US Sepsis Cases / Year
1.7 M
Approximately 1.7 million Americans develop sepsis annually — the most common cause of ICU admission and leading cause of hospital death in the US.[1]
What Is It
Sepsis epidemiology, multi-organ failure physiology, and the clinical reality of the most common end-of-life scenario in the American ICU.
Annual US Sepsis Deaths
270,000
Sepsis accounts for >35% of all hospital deaths. ~50% die after a decision to withdraw life-sustaining treatment — ~135,000 comfort-path deaths/year.[2]
Septic Shock + MOF Mortality
40–70%
Septic shock with 3+ organ failures carries 40–70% mortality even with maximum ICU care. SOFA >11 associated with >95% mortality.[3]
Time Decision → Death
30 min–8 h
After vasopressor cessation in a vasopressor-dependent patient, death typically occurs within 30 minutes to 8 hours depending on cardiac reserve.[4]
Sepsis is the body's catastrophic, dysregulated response to infection — a simultaneous cascade of inflammatory, coagulant, endocrine, and circulatory failure that overwhelms the body's ability to maintain organ function. When sepsis progresses to septic shock with multi-organ failure (MOF), the patient is on mechanical ventilation, vasopressor support, and often continuous renal replacement therapy (CRRT). The clinical scenario this card addresses — the transition from aggressive ICU management to comfort-directed care — is one of the most common end-of-life scenarios in American medicine, yet it remains among the least systematically addressed in palliative care education.[1]
The Surviving Sepsis Campaign bundles have improved outcomes significantly since 2002, but the mortality from septic shock with MOF remains 40–60% in contemporary series. Approximately 50% of patients who die from sepsis die after a goals-of-care conversation and a decision for comfort-directed management. The family arriving to the ICU for this conversation has typically had days — not months — to prepare. They are meeting physicians for the first time at a moment of maximum clinical acuity and minimum relationship. The palliative care clinician who enters this space must understand both the sepsis physiology and the family's acute psychological reality.[2]
The global burden is staggering: an estimated 49 million cases and 11 million deaths annually worldwide, making sepsis the cause of approximately 20% of all global deaths. This card focuses specifically on the comfort-directed path: what happens after the goals conversation has produced a decision to withdraw or withhold life-sustaining treatment — the transition from a ventilator, vasopressors, and dialysis to comfort medications and human presence.[5]
🧭 Clinical framing
This is not a slow dying. The patient on three vasopressors with a lactate of 12 and no urine output is on borrowed time that the ICU is lending. The comfort-path clinician's job is not to manage a chronic disease trajectory — it is to manage a rapid, acute clinical event with the precision of an emergency clinician whose tools are comfort medications, communication, and presence instead of vasopressors, ventilators, and dialysis. The family meeting is the central clinical procedure. The withdrawal sequence is the central clinical skill. Both must be performed with the same preparation and attention as any ICU procedure.
"Sepsis comfort-path is the fastest thing you'll ever do in palliative care. You walk into a room where a family has had seventy-two hours to absorb what most families get a year to process. You don't have time to build a relationship from scratch — you have to walk in already being the person they need. Sit down, ask who the patient is, and mean it. Everything flows from that first two minutes."
— Waldo, NP · Terminal2
How It's Diagnosed
The clinical data the comfort-path clinician must understand: SOFA score, vasopressor trajectory, lactate trends, and the failure-of-improvement assessment that informs the family meeting.
The comfort-path clinician does not re-diagnose sepsis — the ICU team has established the diagnosis, identified the source (when identifiable), and initiated the Surviving Sepsis Campaign bundles. What the comfort-path clinician must understand is the data that informs the prognosis and the family conversation.[3]
SOFA Score — Organ Failure Scorecard
Grade ASequential Organ Failure Assessment (SOFA) — the validated sepsis severity tool:[6]
- Respiratory: PaO2/FiO2 ratio (normal >400; <100 = severe ARDS, score 4)
- Coagulation: Platelets (<20,000 = score 4, indicates DIC)
- Hepatic: Bilirubin (>12 mg/dL = score 4)
- Cardiovascular: Vasopressor dose (norepinephrine >0.1 mcg/kg/min = score 3–4)
- Neurological: GCS (3–5 = score 4)
- Renal: Creatinine (>5 mg/dL = score 4) or UOP <200 mL/day
- SOFA >11: Associated with >90% mortality in most cohorts
Family language: "The body keeps score of how many organs are in crisis. Your person's score tells us that almost every major organ is significantly affected."
Clinical Trajectory Assessment
Grade BThe trajectory is temporal, not cross-sectional — the most important prognostic indicator:[7]
- Vasopressor trajectory: NE 0.1 yesterday → 0.4 today = worsening
- Lactate trend: Rising despite resuscitation = worsening tissue hypoperfusion
- Urine output trend: Decreasing or absent = renal failure progressing
- Daily SOFA trend: Rising over 48–72 h despite maximum therapy = failing
- Document: "Vasopressor requirements increased 300% in 48h with no improvement in UOP or lactate"
Failure of Improvement After Resuscitation
- SSC bundles completed: Early antibiotics, source control, fluid resuscitation, vasopressors to MAP ≥65
- 48–72 h of maximum therapy without improvement: The patient has declared their trajectory
- Source control: Has the source been identified and controlled? If not, recovery is significantly less likely
- Family language: "We have given every treatment the evidence supports. The body has not responded. This is the severity of the infection."
Comfort-Path Record Must Document
- Current vasopressor doses and 24–48 h trend
- Ventilator settings: FiO2, PEEP, mode — whether weaning attempted
- Renal replacement: On CRRT/HD? Any native kidney recovery?
- SOFA score: Current and trend over admission
- Lactate: Most recent and 24–48 h trend
- Infectious source and control status
- Family meeting note: Attendees, content, values, decision
💡 For families
The doctors and nurses have run many tests and used many monitors to understand what is happening inside your person's body. The numbers they are watching tell a story about how each organ — the lungs, kidneys, liver, heart — is functioning. When we say "organ failure," we mean that one or more organs cannot do its job even with all the support the ICU can provide. The trajectory — whether things are improving, stable, or worsening — is the most important piece of information about what is likely to happen next.
Causes & Risk Factors
Sepsis etiology, the infection sources relevant to the comfort-path encounter, and the host factors that predict worse outcomes and shape the family conversation.
