Tom Franklin was admitted to the surgical intensive care unit (ICU) 8 weeks ago after resection of necrotic bowel due to superior mesenteric artery occlusion. On postoperative day 3 he suffered a cardiac arrest and was resuscitated. Mr Franklin’s course since then has been complicated by acute respiratory distress syndrome, stroke, renal failure, and multiple episodes of septic shock. He has a sacral decubitus requiring twice-daily dressing changes, during which he grimaces while his blood pressure and oxygen saturation drop. His decision-making capacity has been intermittent. Throughout Mr Franklin’s surgical ICU stay, his care team addressed each acute event and complication with additional treatment interventions. His wife, Mrs Franklin, has power of attorney for health care and has come to view these treatments, including cardiopulmonary resuscitation, as necessary for her husband’s survival. The clinical team is concerned that they are participating in a course that is incrementally adding burden with...

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