Although the intensive care unit offers technology and treatment aimed at prolonging life, many patients die in ICUs, and most ICU patients experience pain and/or other distressing symptoms. Accordingly, palliative care, emphasizing effective management of symptoms, communication about the goals and expected outcomes of therapy, and attention to a broad range of patient and family needs, deserves a central place in critical care practice, research, and education. In this two-part series we review the role of palliative care in the intensive care unit. Part I focuses on aspects of death and distress among the critically ill that mandate expertise and education in palliative medicine, and identifies obstacles to the delivery of optimal palliative care in the ICU setting. In Part II we will review the practice of withdrawal and withholding of life support, which now precede the majority of ICU deaths, address issues in management of distress and discomfort experienced by critically ill patients, and suggest strategies for improving palliative care in the ICU. As a conceptual framework we discuss an integrated model in which all patients receive both intensive care and palliative care in a concurrent and coordinated manner, in preference to the traditional dichotomization of palliation and curative or life-prolonging care.