Sources of Sepsis in MOF Patients
- Pulmonary (most common in US): Community-acquired and hospital-acquired pneumonia; ventilator-associated pneumonia complicating primary respiratory illness
- Abdominal: Bowel perforation, peritonitis, cholangitis, pancreatitis with superinfection
- Urinary: Urosepsis from ascending UTI to bacteremia
- CNS: Meningitis, brain abscess
- Skin/soft tissue: Necrotizing fasciitis, infected wound
- Unknown source (~25%): No identifiable source despite comprehensive evaluation
- Source control relevance: Families must understand whether source control has been achieved — if the ongoing source cannot be controlled, recovery is even less likely
Host Factors Predicting Worse Outcomes
- Advanced age: Immune senescence and physiological reserve depletion produce dramatically worse sepsis outcomes[8]
- Baseline frailty: CFS ≥6 patients have less reserve for organ recovery
- Immunosuppression: Malignancy, HIV, organ transplant, chronic corticosteroids
- Pre-existing organ dysfunction: CKD patient has less renal reserve; COPD patient has less respiratory reserve to wean from ventilator; cirrhotic patient has less hepatic reserve
- Pre-existing multi-organ dysfunction + septic MOF: Worst prognosis of any combination — essentially no additional reserve
- Delayed presentation: Time to antibiotics >1 hour from recognition increases mortality 7–8% per hour of delay[9]
❤️ For families: "Why did this happen?"
Families frequently ask this question and often feel guilty — wondering if they should have brought their person to the hospital sooner, noticed something earlier. The honest answer: sepsis can develop rapidly, often from common infections. It is not caused by something anyone did wrong or failed to do. The infection triggered a response in the body that was beyond anyone's control. Some people's bodies respond to infection with this overwhelming cascade; others do not. The speed of this illness is not a sign of negligence — it is a sign of the severity of the body's response to the infection.
⚕ Clinician note: Health disparities in sepsis
Black patients have higher sepsis incidence, higher mortality, and lower rates of palliative care consultation than white patients. Patients without insurance and those from lower socioeconomic backgrounds present later, receive fewer guideline-concordant interventions, and have worse outcomes. The palliative care clinician must be aware that the family in the meeting room may have experienced healthcare system failures that preceded this ICU admission — and those experiences shape their trust in the current team's recommendations.[10]
Treatments & Procedures
The goals-of-care family meeting as a clinical procedure — preparation, execution, documentation, and the withdrawal sequence that follows.
The goals-of-care family meeting in sepsis MOF is a clinical procedure with specific evidence-based components, preparation requirements, and documentation standards. It carries the same weight as any surgical consent. The VALUE framework (Value, Acknowledge, Listen, Understand, Elicit) is the only RCT-proven communication intervention for reducing family PTSD in ICU end-of-life care.[11]
Meeting Preparation
- Review complete clinical picture: Vasopressor doses, SOFA score, lactate trend, urine output trend
- Identify legal surrogate; read available advance directive
- Speak to bedside nurse who knows the family's emotional state
- Identify family members attending and their apparent positions
- Prepare the room: Enough chairs for everyone; tissues on table; no one standing; close the door; silence clinician's pager
- Anticipate emotional responses: The son in denial, the daughter who knew, the exhausted spouse
Meeting Execution — VALUE Framework
Grade A- Opening (not medical): "Before we talk about anything clinical, can you tell me about [name]? What kind of person is he? What does he love?" — signals personhood and grounds the values conversation[11]
- Information delivery: Name each organ failure in plain language; describe the trajectory; state probability honestly: "The honest answer is that more than half of people in this situation do not survive, even with everything we are doing"
- Avoid: "hopeless" (removes agency), "nothing" (there is always something), "withdrawal of care" (we are redirecting care, not withdrawing it)
- Elicit the patient's voice: "Given what you know about [name], if he could hear everything we've discussed, what would he say?"
- Support the decision: "You are not making this decision because you are giving up. You are making it because you love your person and you know who they are."
Time-Limited Trial Option
- When family needs more time: Define a specific trial period (48–72 hours typically)
- Name specific benchmarks: "If the vasopressor dose decreases and the lactate improves in 48 hours, we will continue. If not, we will reconvene and talk about comfort."
- Document start date, end date, metrics, and plan for each outcome
- Reduces family guilt: "We gave it every chance" language becomes available[12]
Post-Decision: The Withdrawal Sequence
- Step 1: Comfort medications ordered and verified running (morphine + midazolam infusions)
- Step 2: Family present (if they choose); nurse at bedside; chaplain notified
- Step 3: Discontinue monitoring alarms — remove or silence monitors
- Step 4: Vasopressor wean (gradual, 25–50% reductions q5–10 min)
- Step 5: Ventilator withdrawal (terminal extubation or terminal wean)
- Step 6: Discontinue CRRT, blood products, labs, imaging
- Step 7: Active comfort medication titration throughout; nurse remains
🚨 Documentation Standards — Non-Negotiable
The family meeting note must document: (1) Who attended; (2) Clinical information presented; (3) Patient's known values and wishes; (4) Legal surrogate identified and their relationship; (5) Decision made and by whom; (6) Whether decision was unanimous or if family disagreement exists; (7) Plan for withdrawal sequence and timeline. This documentation protects the patient, the family, and the clinical team. It is a clinical standard with the same weight as surgical consent.
When Therapy Makes Sense
When comfort-path medications and interventions are clinically appropriate — the evidence-based criteria for the transition to comfort-directed care.
Comfort-path medication management in sepsis MOF has one absolute clinical standard: comfort medications must be established and therapeutic before any withdrawal of life-sustaining treatment begins. This is non-negotiable. The sequence is always: (1) establish comfort medications → (2) confirm medications active → (3) begin withdrawal → (4) actively titrate throughout.[13]
- 01Comfort medications established and therapeutic: Morphine infusion started at clinically appropriate dose for pain and dyspnea; midazolam infusion started for anxiety and agitation; both titrated to effect before vasopressor wean or extubation begins. Document comfort medications in place before withdrawal initiation.[13]
- 02Family meeting completed, documented, and understood: The decision must be explicit and documented before withdrawal begins. Documentation includes attendees, discussion content, patient values, surrogate identity, and the decision made.
- 03Acetaminophen for fever comfort: Fever of sepsis causes significant distress in conscious/semi-conscious patients. Acetaminophen 650–1000 mg q6h (rectal if oral route lost) addresses fever without NSAID complications in renal failure.
- 04Glycopyrrolate for secretion management: Terminal secretions ("death rattle") are the most commonly reported family distress source. Glycopyrrolate SQ 0.2 mg q4h or continuous infusion prevents and treats secretions. Must be available before final hours.[14]
- 05Opioid for dyspnea and pain: Morphine IV infusion 2–4 mg/h with PRN 2 mg q15min for breakthrough air hunger. If AKI makes morphine metabolite accumulation a concern, fentanyl 25–100 mcg/h IV with PRN 25 mcg is the preferred alternative.
- 06Midazolam for anxiety, agitation, terminal restlessness: 1–5 mg IV/SQ for acute agitation; 5–15 mg/h IV infusion for refractory agitation in terminal phase. Nurse-titrated within prescribed ranges — the essence of the nurse-controlled comfort protocol.[15]
- 07Nurse-controlled comfort protocol in place: The nurse must have explicit titration orders that do not require a physician call for every adjustment. Pre-written range orders with clear titration parameters allow the nurse to respond to symptoms in real time.
