The intensive care unit (ICU) is where some of the most critical decisions are made. It’s a place where advanced technology can keep people alive when their bodies are failing, but it’s also where doctors, nurses, patients and families are often faced with deeply emotional and difficult choices. One of the most challenging questions in ICU care is this: Should we continue life-prolonging treatment if it no longer improves the person’s quality of life? We explore how ICU teams in Australia navigate these difficult situations, balancing the power to prolong life with the responsibility to honour the patient’s values, comfort and right to a peaceful death.

“Quality of life” is a deeply personal idea, and there’s no one-size-fits-all definition. For some people, quality of life might mean being able to walk, talk and live independently. For others, it could be about being free from pain, having time with family, or simply being conscious and aware of their surroundings.

In the ICU, decisions often come down to whether continuing treatment will help the patient return to a life that they would consider meaningful. If a person is unlikely to ever breathe on their own again, or if they’re permanently unconscious, would they want to be kept alive? These are difficult questions that doctors and families must consider, often under enormous stress.

Cultural and religious beliefs can also shape how patients and families view suffering and medical intervention. Some may wish to continue all available treatments, no matter the outcome, while others may prefer to focus on comfort and dignity.

One of the best ways to avoid confusion or conflict in the ICU is through advance care planning. It’s an opportunity to outline a person’s preferences, such as whether they would want to be placed on life support, receive CPR, or have certain treatments withdrawn if their condition worsens. These documents help guide doctors and nurses, reduce stress for families, and ensure the patient’s voice is heard, even when they can’t speak.

Starting these conversations early is key. It allows people to consider their values, ask questions, and feel more in control of their future care. It’s not about choosing to die, it’s about choosing how to live, even in the most difficult moments.

Unfortunately, many patients arrive in ICU without having had these conversations with loved ones or documented their wishes in an advance care plan. In those cases, families and clinicians are left to make decisions without clear guidance. This is where ethical questions arise. When is it right to keep going, and when is it kinder to stop?

As the Australian and New Zealand Intensive Care Society (ANZICS) explains in its guidelines, care should focus not only on prolonging life, but also on ensuring comfort and supporting patients and families through the end-of-life journey. In these moments, the goal is not to give up, but to shift the focus from cure to comfort, and to honour what the patient would want if they could speak for themselves.

For doctors, nurses, and other ICU staff, making decisions about continuing or stopping treatment can be emotionally and ethically challenging. Every patient is different, and the right course of action isn’t always clear.

One of the biggest difficulties is balancing hope with honesty. Families often want to believe that their loved one will recover, especially when machines are keeping them alive. But medical staff must gently explain when treatments are unlikely to help and may even cause more harm. These conversations require great care, compassion and clarity.

Sometimes, families and doctors don’t agree on what’s best. A family may want "everything done," even when doctors believe further treatment will not change the outcome. In other cases, doctors may recommend continuing treatment, but a family might feel it’s time to let go. Cultural beliefs, religion and past experiences with illness can all shape these decisions.

Some hospitals also offer support from ethics committees if disagreements arise or the situation is particularly complex. These groups can help guide decisions in a fair, respectful way and make sure everyone’s views are considered.

NSW Health’s Conflict Resolution in End-of-Life Treatment review offers practical tools to ease ICU dilemmas. It emphasises putting advance care directives easily into patient records and sharing them across settings, which helps guide ICU teams when treatment choices aren't obvious. It also promotes structured family communication, like using the VALUE mnemonic (“Value, Acknowledge, Listen, Understand, Elicit”), and early involvement of palliative care. For persistent or unresolved differences, the report suggests trained mediators or ethics consultation before considering legal routes. These strategies support shared understanding, reduce conflict, and help align urgent care decisions with patients’ values and dignity.

These ethical dilemmas don’t have easy answers. Every patient is different, and so are their values, beliefs and hopes. That’s why it's so important to listen to patients and families, have open conversations, and use compassion alongside medical knowledge.

Advance care planning, honest communication, and teamwork between families and ICU staff can help make sure decisions are made with care and respect. Hospitals also need to support their staff through these emotional moments, offering guidance and space for reflection.

In the end, it’s not just about how long we can extend life, but how we can make every moment as meaningful and dignified as possible.