Table 1.

Case vignettes’ descriptions

Description	Geriatric age-group	Poor/deteriorating chronic functional status	Lack of improvement with acute supportive therapies	Family requesting advanced supportive therapies	Clinical course and medical decision made during ICU admission by consensus between intensivist, primary physician, and patient/family
1. A 76-year-old woman presents with worsening lower limb edema. She is morbidly obese and a smoker with a 50-pack-year history and has severe COPD, CCF, OSA (on nocturnal CPAP), severe cor pulmonale, severe pulmonary hypertension, and acute-on-chronic renal failure. She is on 24-hour home O2 and is limited to an exercise tolerance of 10 meters due to exertional dyspnea. Although she still lives at home, she has become increasingly dependent on her 2 daughters for all activities. Also, she has been having 1–2 unplanned hospital admissions every month in the past year. Her most recent discharge was ~1 week ago. She had a deterioration in the ward with acute hypoxemic and hypercarbic respiratory failure requiring ICU admission and continuous (24 hours) BiPAP for the past 5 days, complicated by pressure ulcerations from the BiPAP mask. Her family “wants everything done”	Yes	Yes	Yes	Yes	Poor prognosis flagged by ICU nurse to medical team, followed by acknowledgement of likely long-term poor functional status by treating physicians (renal, respiratory, and ICU) Formal ACP/GoC discussions between multidisciplinary physicians, patients, and families, who understood the limitations and harms associated with supportive therapies Treatment capped at ward-level measures. Patient discharged home with community palliative care services.
2. An 86-year-old man who was previously high-functioning with a very good effort tolerance has bad pneumonia requiring ventilation. He has developed severe anuric renal failure. After 2 weeks of ventilation and dialysis in the ICU, he has lost 20 kg and has become weak and deconditioned. He remains anuric, needing thrice-weekly hemodialysis. He and his family have left it to the doctors to determine the appropriate next step	Yes	No	Yes	No	Severe multi-organ dysfunction and supports with significant deconditioning in an elderly man No discussions by treating team (both primary physician and intensivists) Family initiated ACP/GoC discussions via the ICU social worker resulted in an acknowledgment by primary physician and intensivist regarding likely long-term poor functional status Consensus to withdraw active treatments and initiate comfort care measures.
3. A 46-year-old man with stage 4 non-small cell lung cancer presents with bilateral pneumonia. Despite broad-spectrum antibiotics and intravenous fluids, he develops hypoxia, hypotension, and oliguric renal failure in the ward, for which he is admitted to the ICU in the middle of the night. Since the on-call oncologist is unaware of prior ACP/GoC discussions, the recommendation is to offer all measures till the primary oncologist is contacted in the morning.	No	No	Yes	Unknown	No prior ACP/GoC discussions despite the diagnosis of terminal cancer Acknowledgment by primary physician and intensivist regarding likely long-term poor prognosis Medical consensus to withdraw supportive therapies and initiate comfort measures

ICU, intensive care unit; ACP/GoC, advance care planning/goals of care