Box 1.

Illustrative case

Ms R, a 52 year old woman with severe rheumatoid arthritis and chronic immobility, was brought to the emergency department. Her health was poor, although stable, until the morning of admission, when she became disoriented and lethargic. She was admitted to intensive care, where she was treated for septic shock secondary to decubitus ulcers and for acute renal failure. On the day after admission she was requiring increasing doses of vasopressor drugs and developed acute respiratory distress syndrome. Some members of the intensive care team became increasingly concerned about the “futile” care they felt they were providing. The patient's family requested that the medical team “do everything” to keep her alive.

See box B2 for follow up.