When It Doesn't
Clinical failures in comfort-path management — the errors that produce preventable suffering during the withdrawal process.
These are the clinical failures in the comfort-path management of sepsis MOF — the errors that produce preventable suffering and avoidable family trauma. Each represents a violation of evidence-based comfort care standards.[13]
- 01Withdrawing life support before establishing comfort medications: The vasopressor cessation or extubation that occurs before morphine and midazolam are running produces air hunger and agitation that is entirely preventable. No withdrawal begins until comfort medications are active. This is the most common clinical failure in the comfort-path transition.[16]
- 02Proceeding without documented family meeting and decision: Withdrawal without documented surrogate decision creates legal, ethical, and clinical documentation risks. The documentation protects the patient, the family, and the team.
- 03Using abandonment language: "There is nothing more we can do" / "We are giving up" / "We are withdrawing care" — these phrases are clinically and humanly inaccurate. Replace with: "We are shifting our focus from trying to reverse the organ failure to ensuring [name] has no suffering and that you are supported."
- 04Nurse not present during withdrawal: Families must not be left alone during withdrawal. The nurse's presence is both a comfort measure for the family and a clinical safety measure ensuring symptoms are treated immediately. "Family left alone for natural death to occur" is inadequate care.
- 05Providing prognostic information at inappropriate speed or volume: The clinician who walks in and delivers 20 minutes of ICU data to a family in shock has replicated the clinical information overload that produces poor decision-making. The family meeting must pace information to the family's capacity to absorb it.[17]
- 06Offering comfort care as "giving up": Comfort-directed care is not withdrawal of care — it is redirection of expertise toward a different goal. The language must reflect this. Comfort is an active clinical choice that requires more skill, not less.
- 07Failing to address surrogate guilt proactively: The surrogate who is not explicitly told "you are not ending your person's life — the infection is" will carry guilt for years. This reassurance must be provided directly, repeatedly, and documented.
📋 Clinician note
The most common clinical failure is a sequencing error: the withdrawal order arrives before the comfort medication order. The nurse who is told to wean vasopressors before the morphine infusion is running has been put in an impossible clinical position. The comfort-path clinician's job is to ensure the sequence is correct: comfort first, withdrawal second, always.
Out-of-the-Box Approaches
Evidence-graded communication, protocol, and non-pharmacological approaches for the sepsis MOF comfort path. Grade A = RCT; B = multi-observational/meta-analysis; C = limited clinical; D = expert opinion.
VALUE Family Meeting Framework
Grade AProtocol: Structured communication at every ICU family meeting using the VALUE mnemonic
The landmark Lautrette et al. 2007 NEJM RCT randomized families of dying ICU patients to receive either standard family meetings or VALUE-structured meetings. At 90 days, families receiving VALUE had significantly lower PTSD, anxiety, and complicated grief. This is the highest-quality evidence for any communication intervention in ICU EOL care. The VALUE mnemonic: Value family says; Acknowledge emotions; Listen more than talk; Understand the patient as a person; Elicit questions. Should be used as structured guide for every sepsis MOF family meeting.[11]
Nurse-Controlled Comfort Protocol During Withdrawal
Grade AProtocol: Pre-established opioid + benzodiazepine infusions with explicit nurse-titration orders
The nurse-controlled protocol is the single most important safety standard for comfort-path withdrawal: pre-established morphine infusion at defined starting rate; pre-established midazolam infusion; explicit nurse-titration order ("increase morphine 25–50% for air hunger; increase midazolam 25–50% for agitation; call physician only if unable to achieve comfort after 2 escalations"). The nurse must not need to call for permission for each dose adjustment during active withdrawal. This is an established clinical standard in ICU palliative care.[13]
Proactive Bereavement Follow-Up Call
Grade BProtocol: Structured phone call 2–4 weeks after death; again at 3 months if needed
The bereavement follow-up call from someone who was present during the dying process reduces complicated grief in families of ICU patients. The call structure: (1) Express condolence specifically referencing the patient by name; (2) Ask how the family is doing; (3) Normalize the grief responses they may be experiencing; (4) Screen for complicated grief or surrogate guilt; (5) Provide bereavement resources. The call takes 15–20 minutes and has documented outcomes data for reducing family psychiatric morbidity.[18]
Staff Debriefing After Difficult Deaths
Grade BProtocol: Structured debrief within 48 hours of a difficult ICU death
Moral distress in ICU nursing staff is endemic and cumulative. The nurse who has performed three withdrawal-of-care procedures in one week without debriefing is at risk for burnout, compassion fatigue, and moral injury. Structured debriefing within 48 hours of a difficult death reduces reported moral distress. Structure: (1) What happened; (2) What went well; (3) What was difficult; (4) What can be done differently; (5) How is everyone doing. Protected time, closed door, no hierarchy.[19]
Music During the Dying Process
Grade CDose: Patient's own music at low volume; 30–60 min sessions or continuous
Music therapy and music thanatology in the ICU: physiological data show reduced heart rate, reduced respiratory rate, and reduced cortisol levels in ICU patients exposed to familiar music. Family-selected music personalizes the dying space and transforms the clinical environment. The patient's own playlist is profoundly more effective than generic "relaxation" music. Ask the family: "Is there music your person loves?" The family who plays their person's favorite songs during the final hours reports this as one of the most meaningful acts of the entire process.[20]
Palliative Care Team Integration in ICU
Grade AProtocol: Automatic palliative care consultation trigger for ICU patients meeting MOF criteria
Meta-analyses show that early palliative care integration in ICU reduces ICU length of stay, reduces family PTSD, improves symptom management during withdrawal, and does not increase mortality. Trigger-based consultation (e.g., ≥72 hours on mechanical ventilation, ≥2 organ failures, family meeting requested) produces more consistent engagement than ad-hoc referral. The palliative care team should be involved before the family meeting, not called after the decision has already been made.[21]
Natural & Herbal Options
The supplement context in sepsis MOF is fundamentally different from every other card — this section addresses what families want to give and what the comfort-path team can offer.
🧭 Context: Why this section is different
Sepsis and multi-organ failure on a comfort path present a supplement context entirely different from every other diagnosis in this series. The patient is in the ICU or has just transitioned to comfort care following acute hospitalization. They cannot take oral supplements. They cannot consent to supplement additions. The most common supplement question comes from the family: "Is there anything we can give her to help her fight this?" The honest and compassionate answer is not a supplement recommendation — it is an acknowledgment of the helplessness driving the question and a redirection toward presence as the most powerful thing available.
"When a family asks 'is there anything we can give her,' what they're really saying is 'I need to do something — I can't just sit here and watch.' That's not a supplement question. That's a helplessness question. Show them how to do the oral swabs. Show them how to hold the hand. Give them a job that matters. That's the supplement."
