Critical Care · Year 4 · from Critical Care
Case 3: ICU Handoff and Goals of Care
Clinical Image
Source: Wikimedia Commons - ICU Monitor - CC BY-SA 3.0
Case Presentation
A 78-year-old man with advanced COPD (FEV1 28% predicted), coronary artery disease with prior CABG, and chronic kidney disease stage 4 is on ICU day 7 following intubation for a COPD exacerbation complicated by hospital-acquired pneumonia. Despite appropriate antibiotic therapy, he has failed two spontaneous breathing trials due to tachypnea and hypercapnia. He remains on pressure support ventilation with FiO2 40% and PEEP 8 cmH2O. During morning rounds, the team reviews his trajectory: he has not improved over the past 3 days and now requires low-dose norepinephrine for hypotension. His wife and daughter are at bedside. The team conducts a systematic organ-by-organ assessment: neurologically, he is awake but fatigued and intermittently delirious (CAM-ICU positive); cardiovascularly, he is on norepinephrine 0.05 mcg/kg/min with MAP 68; respiratory status shows FiO2 requirement decreased from 60% to 40% but weaning attempts unsuccessful; renal function stable with creatinine 2.1 mg/dL and adequate urine output; he is receiving enteral nutrition at goal. The assessment is that he has a stable but worsening trajectory with limited reserve. The plan includes continuing current support, daily spontaneous breathing trial when vasopressors weaned, and a family meeting to discuss goals of care including the possibility of tracheostomy if extubation continues to fail. The team documents clear daily goals: achieve sedation vacation, attempt SBT if off vasopressors, physical therapy for bed exercises, and family meeting scheduled for 2 PM.
Key Learning Points
- ICU rounds follow a systematic structure: one-liner with diagnosis and ICU day, overnight events, current status with vital signs and exam, by-system assessment, overall trajectory, and plan with specific daily goals
- Trajectory assessment (improving, stable, worsening, dying) guides treatment intensity and goals of care discussions
- The ABCDEF bundle coordinates awakening trials (A/B), choice of sedation (C), delirium assessment (D), early mobility (E), and family engagement (F)
- Goals of care discussions should occur at key inflection points including day 3-5 without improvement, before major interventions like tracheostomy, and when trajectory changes