Acute respiratory distress syndrome (ARDS) is a lethal form of acute respiratory failure, and as no specific treatments exist, supportive care remains the primary management strategy in these patients. Extracorporeal membrane oxygenation (ECMO) has emerged as an intervention in patients with severe ARDS to facilitate gas exchange and the delivery of more lung protective ventilation. Over the past 20 years, improvements in ECMO technology has increased its safety and transportability, making it far more available to this patient population globally. Deciding which patients with ARDS should be initiated on ECMO remains a challenging question. Numerous clinical and laboratory markers have been investigated, and multiple risk scores developed, to aid clinicians in this decision-making process. However, they are still imperfect, and the choice is often based on institutional guidelines and the clinical impression of the treating physician. Given the potential risks and resource implications for this intervention, patient selection is critical and it is important to provide ECMO only to patients who have a reasonable chance for recovery or bridge to transplantation. In ECMO patients where there is no potential for recovery or transplant, the only option may be withdrawal of ECMO and palliation. These patients may be awake and interactive, which is often a very challenging scenario for patients, families, and the clinical team. In this article, we present a more controversial case and a review of the literature regarding the selection of ARDS patients who should receive ECMO.