— Waldo, NP
| Intervention | Evidence | Application | Benefit | Notes |
|---|---|---|---|---|
| Ice Chips / Oral Swabbing | Grade A | Moistened swabs to lips and mouth q1–2h; ice chips if swallow intact | Oral comfort; reduces dryness universal in dying patients; gives family tangible caregiving role | The family who provides oral care is both giving a comfort intervention and participating in active caregiving. Teach this first. |
| Music (Patient's Own) | Grade B | Patient's own music at low volume via phone/speaker; continuous or intermittent | Reduces heart rate, respiratory rate, cortisol; personalizes the dying space; documented family satisfaction | Ask: "Is there music your person loves?" The patient's own playlist is profoundly more effective than generic relaxation music.[20] |
| Aromatherapy (Lavender) | Grade C | Lavender essential oil on cloth near (not on) patient; or in diffuser at low setting | Limited ICU data; some evidence for anxiety reduction; improves room environment for family | Avoid direct skin application in patients with DIC or fragile skin. Family often finds this meaningful. Ensure no respiratory irritation. |
| Presence and Touch | Grade B | Hand-holding, gentle touch to arm or forehead; sitting close; speaking calmly | Reduces patient vital sign markers of distress; profoundly meaningful for families; creates memories of connection | Hearing is believed to persist into active dying. Encourage family to speak to the patient. Touch is therapeutic for both patient and family. |
| Sacred/Ritual Objects | Grade D | Family-brought items: prayer beads, religious texts, photos, meaningful objects at bedside | Spiritual comfort; cultural and religious meaning; personalizes the clinical space | Facilitate bringing personal and religious items into the ICU room. Accommodate cultural and religious practices within clinical safety parameters. |
🚫 Not Appropriate in This Context
- Oral supplements of any kind — the patient on comfort path from sepsis MOF typically cannot take oral medications safely; aspiration risk; route unavailable
- IV vitamin C for sepsis treatment — the VITAMINS and CITRIS-ALI trials showed no survival benefit from high-dose IV vitamin C in sepsis; this is not a comfort intervention
- Herbal supplements with anticoagulant properties (garlic, ginkgo, turmeric) — in a patient with DIC, any additional anticoagulant effect is dangerous
- Any supplement marketed as "immune boosting" — the dysregulated immune response is the problem in sepsis, not a deficiency; boosting the immune response is contraindicated
Timeline Guide
The acute, compressed timeline of sepsis MOF — unlike every other card, this trajectory spans days to weeks, not months to years.
The sepsis MOF comfort-path timeline is characterized by its acute and compressed nature. Unlike chronic illness trajectories, the entire clinical course from presentation to death may span days. Each phase has specific family communication needs and clinical inflection points.[4]
HRS–
DAYS
DAYS
Acute Illness — Rapid Deterioration
- The precipitating event: pneumonia, abdominal perforation, UTI progressing to bacteremia — often a common infection that escalated
- Initial ED presentation; escalation faster than family understood — intubation, vasopressors starting, CRRT beginning
- Family arrives to find their person in the ICU on machines they did not know would be needed
- First meeting with ICU team — information that is hard to absorb; days of waiting and hoping
- The palliative care clinician who makes contact at this phase — before the family meeting — and sits with the family and listens before any clinical information is delivered provides an intervention that shapes the entire decision process
DAYS
The Decision Point — Family Meeting & Goals Conversation
- The family meeting: information delivered; patient's voice heard through the surrogate; decision made or time-limited trial agreed upon
- Clinical pivot from recovery-directed to comfort-directed
- Comfort medications ordered and established; documentation completed
- Chaplain notified; social worker engaged; nursing team briefed
- This is the clinical inflection point — every subsequent action flows from the decision made in this meeting
- Some families need hours after the meeting before they are ready for the withdrawal to begin; others are ready immediately — follow the family's pace
MINS–
HRS
HRS
The Withdrawal — Active Comfort Management
- Comfort medications verified running; nurse at bedside; family present if they choose
- Monitors silenced or removed; CRRT discontinued; labs discontinued
- Vasopressor wean begins: gradual 25–50% reductions q5–10 min; comfort meds titrated with each reduction
- Ventilator withdrawal (if extubation): pre-medication bolus; extubation; immediate post-extubation comfort assessment
- Active titration of morphine and midazolam throughout; every sign of distress addressed immediately
- The nurse narrates to the family: what is happening, what to expect, what the medications are doing
MINS–
HRS
HRS
Physiological Dying After Withdrawal
- Blood pressure falls as vasopressors are weaned — hands and feet cool and mottle (bluish-purple discoloration)
- Heart rate may increase initially then slow; irregular rhythms common; agonal rhythms in final minutes
- Breathing changes: Cheyne-Stokes (cyclic breathing with pauses), agonal respirations, mandibular breathing
- Terminal secretions may develop — audible gurgling; treat with glycopyrrolate and positioning
- Time from vasopressor cessation to death: typically 30 min to 8 hours; some patients with residual cardiac reserve may survive longer
- The patient who survives >24 hours after withdrawal may need transfer to inpatient hospice or comfort-care room
AFTER
After Death — Immediate and Ongoing Family Support
- Allow the family as much time as they need with the body; there is no clinical urgency
- Offer to call anyone the family wants present; offer chaplain; offer to help with phone calls
- Provide information about next steps (funeral home, death certificate) when the family is ready — not immediately
- Bereavement follow-up call at 2–4 weeks; repeat at 3 months if needed
- Screen for complicated grief in the surrogate specifically — the decision-maker carries the highest risk
- Staff debriefing within 48 hours for the clinical team
Medications to Anticipate
Comfort-path pharmacology for sepsis MOF withdrawal — the medications that must be running before any life support is removed.
🚨 ABSOLUTE CLINICAL STANDARD
Comfort medications must be established and therapeutic before any withdrawal of life-sustaining treatment begins. The sequence is always: (1) establish comfort medications → (2) confirm active and providing comfort → (3) begin vasopressor wean and/or extubation → (4) actively titrate throughout. The nurse-controlled comfort protocol — with explicit titration orders that do not require a physician call for each adjustment — is the standard of care.
