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The management of patients with malignant bowel obstruction (MBO) can be one of the most challenging aspects of advanced cancer care, and as a result, their symptoms are often palliated poorly, especially near the end of life. The term MBO encompasses a heterogeneous clinical syndrome,defined as obstructive symptoms due to the presence of intra-abdominal neoplastic disease. Radiological imaging, particularly with computed tomography, is critical in determining the cause of obstruction and possible therapeutic interventions. Options include laparotomy with or without a stoma, decompression with a stent, or aggressive medical therapy. Surgical decision-making involves the selection of the intervention most likely to relieve symptoms and improve quality of life for a particular patient at that particular point along his or her disease course. Although MBO is a relatively common dilemma encountered in clinical practice, there are no simple treatment guidelines or algorithms to follow. Instead, each patient must be assessed individually to devise a treatment plan that best balances the advantages and disadvantages of the intervention, considering the patient's prognosis, tumor biology, and-most importantly-his or her goals of care, as determined through an honest discourse between physician and patient. This review outlines a surgical framework for clinicians managing patients with MBO.