End-of-life decision making is a growing need in the ICU, covering a continuum of treatment possibilities. The author describes end-of-life decision making in the ICU and suggests strategies for improving the process for healthcare providers as well as patients and patients’ families.

Mrs J., a 75-year-old widow, was admitted to the intensive care unit (ICU) after heart surgery. Before the surgery, she hd been active in her community and enjoyed canning, quilting, and helping her elderly friends. Her greatest fear about surgery was that she might have a stroke, and she asked her daughter, Grace, who was the designated decision maker on Mrs J.’s advance directive, to promise that if something happened to prevent Mrs J. from returning to her independent lifestyle, Grace would make sure that life-prolonging treatment was not continued.

Initially, Mrs J. did well after surgery, but she had a debilitating brain stem stroke several days later...

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