The pace of technological advancements in the intensive care unit (ICU) challenges clinicians’ ability to manage ethical and decision-making challenges near the end of life. Modern medicine has advanced to the point where we can support multiple organ systems simultaneously and sustain life when the benefits of treatments to overall survival and quality of life are not always clear. Physiological and technological limits no longer always tell us when to stop, and clinicians and families are now forced to take over the role that was once played by nature to make decisions as to whether and when life-sustaining therapies should be withdrawn or withheld.

Unfortunately, we often do not do a very good job of making these tough decisions even when patients can participate in the discussion. To add to that challenge, patients often lack decision-making capacity during their ICU stay. Clinicians and families struggle to balance the inherently imperfect practice of substituted judgement with their own views on the best interests of the patient. Advance care planning can facilitate this process, but even with the best advance care planning, it is often a complex and uncertain process.

Recent evidence indicates that we are not negotiating this complex process well.1 2 Life-sustaining therapies are increasingly provided at the end of life in a way that confers no survival benefit and can cause harm. Older Americans with advanced dementia have experienced a doubling in the use of mechanical ventilation and a rise in ICU admission from 17% to 38% of those hospitalised in the last 30 days of life without substantial survival benefit.1 2 A recent cluster-randomised trial suggests that systematically increasing ICU admissions for older adults confers no mortality benefit,3 and other studies have shown a trend towards harm.4 5 Hospitals with higher frequency of ICU use have higher …