Therapy decisions in the care of critically ill and dying patients in intensive care and emergency medicine must reflect probably conflicting issues of medical indications, ethics and law. This is of particular relevance when treatment preferences of patients are not known or are in contrast to those of the carers. Difficulties regarding prognostication or with determining the beginning of an irreversible dying process may also lead to treatment situations that need ethical reflection. It is recommended to tackle medico-ethical issues by discussion of the meaning of relevant terms and medico-ethical principles, analyzing the professional self-image in intensive care and emergency medicine, consideration of options of palliative medicine and by use of an ethics case consultation.