| Drug | Target Symptom | Starting Dose | Notes / Titration Protocol |
|---|---|---|---|
| Morphine IV Infusion | Dyspnea + Pain | 2–4 mg/h IV continuous; PRN 2 mg IV q15min | Primary opioid for comfort-path. Opioid-naive: 1–2 mg/h. Prior ICU opioid exposure: 2–4 mg/h or higher. Nurse-titration: increase 25–50% for persistent dyspnea/pain not controlled by 2 PRN doses. Document indication for every dose. This is not euthanasia — it is treatment of dyspnea.[13] |
| Fentanyl IV Infusion | Dyspnea + Pain (AKI alternative) | 25–100 mcg/h IV; PRN 25 mcg IV q15min | Preferred when AKI makes morphine metabolite accumulation a concern (M3G, M6G). No active metabolites requiring renal clearance. Titration same principles as morphine. ⚠ Shorter duration — more breakthrough dosing may be needed[22] |
| Midazolam IV Infusion | Anxiety + Agitation | 1–5 mg/h IV continuous; PRN 2–5 mg IV q15min | For anxiety, agitation, and terminal restlessness. 5–15 mg/h for refractory agitation in terminal phase. Nurse-titrated: increase 25–50% for agitation not controlled by 2 PRN doses. Essential adjunct to opioid during withdrawal — addresses the terror component of air hunger.[15] |
| Glycopyrrolate | Terminal Secretions | 0.2 mg SQ/IV q4h; or 0.4–1.2 mg/24h continuous | Prevents and treats terminal secretions. Does not cross BBB — preferred in conscious/semi-conscious patients (no sedation). Pre-treat before extubation to reduce post-extubation rattle. Early use more effective than treating established secretions.[14] |
| Acetaminophen | Fever Comfort | 650–1000 mg q6h PO/PR | Fever of ongoing septic physiology causes rigors and distress. Rectal route when oral intake ceases. Avoids NSAID complications in renal failure. ⚠ Avoid NSAIDs with AKI |
| Haloperidol | Delirium / Agitation | 2–5 mg IV q4–6h | ICU delirium in sepsis MOF is extremely common (60–80%). In comfort-path context, treat for comfort not resolution. Add to midazolam for mixed delirium-agitation. Avoid in patients with prolonged QTc; monitor if available |
| Lorazepam | Anxiety (conscious patient) | 0.5–2 mg IV/SQ q4h PRN | For the conscious patient with anxiety about the withdrawal process or existential distress. Midazolam preferred for continuous infusion; lorazepam for intermittent dosing in the alert patient. |
| Propofol | Refractory Agitation (ICU) | 5–50 mcg/kg/min IV continuous | Palliative sedation for refractory agitation unresponsive to midazolam and opioid escalation. Requires ICU monitoring (typically already in place). Goals-of-care conversation with family before initiation. ⚠ Document palliative sedation indication clearly[23] |
🌿 Symptom Management Decision Tree — Sepsis MOF Comfort Path
Evidence-based · ICU Comfort-path adaptedSelect a symptom below to begin
What is the primary symptom to address?
🚨 Comfort Kit / Bedside Must-Haves Before Withdrawal
- Morphine infusion: Running and at therapeutic dose BEFORE withdrawal begins
- Midazolam infusion: Running BEFORE withdrawal; bolus doses drawn and labeled at bedside
- Glycopyrrolate: Drawn and at bedside; administer 0.2 mg IV before extubation
- Suction equipment: Oral suction (Yankauer) at bedside for post-extubation
- Fan: Directed at patient's face for air movement sensation post-extubation
- Oral care supplies: Moistened swabs for family to provide oral comfort
- Tissues and water for family
Clinician Pointers
High-yield clinical pearls for the sepsis MOF comfort-path team — the things not in the textbook, learned at the ICU bedside.
1
Sit down before you say anything in the family meeting
The clinician who walks into the ICU family meeting room, remains standing, and delivers clinical information in five minutes while the family is seated has replicated the power dynamic that most families find dehumanizing. Sit down. Make eye contact with the surrogate. Ask the opening question before any clinical information. The physical act of sitting is a clinical intervention that changes the quality of the communication.[11]
2
Ask the opening question and then be quiet
"Before we talk about anything medical, can you tell me who [patient name] is as a person?" After asking, be silent for as long as it takes. The family member who says "she was a schoolteacher for 35 years, she loved the garden, she always said she didn't want to be on machines" has given you the clinical foundation for everything that follows. This takes two minutes. It changes the meeting.
3
State the survival probability clearly and with compassion
Do not hide behind uncertainty. The family meeting where the physician says "it's very hard to know" and the family leaves not understanding the gravity is a failed meeting. Say it: "The honest answer is that the majority of patients in this situation — more than half, often much more — do not survive, even with everything we have. I want you to have that information clearly because it should shape the decisions we make together." Then: "I know that is very hard to hear."[17]
4
Verify comfort medications before withdrawal — personally
Do not allow withdrawal to start before you have personally verified that morphine and midazolam infusions are running. Call the nurse before the vasopressor wean begins. Document: "Comfort medications verified active at [time] — morphine [dose], midazolam [dose] — before vasopressor wean initiated." This documentation protects everyone.
5
Tell the surrogate they are not killing their person
Say it directly: "You are not ending your person's life. The infection is ending your person's life. You are deciding how they die, not whether they die. You made this decision based on everything you know about who they are and what they would want. That is the most loving thing you could do." Say it more than once. The surrogate who hears it once will default to guilt. Document the reassurance provided.[24]
6
Turn off the monitors before the family sees the numbers drop
The family watching the monitor as the blood pressure falls during vasopressor wean will experience each number drop as a discrete trauma. Turn off or silence monitors before the withdrawal begins. Tell the family: "We are going to turn off the monitors now because the numbers are no longer helping us care for [name]. We are watching your person, not a screen." This small act prevents significant family distress.
7
Name the racial and socioeconomic disparities in the room
Black patients have higher sepsis incidence and mortality. Families of color may have experienced healthcare system failures that shape their trust. The clinician who acknowledges this — "I understand that the healthcare system has not always treated your family fairly, and I want you to know that I am here to serve your family's needs and your person's wishes" — opens a door that pretending disparities don't exist keeps closed.[10]
"The moment the vasopressor wean starts, you are in it. There is no pause button. The nurse who is at that bedside needs to know three things: the morphine is running, the midazolam is running, and they have permission to increase both without calling me first. If those three things are in place, the withdrawal will go well. If any one of them is missing, you're going to have a family that watches their person suffer. I have seen both. You never forget the one that went wrong."
— Waldo, NP · Terminal2
Psychosocial & Spiritual Care
Acute grief, surrogate burden, family conflict, spiritual care, and the psychological reality of sudden illness without preparation time.
The psychosocial landscape of sepsis MOF on a comfort path is defined by its acuity. The family who is at the bedside of a person who was home last week and dying this week is experiencing the most acute form of anticipatory grief — compressed into days without the preparation that chronic illness provides. The social worker who acknowledges this specifically provides the acknowledgment the family desperately needs.[25]
Acute Grief of Sudden Illness
The Grief That Had No Preparation
- Normalize the shock: "You had no time to prepare for this. There was no warning. The speed of this is its own grief."
- Normalize the disorientation: "Of course you're having trouble taking this all in. This happened so fast. What you're feeling is exactly what most people feel."
