Background Integration of palliative care into the neurological intensive care unit (neuro-ICU) is increasingly recommended, but evidence regarding best practice is lacking. We conducted a qualitative analysis exploring current practices and key themes of specialist palliative care consultations in patients admitted to a single neuro-ICU. Methods We retrospectively identified all patients who were admitted to the neuro-ICU for ≥ 24 hours and received a palliative care consultation between January and August 2014. We reviewed palliative care consultation notes and neuro-ICU progress notes from the electronic health records of these patients. We performed content analysis on the palliative care notes. Results Twenty-five neuro-ICU patients (4%) received a palliative care consultation over 8 months with the most prevalent reason of clarifying goals of care. The main distinctions between patients with and those without (n=580) a palliative care consultation were ICU length of stay (median 8.2 vs. 2.8 days) and death in the neuro-ICU (56 vs. 11%). The most prevalent themes addressed in the palliative care consultation notes were (1) discussing prognosis, (2) eliciting patient and family values, (3) understanding medical options, and (4) identifying conflict. Conclusions Palliative care consultations in the neuro-ICU emphasize family coping and decision-making by helping discuss prognosis and exploring patient and family values as well as their ability to understand the medical information. Several features suggest that earlier integration of palliative care into neuro-ICU care may enhance both coping and the decision-making process.