Despite advances in critical care medicine and resuscitation, many patients who are admitted to the intensive care unit (ICU) will ultimately die. Although outcomes may be better for surgical rather than medical ICU patients, addressing the end of life is a fundamental and necessary aspect of critical care for all patients. Over the last few years, we have increasingly recognized the role of palliative care in the surgical and trauma ICU. Palliative medicine in the surgical ICU setting results in decreased length of stay, improved communication with family and patients, and earlier identification of goals of care. This review covers indications for palliative care consultation, practical considerations at the end of life, withdrawal of mechanical ventilation, and symptoms and symptom management at the end of life. Tables list the American College of Surgeons statement on the principles guiding care at the end of life, guidelines for palliative care consultation in the surgical ICU, ABCDs of dignity-conserving care, palliative care principles on transitioning a patient to comfort measures only, and the process of withdrawing ventilatory support. This review 5 tables, and 33 references. Key words: comfort measures; end of life; intensive care unit end-of-life care; palliation; palliative care; palliative care consultation; palliative medicine; quality of dying; withdrawal of life support