What are the appropriate goals of care for a patient with Acute Respiratory Distress Syndrome (ARDS) and a poor prognosis?

Goals of Care for ARDS Patients with Poor Prognosis

For patients with ARDS and poor prognosis, goals of care should shift from curative to palliative, prioritizing physical and psychological comfort, supporting family decision-making around end-of-life preferences, and when appropriate, making dying at home possible. 1

Recognizing Poor Prognosis in ARDS

The following clinical indicators signal poor prognosis and should trigger goals-of-care discussions:

Multi-Organ Failure (Primary Determinant)

• The number of failing organ systems is the single most important prognostic indicator 2, 3
• Mortality increases exponentially with each additional organ failure, with overall ARDS mortality approximately 40% but reaching 46-60% in severe cases 2, 4
• Death results primarily from multi-organ dysfunction and sepsis rather than isolated respiratory failure 2, 3
• Liver failure in association with ARDS carries particularly poor prognosis 2, 3

Specific High-Risk Clinical Features

• Right ventricular failure, especially in pneumonia-related ARDS 1, 2
• Driving pressure ≥18 cmH₂O despite optimal ventilator management 1, 2
• PaO₂/FiO₂ ratio <150 mmHg with PaCO₂ ≥48 mmHg 1
• Development of progressive pulmonary fibrosis (after 7-10 days) with persistently elevated dead-space ventilation 2, 3
• Inability to concentrate protein in edema fluid during first 12 hours, indicating impaired epithelial barrier integrity 2, 3
• Lack of improvement in oxygenation parameters within first 48 hours of treatment 2

Appropriate Goals of Care Framework

Palliative and Comfort-Focused Goals

When poor prognosis is established, goals should include:

• Physical and psychological comfort as the primary objective 1
• Relief of dyspnea, pain, and anxiety through appropriate sedation and analgesia 1
• Minimizing invasive interventions that prolong suffering without improving meaningful outcomes 1
• Supporting family presence and communication 1

Home-Based End-of-Life Care (When Feasible)

• Making dying at home possible for patients with terminal respiratory illness 1
• Hospice services provide palliative and end-of-life care for terminally ill patients 1
• Home care goals explicitly include physical and psychological comfort for terminal illnesses 1

Negotiated Care Planning

• Specific goals must be negotiated by patients and families in partnership with physicians and home care professionals 1
• Goals should be patient-centered and reflect individual values and preferences 1
• Discussions should occur early when poor prognostic indicators emerge, not delayed until imminent death 2, 3

Critical Clinical Pitfalls in Goals-of-Care Discussions

Avoid Misattributing Prognosis

• Do not attribute death solely to respiratory failure—aggressively investigate evolving multi-organ dysfunction, particularly hepatic and cardiovascular systems 2, 3
• The degree of initial hypoxemia is NOT a reliable prognostic indicator 3
• After 7-10 days, persistent high minute ventilation requirements despite improving oxygenation indicates developing fibrosis with poor prognosis 2, 3

Recognize Iatrogenic Contributions

• Ventilator settings themselves can contribute to mortality through cytokine release and multi-organ injury from excessive plateau pressures and driving pressures 2, 3
• Injurious mechanical ventilation produces end-organ damage independent of the primary disease process 3

Timing of Goals-of-Care Conversations

• Initiate discussions when multiple organ failures develop, not just respiratory failure 2, 3
• Reassess goals when fibroproliferative changes emerge (typically after 7-10 days), as these patients require different management and have worse outcomes 2, 3
• Consider goals-of-care discussions when inability to concentrate edema fluid protein in first 12 hours predicts poor outcome 2, 3

Balancing Aggressive Support vs. Comfort

When Continued Aggressive Support May Be Appropriate

• Single organ failure (respiratory only) with intact epithelial barrier function 2
• Rapid improvement in oxygenation within first 48 hours 2
• Absence of progressive fibrosis and maintained lung compliance 2

When Transition to Comfort-Focused Care Should Be Strongly Considered

• Three or more organ system failures despite maximal support 2, 3
• Progressive fibrosis with obliteration of vascular bed after 10+ days 2, 3
• Liver failure developing in conjunction with ARDS 2, 3
• Refractory right ventricular failure 1, 2
• Persistent requirement for injurious ventilator settings (driving pressure ≥18 cmH₂O, plateau pressure >30 cmH₂O) 1, 2