Providing excellent surgical care for patients at the end of life can present many ethical dilemmas. In this chapter many of the most commonly encountered ethical dilemmas encountered by surgeons during to end of life care are examined, organized around a fitting ethical principle. Tools that surgeons can use to help with avoiding unduly influencing preference construction, making decisions to withdraw life support, and attempting to prognosticate outcome in complex situations with incomplete information are discussed. The theme of improved multidisciplinary communication with patients and their families runs through the practical application of beneficence, non-maleficence, respect for autonomy, justice, and fidelity in these settings. Through working to understand who our patients are, discover what they value, and mitigate gaps in medical knowledge, we can provide ethical, high-quality end of life care.