Study guide
29.1 Advance Care Planning, Nonbeneficial Treatment, Informed Consent & Confidentiality
ABIM Critical Care Medicine Study Guide Exam
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1 Chapter 1: Exam Orientation: Format, Blueprint & Study Strategy
1.1 ABIM Critical Care Medicine Exam: Format, Blueprint & Study Strategy
2 Chapter 2: Acute Respiratory Failure & ARDS
2.1 ARDS Definition, Pathophysiology & Phenotypes 2.2 Lung-Protective Mechanical Ventilation 2.3 Refractory ARDS: Prone Positioning, Neuromuscular Blockade & VV-ECMO
3 Chapter 3: Obstructive Airways, Pulmonary Vascular & Pleural Emergencies
3.1 Severe Asthma & COPD Exacerbations in the ICU 3.2 Massive & Submassive Pulmonary Embolism 3.3 Pulmonary Hypertension & Right Ventricular Failure in the ICU 3.4 Massive Hemoptysis, Complex Pleural Effusions & Thoracic Drainage
4 Chapter 4: Airway, Parenchymal & Nonthrombotic Pulmonary Emergencies
4.1 Airway Management, Upper-Airway Obstruction & Artificial-Airway Complications 4.2 Diffuse Alveolar Hemorrhage, Interstitial Lung Disease, Pulmonary Vasculitis & Noncardiogenic Edema 4.3 Severe Community-Acquired & Viral Pneumonia 4.4 Nonthrombotic Embolism (Air, Fat, Amniotic Fluid, Tumor, Septic) & Acute Chest Syndrome
5 Chapter 5: Mechanical Ventilation Modes, Dyssynchrony & Liberation
5.1 Mechanical Ventilator Modes & Advanced Breath Delivery 5.2 Patient-Ventilator Dyssynchrony & Waveform Analysis 5.3 Ventilator Liberation, Spontaneous Breathing Trials & Post-Extubation Support
6 Chapter 6: Shock Syndromes & Hemodynamic Principles
6.1 Shock Classification, Cellular Pathophysiology & Biomarkers 6.2 Hemodynamic Monitoring: Arterial Lines, CVP & Pulmonary Artery Catheter 6.3 Dynamic Assessment of Fluid Responsiveness & Resuscitation Targets
7 Chapter 7: Vasoactive Therapies & Mechanical Circulatory Support
7.1 Vasopressors & Inotropes: Pharmacology & Clinical Titration 7.2 Temporary Mechanical Circulatory Support: IABP, Impella & TandemHeart 7.3 Venoarterial ECMO (VA-ECMO) & Differential Hypoxemia 7.4 Post-Cardiac Arrest Care, Targeted Temperature Management & Neuroprognostication
8 Chapter 8: Acute Kidney Injury & Renal Replacement Therapy
8.1 KDIGO AKI Classification, Etiologies & Diagnostic Evaluation 8.2 Continuous Renal Replacement Therapy (CRRT) vs Intermittent Hemodialysis 8.3 Indications & Timing for RRT in Critical Illness: AKIKI & STARRT-AKI
9 Chapter 9: Electrolyte, Acid-Base & Endocrine Emergencies
9.1 Severe Dysnatremias: Hyponatremia, Hypernatremia & Osmotic Demyelination 9.2 Potassium, Calcium, Magnesium & Phosphate Disorders 9.3 Complex & Mixed Acid-Base Disorders: Boston vs Copenhagen vs Stewart 9.4 Endocrine Crises: DKA, HHS, Thyroid Storm, Myxedema Coma & Adrenal Crisis
10 Chapter 10: Glycemic Control, Hyperammonemia, Pituitary & Adrenal Disorders
10.1 ICU Glycemic Control & Severe Hypoglycemia 10.2 Non-Hepatic Hyperammonemia & Metabolic Encephalopathy 10.3 Pituitary Emergencies, Adrenal Excess & Critical Illness-Related Corticosteroid Insufficiency
11 Chapter 11: Acute Coronary Syndromes & Cardiac Arrhythmias
11.1 Acute Coronary Syndromes & Mechanical Complications of Myocardial Infarction 11.2 Critical Tachyarrhythmias: Atrial Fibrillation with RVR, VT & VF 11.3 Critical Bradyarrhythmias, Conduction Blocks & Temporary Cardiac Pacing
12 Chapter 12: Acute Heart Failure, Valvular & Pericardial Emergencies
12.1 Acute Decompensated Heart Failure & Cardiogenic Pulmonary Edema 12.2 Acute Valvular Regurgitation & Prosthetic Valve Emergencies 12.3 Pericardial Tamponade & Acute Aortic Syndromes
13 Chapter 13: Myocardial Disease, Hypertensive & Cardiac Device Emergencies
