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Introduction: End-of-life (EOL) decision-making in the intensive care unit (ICU) is difficult, but is rarely practiced in simulated settings. We wanted to explore different strategies ICU physicians use when making EOL decisions, and whether attitudes towards EOL decisions differ between a small-group simulation setting and a large-group plenary setting.Methods: The study took place during a Scandinavian anaesthesiology and intensive care conference. The simulated ICU patient had a cancer disease with a grave prognosis, had undergone surgery, suffered from severe co-morbidities and had a son present demanding all possible treatment. The participants were asked to make a decision regarding further ICU care. We presented the same case scenario in a plenary session with voting opportunities.Results: In the simulation group (n = 48), ICU physicians used various strategies to come to an EOL decision: patient-oriented, family-oriented, staff-oriented and regulatory-oriented. The simulation group was more willing than the plenary group (n = 47) to readmit the patient to the ICU if the patient again would need respiratory support (32% vs. 8%, P < 0.001). Still, fewer participants in the simulation group than in the plenary group (21% vs. 38%, P = 0.019) considered the patient's life expectancy of living an independent life to be over 10%.Conclusion: There was great variation between ICU physicians in the approach to making EOL decisions, and large variations in their life expectancy estimates. Participants in the simulation group were more willing to admit and readmit the patient to the ICU, despite being more pessimistic towards life expectancies. We believe simulation can be used more extensively in EOL decision-making training. [ABSTRACT FROM AUTHOR]