Clinical Practice Guidelines on Adult End-of-Life Care in the ICU

Mary Faith Marshall, PhD, HEC-C, FCCM Karen A. Korzick , MD, MA, FCCP, FACP, FCCM

PUBLISHED: 12/05/2025

Clinical Practice Guidelines on Adult End-of-Life Care in the ICU

Citation: Marshall, MF, Davis, FD, Fogelman, PA, et al. Society of Critical Care Medicine clinical practice guidelines on adult end-of-life care in the ICU. Crit Care Med. 2025 Dec;53(12):e2734-e2746.

Jump to Recommendations

RATIONALE: Evidence-based practice has evolved significantly since the release of the 2008 American College of Critical Care Medicine (ACCM) Consensus Statement of recommendations for end-of-life (EOL) care in the ICU. These guidelines represent new knowledge and address previously unconsidered issues

OBJECTIVES: To identify and disseminate evidence-based recommendations based on current research to better understand how to deliver appropriate and effective adult EOL care in the ICU.

METHODOLOGY: Detailed methods can be found in the Supplementary Materials.

PANEL SELECTION: A call for interested panel members was submitted to the Society of Critical Care Medicine (SCCM) membership and through the SCCM Ethics Committee membership in 2021. Selection criteria included: diversity of professional expertise in clinical care and/or research in topic areas associated with EOL care in the ICU and/or ethics; diversity of practice environment to include urban, suburban, and rural healthcare system representation; diversity of stage in career to include early-, mid-, and advanced-career clinicians; diversity in personal demographics; and representation of patient/family perspectives with the intent that our panel represent the diverse communities to which our adult ICU patients belong.

Guideline Type: Clinical

Read Full Guideline

We suggest using structured tools to facilitate shared decision-making for EOL treatment decisions in the ICU.
Certainty of evidence: Moderate

Remarks

While there is no single ideal tool to use, those studied in the ICU setting include communication facilitators, structured meeting plans, and paper-/web-based decision aids.

Conditional Communication Structured tools

We suggest ICUs develop resources for educating substitute decision-makers on their role in making decisions on behalf of decisionally incapable patients.
Certainty of evidence: Low

Conditional Communication Substitute decision-making

ICUs should have a standardized process for identifying and documenting the legal surrogate decision-maker for decisionally incapable patients, including those for whom a surrogate cannot be identified, in accordance with local laws and organizational policy.

Remarks

The process for doing this is best done at a hospital/system level, and the persons responsible may vary between ICUs but could include the clinical team, social workers, ethics team, legal services, or risk management.

Good practice statement Communication Surrogate decision-making

We suggest proactive consultation of palliative care/palliative medicine and/or ethics consult service, when available, to assist with defining goals of care for ICU patients who may no longer benefit from critical care.
Certainty of evidence: Low

Conditional Communication Consultation

We suggest implementing institutional policies to address conflicts over futile and potentially inappropriate treatments in the ICU.
Certainty of evidence: Low

Conditional Communication Institutional policies

We suggest using protocolized approaches to withdrawal of life-sustaining treatments and symptom management in the ICU, including assessment and management of symptoms pre-extubation, during weaning, and after extubation.
Certainty of evidence: Moderate

Conditional Provision Protocolized approaches

ICU clinicians should explore and support patient and family cultural, spiritual, and family traditions at the EOL.

Good practice statement Provision Family preferences

We suggest using a semi-structured approach to supporting patients and families and addressing spiritual care needs including an introductory meeting, weekly follow-up, and post-hospital discharge follow-up.
Certainty of evidence: Low

Conditional Provision Semi-structured support

We suggest consultation and collaboration with an ethics consult service and/or palliative medicine, when available, to address the suffering of ICU patients and families at the EOL, when there are challenges in mitigating conflicts, distress, or suffering.
Certainty of evidence: Low

Conditional Provision Consultation

We have insufficient evidence to recommend for or against specific interventions to identify and reduce unmet palliative care needs of specific populations receiving EOL care in the ICU.
Certainty of evidence: Low

Education Inequity

ICU clinicians providing EOL care should explore and address patient palliative care needs, considering a patient’s gender, gender identity, sexual identity, race, ethnicity, faith traditions, country of origin, primary language, and socioeconomic status.

Good practice statement Education Palliative care

We suggest providing education and training in palliative care for all ICU team members to improve the capability of providing EOL care in the ICU.
Certainty of evidence: Very low

Conditional Education Education and training

We suggest clinicians provide educational interventions to patients/families/surrogates at risk of ICU admission to improve their understanding of ICU and EOL treatment options, realistic treatment outcomes, and advance care planning.
Certainty of evidence: Low

Conditional Education Education and training

EOL = end-of-life.

Author

Mary Faith Marshall, PhD, HEC-C, FCCM

Mary Faith Marshall, PhD, HEC-C, FCCM, is director of the Center for Health Humanities and Ethics and director of the Program in Biomedical Ethics at the University of Virginia School of Medicine. She is a professor of Public Health Sciences in the School of Medicine, and a professor in the Department of Acute and Specialty Care in the School of Nursing. She served as cochair of the Adult End-of-Life Care in the ICU guidelines panel.

Author

Karen A. Korzick , MD, MA, FCCP, FACP, FCCM

Karen A. Korzick , MD, MA, FCCP, FACP, FCCM, is a board-certified and fellowship-trained specialist in internal medicine, pulmonary, and critical care medicine. She is program director of the critical care medicine fellowship at Geisinger Medical Center. She served as cochair of the Adult End-of-Life Care in the ICU guidelines panel.