Mechanical ventilation is known to be an effective means of relieving symptoms of chronic hypoventilation and prolonging life in patients with amyotrophic lateral sclerosis (ALS). Various methods of mechanical ventilation are available to patients with ALS. However, attitudes towards mechanical ventilation in ALS vary widely across different cultures, and even within a given medical system. This article describes differences and similarities between a North American, a European and a Japanese approach, based on the respective medical and cultural traditions. The common goal is to provide optimal palliative care to patients with ALS.