Table 2.

Challenges

Concern	Explanation/Elaboration	Management Approach
Can’t one both treat for survival and plan for death at the same time?	Is there a false dichotomy being created between curative and palliative care, which often coexist in contemporary best practice?	Often both can be done. But I believe that there does come a time when further treating for survival is inappropriate, perhaps even wrong. When such a time comes, it often is in the patient’s and family’s interests for us to name it as “acutely dying”.
What is “inevitable”? How small a probability? How short a time frame?	It is currently impossible to reliably quantitate the probability of death under alternative treatment strategies. Can one accept ever being wrong in this situation?	I tend to use the framing of a “reasonable probability,” with “reasonable” titrated in part based on what I know of the patients’ values. I believe one should strive for ever-improved accuracy, but that there is real harm to errors in either direction. The balance of those harms should be done with the patient’s and family’s preferences in mind, not just the clinician.
Whose perspective on suffering should be definitive?	What if the patient believes something to be unacceptable suffering that the clinical team thinks should be fine, or vice versa?	These problems are no worse here than in every part of medicine that incorporates patient preferences, and the same tools can be used.
Aren’t I just being ableist?	Does such a framework risk naming some lives as not worth living, and therefore recapitulating long histories of discrimination, and of medicine’s refusal to see people with disabilities in their full humanity, entitled to the same dignity as others?	These problems of implicit and explicit bias are no worse here than in every part of medicine that incorporates patient preferences, and the same tools can be used.
Future selves and adaptation	Does choosing death deny one’s future self the ability to find a meaningful experience after adaptation (8)? People are often far more able to adapt to situations than they expect to be able to	This may be true. However, we are not obliged to force people to suffer pain and indignity in order to see if their future self could adapt to it.
But ICU doctors can’t be expected to know what outpatient treatment options are available!	Outpatient quality of life depends on the treatment and support options that the patient will have access to	Intensivists have an obligation to maintain an up-to-date understanding of what is feasible in the outpatient setting and to seek expert consultation where necessary.
How is this different than a goals-of-care conversation?	Goals-of-care conversations often include transmitting prognostic estimates to patients and surrogates	Goals-of-care conversations, in modern best practice, are about eliciting patient preferences and values—an essential input into the physician task of deciding if a patient is acutely dying at a given moment. This article seeks to improve the process of formulating a relevant prognostic estimate for acutely dying patients, rather than focus on the specific skills of communicating that prognosis.
Isn’t this just paternalism?	Is declaring someone “acutely dying” just a way to end-run around patient and family preferences?	What I am proposing is meant to encourage physicians to step into the full obligation of truly shared decision-making and share their expert judgement on survivability under different scenarios.
Who is experienced enough to do this?	Can any physician do this? If interns start doing this in their first week on the ICU service, won’t that cause harm?	I think this is a task that should always be done by attending physicians at this point, with input from all members of the multidisciplinary team, and seeking advice from other senior clinicians as appropriate and the situation permits.*

Definition of abbreviation: ICU = intensive care unit.

^*There is a critical role of nursing in this, as partners, but for this forum I write to an audience of physicians about physicians’ responsibility.