The prognosis of the brain-injured patient is very much dependent on the extent of the primary injury, the cumulative effects of the secondary brain insults, the type of care offered and whether this takes place in a dedicated neuroscience centre. The ethical and legal underpinnings of our management of incapacitated brain-injured patients and their inclusion in research protocols can often present dilemmas that demand a considered approach relying as much on experience as expert knowledge. End-of-life decision-making benefits from an approach that shares the burden of responsibility, gives primacy to patient autonomy over medical paternalism and aims for a consensus about a patient's best interests through negotiation with the family, surrogates and all members of the healthcare team. End-of-life care on intensive care units (ICUs) will continue to evolve by promoting the highest ethical and legal standards when withdrawing treatment.