Extracorporeal life support (ECLS) is a high-risk, high-cost intervention that often entails prolonged ICU and hospital stays. Its rapid evolution raises crucial questions of appropriateness, proportionality, and value. Whereas much attention has focused on ECLS withdrawal, understanding when not to start is equally vital. Optimal ECLS care requires rigorous patient selection, clear evidence-based criteria, ongoing reassessment, and integration of ethics and palliative care. Prognostic uncertainty persists, and predictive tools are helpful but limited. Avoiding the ‘bridge to nowhere’ and prioritising interventions with realistic potential for meaningful recovery are essential. Ultimately, the value of ECLS lies in delivering the right therapy to the right patient, in the right setting, at the right time, balancing clinical benefit, ethical responsibility, and social resource stewardship.