During Ontario’s busiest surge of COVID-19 (coronavirus disease) to date, our Pediatric ICU at the Hospital for Sick Children (normally an entirely pediatric referral centre) admitted adult patients under our care. Our extracorporeal life support (ECLS) program quickly adapted to this new reality—we admitted adults previously cannulated to ECLS and cannulated a number of adult patients, while maintaining our usual pediatric ECLS cases. The following reflections stem from the family presence restrictions in place due to COVID-19, in particular the clarity these constraints have lent to our role in supporting families as they navigate the unique tension between life and death that is ECLS.