Clinical Case Scenario
An 82-year-old woman with advanced heart failure, chronic kidney disease stage 4 (baseline creatinine 2.8 mg/dL), and metastatic lung cancer with extensive bony metastases is admitted to the ICU with septic shock due to a urinary tract infection. Despite receiving broad-spectrum antibiotics, IV fluids, and norepinephrine for persistent hypotension, she has been anuric for 24 hours, and her creatinine has risen to 5.8 mg/dL. Her trachea is intubated and she is sedated with propofol and remifentanil infusions, her Sequential Organ Failure Assessment (SOFA) score is 16. Her prior medical records indicate that during a previous hospitalization, she expressed a wish to "focus on comfort and avoid unnecessary interventions," but no formal advance directive or do-not-resuscitate (DNR) order was completed.
Her daughter insists on starting renal replacement therapy (RRT), stating, “We have to do everything possible,” while her son is concerned about prolonging her suffering. The ICU team is divided: one physician suggests a time-limited trial (TLT) of RRT, while another believes it would be futile given her poor prognosis. The patient’s nurse raises concerns about the burdens of aggressive care in this scenario.
Which of the following is the most appropriate next step in managing this complex situation?
