When a standard full dose of a vasopressor fails to normalize blood pressure in a patient with septic shock, escalation begins to yield diminishing returns as the dose and multiplicity of agents approach practical upper limits. Although it is not possible to specify a precise cutoff for limiting vs. intensifying therapy, a mortality of 80% or higher-characterized by two or more concurrent vasopressors at full dose-should prompt shared decision making with the patient's family.

No abstract

No abstract

BACKGROUND Respect for patient autonomy is a core principle of American medicine. Informed consent is required for surgical procedures and blood transfusions but not for most medical treatments of hospitalized patients. HYPOTHESIS If given the option, patients want to give permission for common medical therapies during hospitalization. SUBJECTS Participants in the study were patients admitted to the medical service of a 350‐bed community teaching hospital. METHODS A questionnaire comprising 4 scenarios of varying risk/benefit ratios was administered to all patients who agreed to participate. RESULTS A total of 634 patients were admitted to the medicine service between June and August 2006. Two hundred and ten patients (103 men, 107 women), with a mean age (± SE) of 63.3 ± 1.1 years, agreed to answer the questionnaire. Of these patients, 85% wished to participate in even trivial medical decision making (ie, potassium supplementation), 92% wished to participate in treatments with moderate risk (ie, diuretic for congestive heart failure). When a risk was initially posed as less than a 5% risk of brain hemorrhage and benefits of therapy were substantially higher (eg, thrombolysis for pulmonary embolus), 93% wanted to make the decision. If the risk of brain hemorrhage was 20% or greater, 95% wanted to make the decision. Younger patients (<65 years) were more likely to prefer requiring doctors to obtain their “permission no matter what” than were older patients (≥65 years), and older patients were more likely to waive consent across levels of risk. CONCLUSIONS Most acutely ill hospitalized medicine patients wished to participate in even the most mundane aspects of their medical decision making. Although it is not logistically feasible to obtain informed consent for every treatment of every hospitalized patient, clinicians should be aware of patients' predilections and might consider offering opportunities for patients to participate in clinical decision making, especially for therapies that carry substantial risk. Journal of Hospital Medicine 2008;3:6–11. © 2008 Society of Hospital Medicine.