Introduction: The surgeon will face difficult, oftentimes impossible decisions during their career when confronted with patients necessitating surgical palliation. There are a multitude of factors and subtle nuances to consider when deciding to palliate a surgical patient. These factors must be weighed up with the patient in the first instance when possible and furthermore, should involve the input from a multi-disciplinary team. Case: Our centre assumed the care of a 49-year-old man who presented to the emergency department in extremis and septic, on the verge of death from multiple infected full thickness pressure sores and a necrotising anogenital infection. He was permanently bed bound from a previous ischemic thoracic spinal injury and although expected to pass away in ICU, the patient made an unexpected recovery and was stabilised through ionotropic supportive medical therapy. Without surgical intervention, this patient would inevitably succumb to infection. However, the decision to operate was complicated by the magnitude of the surgery requiring hemipelvectomy to achieve adequate surgical control, extremely high risk of mortality and lack of reconstructive potential including exposed bowel. Through a supported multi-disciplinary meeting of multi-surgical, anaesthetic and intensive care specialists, ultimately a consensus decision was made for surgical palliation due to futility and expected very poor outcome. Discussion: There exist several ethical considerations that arise during these cases that challenge surgical decision making. We discuss the ethics and considerations that helped guide decision making for their care and outline several key learning points that were garnered from managing this difficult case.