Box 1 Vignette scenario

Background: this is an 87-year-old patient, living independently but with new mobility issues (hip osteoarthritis) requiring a stick, clinical frailty scale (CFS) 4, and without cognitive impairment. She has no opinion about limiting medical care

Past medical history: chronic obstructive pulmonary disease (COPD) with 1–2 exacerbations per year, non-ST segment myocardial infarction (NSTEMI) 6 years ago (recent echocardiography: left ventricular ejection fraction 40%, intermediate probability of pulmonary hypertension), hip osteoarthritis, osteoporosis with vertebral fractures

Present complaints: coughing and progressive shortness of breath for 2 days (throat swab: metapneumovirus), new palpitations, new leg oedema, confused for 12 h

Treatment in the emergency room: non-invasive ventilation (NIV) for hypoxia and hypercapnia, failed due to confusion

Treatment in the ICU: invasive ventilation, increasing vasopressor requirements, not fluid-responsive, inotropes added, persistent atrial fibrillation

 acute kidney injury (AKI) and renal replacement therapy (RRT) from day 2

 upper gastro-intestinal haemorrhage on day 4

 embolic stroke with hemiparesis on day 6

 ventilator associated pneumonia (VAP) on day 8