13.1 Fulminant Myocarditis, Stress & Peripartum Cardiomyopathy, and Hypertrophic Cardiomyopathy 13.2 Hypertensive Emergencies & Ruptured Abdominal Aortic Aneurysm 13.3 Implanted Cardiac Devices, LVAD Emergencies & Electrical Storm
14 Chapter 14: Sepsis & Systemic Infectious Diseases
14.1 Sepsis-3 Definitions & Surviving Sepsis Campaign 2026 Guidelines 14.2 Refractory Septic Shock & Adjunctive Therapies 14.3 Multidrug-Resistant Pathogens & Antimicrobial Stewardship in the ICU
15 Chapter 15: ICU-Acquired & Severe Focal Infections
15.1 Hospital-Acquired & Ventilator-Associated Pneumonia 15.2 Central Line-Associated Bloodstream Infections & Catheter-Associated UTIs 15.3 Intra-Abdominal Sepsis, Necrotizing Soft Tissue Infections & CNS Infections
16 Chapter 16: Focal, Special-Host & Systemic Infections
16.1 CNS Infections Beyond Bacterial Meningitis: Encephalitis, Brain Abscess & Epidural Abscess 16.2 Infections in the Immunocompromised Host, Tropical & Bioterror Infections 16.3 Infective Endocarditis, Device Infections & Other Focal Cardiovascular Infections 16.4 Antimicrobial Pharmacokinetics, Allergy, Toxicity & Infection Prevention 16.5 Gastrointestinal & Hepatobiliary Infections: Fulminant C. difficile, Typhlitis, CMV Colitis & Abscesses
17 Chapter 17: Neurocritical Care & Coma
17.1 Coma, Altered Mental Status & Acute Delirium in the ICU 17.2 Status Epilepticus & Non-Convulsive Status Epilepticus 17.3 Acute Ischemic Stroke & Intracranial Hemorrhage
18 Chapter 18: Cerebrovascular Syndromes, Encephalopathy & Withdrawal States
18.1 Cerebral Venous Sinus Thrombosis, PRES & Reversible Cerebral Vasoconstriction Syndrome 18.2 Alcohol & Sedative Withdrawal, Wernicke Encephalopathy & Drug-Induced Encephalopathy
19 Chapter 19: Intracranial Hypertension & Neuromuscular Weakness
19.1 Intracranial Pressure Monitoring, Cerebral Perfusion & Tiered ICP Management 19.2 Acute Neuromuscular Respiratory Failure, ICU-Acquired Weakness & Brain Death Determination
20 Chapter 20: Traumatic Brain Injury, Spinal Cord Injury & Toxin-Mediated Paralysis
20.1 Traumatic Brain Injury Management & Paroxysmal Sympathetic Hyperactivity 20.2 Acute Spinal Cord Injury, Neurogenic Shock & Autonomic Dysreflexia 20.3 Toxin-Mediated Paralysis & Neuromuscular Crises: Botulism, Tetanus, Tick Paralysis & Myasthenic Crisis
21 Chapter 21: Gastrointestinal, Hepatic & Abdominal Emergencies
21.1 Acute Upper & Lower Gastrointestinal Bleeding in the ICU 21.2 Acute Liver Failure & Severe Acute Pancreatitis 21.3 Abdominal Compartment Syndrome & Acute Mesenteric Ischemia
22 Chapter 22: Luminal GI Emergencies & Complications of Cirrhosis
22.1 Esophageal, Gastric & Bowel Emergencies: Perforation, Obstruction, Ogilvie Syndrome & Colonic Ischemia 22.2 Complications of Cirrhosis: Alcohol-Associated Hepatitis, Hepatorenal Syndrome & Pulmonary Vascular Syndromes
23 Chapter 23: Trauma, Burns & Perioperative Critical Care
23.1 Polytrauma Resuscitation, Damage Control & Massive Transfusion 23.2 Severe Burn Injury, Inhalation Injury & Environmental Emergencies 23.3 Perioperative Critical Care for High-Risk Surgical Patients
24 Chapter 24: Thoracic Trauma, Environmental Injury & Obstetric Critical Care
24.1 Thoracic Trauma: Flail Chest, Pulmonary Contusion, Great Vessel & Tracheobronchial Injury 24.2 Environmental Injury: Drowning, Diving, Altitude, Heat, Cold, Electrical & Radiation 24.3 Obstetric & Genitourinary Emergencies and the Physiology of Pregnancy
25 Chapter 25: Transplantation, Donor Management & Post-Cardiac Surgery Care
25.1 Solid Organ Transplant Recipients & Deceased Donor Management 25.2 Post-Cardiac Surgery Critical Care: Bleeding, Tamponade, Low Output & Vasoplegia
26 Chapter 26: Hematologic Emergencies, Toxicology, Critical Ultrasound & ICU Liberation