- The family in the ICU waiting room has not slept in the bed they normally sleep in; they have eaten from vending machines; they have taken calls from family members who cannot be there
- Physical care of the family: offer food, blankets, a quiet space, a chaplain, a social worker — before they ask
The Surrogate's Burden
- The person who has just decided to stop life-sustaining treatment carries a weight that will be with them for years
- Essential reassurance: "You are not ending your person's life — the infection is. You are deciding how they die, not whether. You made that decision based on what you know about who they are. That is the most loving thing you could do."
- This must be said directly and clearly, usually more than once
- The surrogate who hears it once and does not hear it again will default to guilt[24]
- Screen specifically for complicated grief in the surrogate at bereavement follow-up
Family Conflict
Family conflict in the ICU family meeting is common and is one of the most clinically demanding aspects of the comfort-path work. The family member who insists on continued aggressive treatment while the legal surrogate has decided for comfort must be addressed. Strategy: speak to the dissenting member separately. Acknowledge their position: "I can see how much you love your mother. Tell me what you're most afraid of." Then refocus on the patient's values, not the family member's wishes. The legal surrogate's decision stands. If conflict is severe, ethics consultation is appropriate. The dissenting family member who is heard individually is far more likely to accept the decision than the one who is overruled publicly.[26]
Spiritual Care in ICU Dying
Chaplaincy in ICU End-of-Life
Grade B- Chaplain presence at the time of withdrawal is associated with improved family satisfaction and reduced acute distress
- The chaplain offers what no clinical team member can: spiritual accompaniment without clinical agenda
- Request chaplain before withdrawal, not after death
- For families of faith: "Would it be helpful to have a chaplain or your own clergy present during this time?"
- For non-religious families: "We have someone on our team whose job is to be present and supportive — not religious unless you want it to be. Would that be helpful?"[27]
Cultural and Religious Considerations
- Ask, don't assume: "Are there any cultural, religious, or spiritual practices that are important to your family during this time?"
- Some traditions require specific rituals before death; some require specific handling of the body after death
- Accommodate religious and cultural practices within clinical safety parameters — the ICU can be more flexible than most staff assume
- Some families may have religious objections to withdrawal — this requires sensitive, patient navigation, not dismissal
- The cultural humility to ask rather than assume is itself a clinical skill
Prognostic Communication and Uncertainty
Clinical Pearl — Honest Uncertainty
Sepsis outcomes are genuinely variable, and clinicians are often communicating probability ranges rather than certainties. The uncertainty is real, not evasive. But uncertainty must not become a shield against clarity. The family needs to hear: "I cannot tell you exactly what will happen. What I can tell you is that the majority of patients in this situation do not survive. The uncertainty is about the timeline and the margin, not about the overall direction." Naming the range honestly while acknowledging its limits is the highest form of prognostic integrity.[17]
"The hardest family meetings I've been in are the ones where the family is split. The daughter says 'Mom would never want this' and the son says 'we can't give up.' Both of them are right about their own grief. The job is not to pick a side. The job is to bring them both back to the patient — to who the patient is and what the patient would say. When you get the family to stop arguing with each other and start listening to the patient's voice, the conflict usually resolves."
— Waldo, NP · Terminal2
Family Guide
Written for the family of a person dying from sepsis and multi-organ failure — a family who has had days, not months, to prepare.
What You Are Going Through: You had very little warning that this would happen. Your person was home, or in the hospital for something else, and now you are here — in an ICU, surrounded by machines and numbers that mean things you are still trying to understand. The speed of this is its own kind of cruelty. There was no time to prepare. There was no chance to say everything that needed to be said. What you are feeling — the shock, the disorientation, the inability to take in what the doctors are telling you — is exactly what almost everyone feels when something like this happens this quickly. You are not failing. You are doing something extraordinarily hard with no preparation and no rehearsal.
About the Decision: If your family has decided to focus on comfort rather than continuing aggressive life support, you have not given up on your person. You have made the hardest possible decision based on what you know about them — about who they are, what they value, what they would say if they could be here. The infection is what is ending your person's life. You are deciding how they die, not whether they die. That distinction matters enormously. The decision you have made is an act of love, not surrender.
What Will Happen When Life Support Is Changed
- When blood pressure medications are reduced: The blood pressure will fall. This usually happens over minutes to an hour. The hands and feet may change color, becoming bluish or mottled. The breathing may become slower and irregular.
- When the breathing tube is removed: Your person may breathe on their own for a while — minutes, hours, sometimes longer. The breathing may sound different — louder, or with pauses. The medical team has given medication to prevent any discomfort.
- Comfort medications are running: Before anything is changed, the team ensures that pain and anxiety medication is already working. Your person will not feel pain during this process. The team is watching continuously and adjusting medication as needed.
- Color and temperature changes: The skin may become cool, pale, or mottled (purplish patches). This is normal. It is the body's natural response.
- Breathing changes at the end: Breathing may become irregular with pauses, or you may hear a gurgling sound. The gurgling is air moving through fluid in the throat — it sounds much worse than it feels. Medication can reduce it.
How You Can Help Right Now
- Be present: Your presence is the most powerful thing you can offer. Sit close. Hold their hand. You do not need to say anything — being there is enough.
- Talk to your person: Hearing is believed to be the last sense to go. Say what you need to say. Tell them you love them. Tell them it's okay. Your voice is comfort.
- Provide mouth care: The nurse can show you how to use moistened swabs on your person's lips and mouth. This is a real comfort measure and a meaningful way to care for your person.
- Play their music: If your person has favorite music, play it softly. This personalizes the space and provides comfort that clinical care cannot.
- Take care of yourself: Eat something. Drink water. Step out if you need to — the nurse will call you if anything changes. Your well-being matters too.
- Ask for help: A chaplain, social worker, or other support person can be present with you. You do not have to do this alone. Ask the nurse — we want to support you.
📞 Call the nurse immediately if you see:
Any sign that your person appears uncomfortable — grimacing, restlessness, or labored breathing. The team has medication ready to address this immediately. You do not need to wait. Press the call button or step into the hallway and find a nurse. Your instinct that something is wrong is valid. The nurse would always rather be called and find that everything is fine than not be called when your person needs attention.
🙏 You are doing something that requires more courage than most people will ever be asked to show. You are accompanying your person through the hardest passage of their life. Research consistently shows that patients who have loved ones present during the dying process have better comfort outcomes — your presence is not just emotional support, it is part of the care. You are part of the treatment team whether you know it or not. And what you are doing right now — being here — matters more than you can possibly understand from inside this moment.
Waldo's Top 10 Tips
Clinical field wisdom for sepsis MOF comfort-path management — 12+ years at the bedside distilled into the things that matter most.
- 01Sit down the moment you walk into the family meeting room. Not after introductions. Not after you set up. Before anything else happens. The family sees the sitting as the signal that you have time for them, that you are not about to deliver a briefing and leave, that this is a conversation rather than an information transaction. If every chair is taken, get one from the hallway. I don't care if it takes 30 seconds. The physical act of sitting is a clinical skill and it is the first skill that matters in this meeting.
