Family needs during critical illness have been a major focus of nursing research, yet the unique needs of families living in rural America still need to be investigated. This study sought to identify the needs of families in rural southern Appalachia and compare these findings to those from a study that identified the needs of families in a large metropolitan medical center. We found 13 needs to be significantly different between the rural and urban samples and suggest strategies that rural and urban critical care nurses and advanced practices nurses can use to care for families of critically ill patients from rural areas.