26.1 Hematologic Emergencies in the ICU: HIT, DIC, TMA & Anticoagulant Reversal 26.2 Critical Care Toxicology, Toxidromes & Specific Antidotes 26.3 Critical Care Point-of-Care Ultrasound (POCUS) 26.4 ICU Liberation, Analgosedation, Goals of Care & Critical Care Ethics
27 Chapter 27: Transfusion Medicine, Hematologic & Oncologic Disorders
27.1 Transfusion Medicine: Products, Thresholds, Reactions & Apheresis 27.2 Red and White Cell Disorders, Hemoglobinopathies, Factor Deficiencies & Hypercoagulable States 27.3 Oncologic Emergencies, Hematopoietic Cell Transplant Complications & Cellular Therapy Toxicity
28 Chapter 28: Clinical Pharmacology, Adverse Drug Reactions & Specific Poisonings
28.1 Pharmacokinetic Principles, Dose Adjustment & Drug Interactions in Critical Illness 28.2 Adverse Drug Reactions: Anaphylaxis, Severe Cutaneous Reactions & Hyperthermic Syndromes 28.3 Specific Poisonings: Sodium-Channel Blockers, Lithium, Valproate, Theophylline, Iron, Sulfonylureas & Methemoglobinemia
29 Chapter 29: Ethics, Research Methods, Administration & Abdominal Ultrasound
29.1 Advance Care Planning, Nonbeneficial Treatment, Informed Consent & Confidentiality 29.2 Critical Care Research Methods, Statistics, IRB Oversight & Quality Improvement 29.3 Abdominal, Vascular & Procedural Point-of-Care Ultrasound
29.1 Advance Care Planning, Nonbeneficial Treatment, Informed Consent & Confidentiality
Key Takeaways Explain This Topic AI
A living will states the patient's wishes, while a durable power of attorney for health care names a decision-maker; the agent's authority is to interpret and apply the patient's known values, not to substitute their own.
A POLST or MOLST is an actionable medical order set valid outside the hospital, unlike a living will, which guides future decisions.
Professional society guidance uses "potentially inappropriate" rather than "futile" for treatments with some chance of effect that clinicians believe are not justified, and recommends a fair process rather than unilateral refusal.
A time-limited trial sets the intervention, the objective markers of success, and the duration in advance, which reduces conflict and the sense of abandonment.
HIPAA permits disclosure without specific authorization for treatment, payment, and health care operations, and permits limited disclosure to family involved in care when the patient does not object.
Last updated: October 2026
Capacity and Decision-Making Authority
Decision-making capacity is decision-specific and clinically determined (in contrast to competency, which is a legal determination). A patient has capacity when they can:
Communicate a choice .
Understand the relevant information.
Appreciate the situation and its consequences for themselves.
Reason about treatment options.
Delirium, intoxication, and severe depression can impair capacity, and capacity can fluctuate. A patient who refuses a recommended treatment is not thereby incapable: the standard is the quality of the reasoning process, not agreement with the physician.
When capacity is absent , decision-making authority follows this order:
The patient's own clear, applicable instructions in an advance directive. A surrogate cannot override a valid, specific directive.
The appointed agent under a durable power of attorney for health care (or a court-appointed guardian).
A default surrogate in statutory order, which typically runs spouse or domestic partner, adult children, parents, adult siblings, then other relatives or a close friend. The order and its details vary by state.
No surrogate available : follow institutional policy, which may involve an ethics committee, a physician-attestation process, or court appointment. Do not delay emergency treatment while this is sorted out.
