“Unbefriended,” or “unrepresented,” patients are those who are unable to make their own decisions with regard to their medical care and lack an available surrogate decision maker. As we discuss in this Chapter, many terms have been used to refer to this heterogeneous group, although none fully encompass the breadth of clinical scenarios that present in critical illness; we use “unbefriended patient” for consistency. This unfortunate situation may occur because the person is truly without close contacts or those contacts are unable to be contacted to make these critical decisions on behalf of the patient. Patients without available surrogates but with clearly documented goals of care have variably been included or excluded from this cohort. Although these scenarios may, at first glance, seem to be at the edges of the management spectrum, they are not uncommon. In two studies, 16% of patients who were admitted to the intensive care unit (ICU) and 5.5% of patients who died in the ICU were without surrogates.1,2 The care of these individuals strains the legal, ethical, and practical limits of our work and must be explored by both individual physicians and their institutions.