Ruptured abdominal aortic aneurysm is a life-threatening condition that occurs mainly in the elderly patient. The decision whether or not to operate on an elderly patient with a ruptured aneurysm is complicated and should include an evaluation of frailty. Three cases of octogenarians who presented with a ruptured abdominal aneurysm and had varying premorbid degrees of frailty are described, including the decision whether or not to operate on these patients, and their clinical course. A ruptured abdominal aneurysm in the over-80s remains a condition with high mortality and morbidity. However, an acceptable quality of life can be achieved with surgical intervention for selected patients. Currently, there is a lack of specific preoperative tools for prognostication in the elderly patient. Assessment of frailty can contribute to the decision whether surgery will be worthwhile. In addition, the ethics surrounding decisions in the acutely and critically ill elderly patients are discussed. © 2022, Netherlands Society of Intensive Care. All rights reserved.