Up to five percent of patients presenting to a critical care unit for treatment have no advance directive for treatment nor any family, friends, or legally authorized surrogate to consult for medical decision-making. These “unbefriended” patients include the elderly, adult orphans, individuals with developmental disabilities, mental retardation and dementia. Traditional ethical and legal hierarchies for healthcare decision-making cannot be applied. Hospital policies, professional society guidelines, and state laws vary widely regarding who should make life-support decisions for this patient population. State laws are almost uniformly silent regarding these problems, and few states have a workable system to deal with these issues in an ethically proper and/or timely manner. In an attempt to represent patient autonomy, physicians’ default order is typically “do everything” possible to prolong life. Physicians living in fear of legal repercussions find such a default the most convenient and personally cost-effective approach. Overburdened adult protection agencies have not responded to this situation, and court action has uniformly failed to provide guardians or make other appropriate decisions. Although surveys of homeless persons indicate their preference that decision-making to be provided by their physician, such a choice could lead to unwarranted variation in decisions for such patients as well as carry the potential to reflect institutional biases or economic pressures. Unfortunately, unbefriended patients undergo months of inappropriate treatments that may prolong life but at the same time would be rejected by most families as prolonging unnecessary burdens and suffering. For physicians who try to combine recognized ethical and legal standards with neighbor love, these not uncommon situations create considerable angst. Potential solutions will be discussed as well as the personally observed impact of a recently approved Uniform Health Care Decisions Act in the state of Arkansas.