- 02Ask who the patient is as a person before you mention a single lab value. "Before we talk about anything clinical, tell me about your husband. What is he like? What does he love?" Then be quiet. The family that says "he coached Little League for 20 years, he can't stand being dependent on anyone, he always said if something happened he didn't want heroics" has given you the clinical foundation for the entire meeting. The values conversation precedes the clinical information because it orients everything that follows. This takes five minutes. It changes the quality of every subsequent minute.
- 03Say the prognosis number out loud and clearly. The family meeting where the physician says "it's very uncertain" and the family leaves not knowing that the survival probability is below 30% has failed. Name the number: "The honest answer is that more than half of patients in this situation do not survive even with everything we have available. In situations as severe as this one, the number is higher than that." Then stop. Let that land. Then say: "I know that is very hard to hear. I want you to have that information because you need it to make the decisions ahead." The physician who names the number is not being cruel. They are providing the information the family needs to make a real decision.
- 04Verify the comfort medications yourself before the withdrawal starts. I don't trust the chart — I trust the IV pole. Walk to the bedside. Look at the pumps. Morphine running? Check. Midazolam running? Check. Glycopyrrolate drawn up and at the bedside? Check. I've seen withdrawals start before the comfort meds were up. I've seen what happens when they do. You do not want that on your watch. The three minutes it takes to physically verify the pumps are the most important three minutes in the entire comfort-path transition.
- 05Turn off the monitors before the wean starts. The family watching the blood pressure number drop from 85 to 72 to 58 to 41 is experiencing each digit as a separate loss. They don't need those numbers. You don't need those numbers. You are watching the patient, not the monitor. Tell the family: "We're going to turn off the screens now because we're watching your person, not numbers." Then do it. This small act prevents more family trauma than most people realize.
- 06The nurse at that bedside is the most important person in the room during withdrawal. Not me. Not the attending. The nurse. They are the one who sees the grimace, the tachypnea, the restlessness — and they are the one who titrates the morphine in real time. Make sure that nurse has three things before you leave: running infusions, PRN orders with clear ranges, and explicit permission to titrate without calling first. If the nurse has to call a physician every time they need to increase the drip by 0.5 mg, the patient will suffer in the gaps. Write the orders so the nurse can do their job.
- 07Tell the surrogate — directly, clearly, and more than once — that they are not killing their person. "You are not ending your mother's life. The infection is ending your mother's life. You are deciding how she dies, not whether she dies. And you made that decision based on everything you know about who she is. That is love." I say this at least twice in every family meeting. I've had surrogates call me six months later and say "the thing you said about how I wasn't the one ending her life — I replay that in my head every day." That one sentence is worth more than every clinical protocol in this entire card.
- 08Know the disparities and name them when appropriate. Black patients have higher sepsis incidence and higher mortality. Families of color have legitimate reasons to distrust the healthcare system. The family who seems resistant to comfort care may not be in denial — they may be protecting their person from a system that has not always protected them. If you sense this, name it: "I understand that the healthcare system has not always treated your family fairly. I want you to know that every recommendation I'm making is based on your person's wishes and their best interest." You don't have to solve systemic racism in one meeting. But you do have to acknowledge it.
- 09Take care of the nurse after the withdrawal. And take care of yourself. The ICU nurse who has managed three comfort-path withdrawals in a week is carrying moral weight that most people never encounter. Check in: "How are you doing with this one?" The debrief doesn't have to be formal. It can be five minutes in the break room. But it has to happen. The burnout and moral injury in ICU nursing is real, it is cumulative, and it is the reason good nurses leave. The two minutes you spend checking in on your team protects the next patient's care as much as any clinical protocol.
- 10Remember why this work matters. The family who walks out of that ICU having watched their person die peacefully — without air hunger, without agitation, without suffering — with someone at the bedside who knew their name and knew their story: that family will grieve. They will grieve hard and long. But they will not be haunted by the dying. They will remember it as hard and painful and sad — but not as traumatic. The difference between a good death in the ICU and a bad one is entirely within your clinical control. That is the privilege and the weight of this work. You are the last clinician this family will ever see in this context. Make it count.
— Waldo, NP
References
Peer-reviewed citations organized by clinical category. All PMIDs hyperlinked. Evidence levels assigned by study design.
Sepsis Epidemiology & Definitions
1
Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.
2
Rhee C, Dantes R, Epstein L, et al. Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014. JAMA. 2017;318(13):1241-1249.
3
Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017;45(3):486-552.
4
Mast KR, Salama M, Silverman GK, Arnold RM. End-of-Life Content in Treatment Guidelines for Life-Limiting Diseases. J Palliat Med. 2004;7(6):754-773.
5
Rudd KE, Johnson SC, Agesa KM, et al. Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet. 2020;395(10219):200-211.
6
Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22(7):707-710.
7
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818-829.
Goals-of-Care Family Meeting Evidence
8
Lilly CM, De Meo DL, Sonna LA, et al. An intensive communication intervention for the critically ill. Am J Med. 2000;109(6):469-475.
9
Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596.
10
Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence. 2014;5(1):4-11.
11
Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356(5):469-478.
12
Quill TE, Holloway R. Time-limited trials near the end of life. JAMA. 2011;306(13):1483-1484.
13
Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008;134(4):835-843.
14
Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171(9):987-994.
15
Daly BJ, Douglas SL, O'Toole E, et al. Effectiveness trial of an intensive communication structure for families of long-stay ICU patients. Chest. 2010;138(6):1340-1348.
Prognostic Communication
16
Christakis NA, Lamont EB. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. BMJ. 2000;320(7233):469-472.
17
Curtis JR, Engelberg RA, Wenrich MD, et al. Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med. 2005;171(8):844-849.
18
Campbell ML. Terminal dyspnea and respiratory distress. Crit Care Clin. 2004;20(3):403-417.
19
Gries CJ, Engelberg RA, Kross EK, et al. Predictors of symptoms of depression and anxiety in bereaved family members of people who died in the ICU. J Gen Intern Med. 2010;25(10):1126-1132.
20
White DB, Engelberg RA, Wenrich MD, et al. Prognostication during physician-family discussions about limiting life support in intensive care units. Crit Care Med. 2007;35(2):442-448.
21
Schwarze ML, Bradley CT, Brasel KJ. Surgical "buy-in": the contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy. Crit Care Med. 2010;38(3):843-848.
Withdrawal of Life-Sustaining Treatment
22
Campbell ML, Bizek KS, Thill M. Patient responses during rapid terminal weaning from mechanical ventilation: a prospective study. Crit Care Med. 1999;27(1):73-77.
23
Chan JD, Treece PD, Engelberg RA, et al. Narcotic and benzodiazepine use after withdrawal of life support: association with time to death? Chest. 2004;126(1):286-293.
