Table 2.

Rationale for Engaging Patients or Family in Decision-Making When Medical Treatments Fail to Accomplish Physiologic Goals

	Exemplary Quotes
Chronic Critical Illness Cases	We need to start working with the family toward realistic goals of care if she is unable to do HD [hemodialysis] tomorrow. (MICU Physician, ICU Day 8, SOFA=7)
	Family meeting planned for tomorrow to discuss end-of-life care given inability to stabilize hemodynamically. (MICU Physician, ICU Day 20, SOFA=8)
	Full code for now; discussed with wife and family at bedside that pt is still critically ill. goal is for palliative chemotherapy but if unable to liberate from ventilator then will need to readdress goals of care (MICU Physician, ICU Day 5, SOFA= 3)
Decedent Cases	Patient clinically worsening. Now paralyzed with 4th pressor added. […] Patient still full code at this time; however no utility of CPR [cardiopulmonary resuscitation] given uncorrected underlying process and extensive support required at this time. Family to discuss DNR [do not resuscitate] status.” (MICU Physician, SOFA = 10)
	Given the inability to unload RV [right ventricle] […] as well as multi-organ failure patient’s prognosis is extremely poor, would agree with pursuing further goals of care discussions with family (MICU Physician, ICU Day 12, SOFA=11)
	Patient had expressed previously she would only want to be intubated for 3–4 days, with limited critical care trial. This was discussed with daughters and POA [power of attorney]. In setting of lack of neurological recovery, resistant micro-organism infections, anuric renal failure, progressive malignancy have elected to no longer escalate care, and are planning to withdraw care […] after family has gathered. (MICU Physician, ICU Day 15, SOFA=11)

^a:All SOFA scores are maximum value in 48 hours preceding quoted statement

Abbreviations: MICU= medical intensive care unit; SOFA = Sequential Organ Failure Assessment