Purpose of review: Care surrounding end-of-life has become a major topic in the intensive care medicine literature. Cultural and regional variations are associated with transatlantic debates about decisions to forego life-sustaining therapies and lead to recent international statements. The aim of this review is to provide insight into the decisions to forego life sustaining therapies and end-of-life care in Europe. Recent findings: Although decisions to forego life-sustaining therapies are increasingly made in European countries, frequency and characteristics of end-of-life care are still heterogeneous. Moreover, even though many determinants of these variations have been identified, epidemiologic and interventional studies still provide additional information. In agreement with public opinions, recent European laws have emphasized the patient's autonomy. In real life, advance care planning is rarely used. Decisions are often made by caregivers (physicians and nurses) or families, these latter being less involved than in North America. Not only ethic divergences between physicians but also cultural variations account for this disparity. Summary: To optimize end-of-life care in the intensive care unit, there is an urgent need for the development of palliative and multidisciplinary care in Europe. Furthermore, it highlights the need for culturally competent care, adapted to needs and values of every single patient and family. In addition, a lack of communication with families and within the medical team, an uninformed public about end-of-life issues, and insufficient training of intensive care unit staff are crucial barriers to end-of-life care development. Special awareness of professionals and innovative research are needed to promote a high-standard of end-of-life care in the intensive care unit.