multidisciplinary team approach in enhancing therapeutic relationships. The need for effective communication with children with LTI and families while respecting sociocultural norms will allow for trust building and stronger therapeutic alliances.