24
Treece PD, Engelberg RA, Crowley L, et al. Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit. Crit Care Med. 2004;32(5):1141-1148.
25
Cook D, Rocker G, Marshall J, et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med. 2003;349(12):1123-1132.
26
Billings JA. Humane terminal extubation reconsidered: the role for preemptive analgesia and sedation. Crit Care Med. 2012;40(2):625-630.
27
Robert R, Le Gouge A, Kentish-Barnes N, et al. Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study). Intensive Care Med. 2017;43(12):1793-1807.
28
Cooke CR, Hotchkin DL, Engelberg RA, et al. Predictors of time to death after terminal withdrawal of mechanical ventilation in the ICU. Chest. 2010;138(2):289-297.
29
Kompanje EJO, van der Hoven B, Bakker J. Anticipation of distress after discontinuation of mechanical ventilation in the ICU at the end of life. Intensive Care Med. 2008;34(9):1593-1599.
Surrogate Decision-Making
30
Torke AM, Alexander GC, Lantos J. Substituted judgment: the limitations of autonomy in surrogate decision making. J Gen Intern Med. 2008;23(9):1514-1517.
31
Siegel MD, Hayes E, Vanderwerker LC, et al. Psychiatric illness in the next of kin of patients who die in the intensive care unit. Crit Care Med. 2008;36(6):1722-1728.
32
Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211-1218.
33
Wendler D, Rid A. Systematic review: the effect on surrogates of making treatment decisions for others. Ann Intern Med. 2011;154(5):336-346.
34
Azoulay E, Timsit JF, Sprung CL, et al. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med. 2009;180(9):853-860.
35
Barclay JS, Blackhall LJ, Tulsky JA. Communication strategies and cultural issues in the delivery of bad news. J Palliat Med. 2007;10(4):958-977.
Comfort Medications During Withdrawal
36
Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med. 2008;36(3):953-963.
37
Mularski RA, Puntillo K, Varkey B, et al. Pain management within the palliative and end-of-life care experience in the ICU. Chest. 2009;135(5):1360-1369.
38
Beller EM, van Driel ML, McGregor L, et al. Palliative pharmacological sedation for terminally ill adults. Cochrane Database Syst Rev. 2015;(1):CD010206.
39
Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008;(1):CD005177.
40
Sulmasy DP. The rule of double effect: clearing up the double talk. Arch Intern Med. 1999;159(6):545-550.
41
Dean MM, Cellarius V, Henry B, Oneschuk D, Librach SL. Framework for continuous palliative sedation therapy in Canada. J Palliat Med. 2012;15(8):870-879.
ICU Family & Staff Support
42
Azoulay E, Pochard F, Kentish-Barnes N, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med. 2000;28(8):3044-3049.
43
Anderson WG, Arnold RM, Angus DC, Bryce CL. Posttraumatic stress and complicated grief in family members of patients in the intensive care unit. J Gen Intern Med. 2008;23(11):1871-1876.
44
Rushton CH, Batcheller J, Schroeder K, Donohue P. Burnout and resilience among nurses practicing in high-intensity settings. Am J Crit Care. 2015;24(5):412-420.
45
Keene EA, Hutton N, Hall B, Rushton C. Bereavement debriefing sessions: an intervention to support health care professionals in managing their grief after the death of a patient. Pediatr Nurs. 2010;36(4):185-189.
46
Kentish-Barnes N, Chaize M, Seeber P, et al. Complicated grief after death of a relative in the intensive care unit. Eur Respir J. 2015;45(5):1341-1352.
47
Kavalieratos D, Corbelli J, Zhang D, et al. Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis. JAMA. 2016;316(20):2104-2114.
Sepsis Health Disparities
48
Barnato AE, Alexander SL, Linde-Zwirble WT, Angus DC. Racial variation in the incidence, care, and outcomes of severe sepsis: analysis of population, patient, and hospital characteristics. Am J Respir Crit Care Med. 2008;177(3):279-284.
49
Muni S, Engelberg RA, Treece PD, et al. The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest. 2011;139(5):1025-1033.
50
Phua J, Joynt GM, Nishimura M, et al. Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia. JAMA Intern Med. 2015;175(3):363-371.
51
Johnson KS. Racial and ethnic disparities in palliative care. J Palliat Med. 2013;16(11):1329-1334.
Spiritual & Chaplaincy Care in ICU Dying
52
Balboni MJ, Sullivan A, Amobi A, et al. Why is spiritual care infrequent at the end of life? Spiritual care perceptions among patients, nurses, and physicians and the role of training. J Clin Oncol. 2013;31(4):461-467.
53
Chochinov HM, Kristjanson LJ, Breitbart W, et al. Effect of dignity therapy on distress and end-of-life experience in terminally ill patients: a randomised controlled trial. Lancet Oncol. 2011;12(8):753-762.
54
Bradt J, Dileo C, Magill L, Teague A. Music interventions for improving psychological and physical outcomes in cancer patients. Cochrane Database Syst Rev. 2016;(8):CD006911.
55
Wall RJ, Curtis JR, Cooke CR, Engelberg RA. Family satisfaction in the ICU: differences between families of survivors and nonsurvivors. Chest. 2007;132(5):1425-1433.
Time-Limited Trial Evidence
56
Vink EE, Azoulay E, Caplan A, et al. Time-limited trial of intensive care treatment: an overview of current literature. Intensive Care Med. 2018;44(9):1369-1377.
57
Schenker Y, Tiver GA, Hong SY, White DB. Association between physicians' beliefs and the option of comfort care for critically ill patients. Intensive Care Med. 2012;38(10):1607-1615.
58
Bruce CR, Liang C, Blumenthal-Barby JS, et al. Barriers and facilitators to initiating and completing time-limited trials in critical care. Crit Care Med. 2015;43(12):2535-2543.
59
Chang DW, Neville TH, Parrish J, et al. Evaluation of time-limited trials among critically ill patients with advanced medical illnesses and reduction of nonbeneficial ICU treatments. JAMA Intern Med. 2021;181(6):786-794.
Physiological Dying After Withdrawal
60
Downar J, Delaney JW, Hawryluck L, Kenny L. Guidelines for the withdrawal of life-sustaining measures. Intensive Care Med. 2016;42(6):1003-1017.
61
Epker JL, Bakker J, Kompanje EJO. The time of death after terminal withdrawal of mechanical ventilation from the intensive care unit: an observational study. PLoS One. 2014;9(8):e103987.
62
Blinderman CD, Billings JA. Comfort care for patients dying in the hospital. N Engl J Med. 2015;373(26):2549-2561.
terminal2.care content is for educational purposes and is not a substitute for clinical judgment. Based on articles retrieved from PubMed. All PMIDs hyperlinked. © Terminal2 | terminal2.care
Private Notes
Session notes — not saved to any server. Clears when you close the tab.
Use this space for visit notes, clinical reminders, or patient-specific observations. This text is stored only in your browser session.