Standards for surrogate decisions : substituted judgment (what the patient would have chosen) is primary, with the best interests standard used only when the patient's values are genuinely unknown.
Advance Care Planning Documents
Document Nature Scope
Living will A statement of the patient's wishes about future care Guides decisions when the patient lacks capacity and conditions in the document apply; is not itself an order
Durable power of attorney for health care (health care proxy) Appoints a decision-maker Usually broader and more useful than a living will, because it adapts to unanticipated situations
POLST or MOLST An actionable medical order signed by a clinician Travels with the patient, is honored by emergency services, and covers resuscitation, intubation, and sometimes artificial nutrition
- Out-of-hospital DNR order or bracelet A specific order Prevents unwanted resuscitation outside the hospital
- Default statutory surrogate laws State law Determine who decides without a proxy
Practical points :
A DNR order is not a "do not treat" order. It addresses cardiopulmonary resuscitation only and must not reduce other care; discuss intubation, vasopressors, dialysis, and transfer separately.
Perioperative DNR orders are reconsidered rather than automatically suspended: the options are full suspension, procedure-directed limits, or goal-directed limits.
Documents must be reconciled with the current clinical situation. An advance directive written years earlier for "terminal illness" does not automatically apply to a potentially reversible critical illness.
Patients can change their minds. A conscious patient's contemporaneous wishes override any earlier document.
Potentially Inappropriate and Nonbeneficial Treatment
Professional society guidance (ATS, AACN, ACCP, ESICM, SCCM) distinguishes:
Futile treatment : an intervention that cannot accomplish the intended physiologic goal . Clinicians should not provide it, and the term should be reserved for this narrow situation.
Potentially inappropriate treatment : an intervention with some chance of the effect the family wants , but which clinicians believe competing ethical considerations justify not providing. This is where most conflict lives.
The recommended fair process when conflict persists:
Expert, repeated communication about prognosis, goals, and the patient's values; enlist interpreters and cultural or spiritual support.
Second medical opinion and involvement of the multidisciplinary team.
Ethics consultation .
Offer transfer to another willing institution.
Inform the surrogate of the process and their right to seek judicial review .
Only if the process is complete and support still favors the clinicians' position should treatment be limited over objection, in line with institutional policy and law.
Do not unilaterally withhold requested treatment because of a personal judgment about quality of life. Conversely, clinicians are not obligated to provide interventions that cannot work , such as CPR for progressive refractory multiorgan failure in a dying patient when physiologic goals cannot be met.
Time-limited trials are the most useful practical tool: agree in advance on the intervention, the objective markers that would indicate improvement, and the duration after which the plan will be reassessed. This converts an argument about values into a shared empirical question and reduces the family's sense of abandonment.
Informed Consent in Critical Care
Elements : disclosure of the diagnosis, the proposed intervention, its risks and benefits, the alternatives (including doing nothing), and an assessment of voluntary, competent agreement.
Exceptions :
Emergency (implied consent) : a patient without capacity and no available surrogate who faces imminent serious harm may be treated under the emergency exception.
Waiver : a capable patient may decline to receive information or delegate the decision.
Therapeutic privilege : a narrow, rarely justified exception.
Practical issues : separate consent for each significant procedure, document conversations, use interpreters rather than family members for translation, and recognize that a signed form is not consent ; the conversation is.
Confidentiality and HIPAA
Permitted without specific authorization : disclosure for treatment, payment, and health care operations ; required reporting (communicable disease, certain injuries, suspected abuse); and disclosures to prevent a serious imminent threat.
Family and friends : a clinician may share information relevant to the person's involvement in care if the patient does not object, or, when the patient lacks capacity, if it is in the patient's best interest. Verify identity for telephone requests.
Minimum necessary : share only what is needed for the purpose.
Common ICU breaches : discussing patients in elevators and hallways, leaving records visible, accessing charts out of curiosity, posting details or images on social media, and texting unsecured protected health information. These are reportable and sanctionable.
Patient access : patients have a right to their records and to an accounting of disclosures.
Research use requires IRB-approved authorization or a waiver (see the research section).
Special protections apply to substance use disorder treatment records (42 CFR Part 2), psychotherapy notes, and sometimes HIV and genetic information under state law.
Other Recurring Ethical Issues
Situation Key principle
Refusal of life-saving treatment by a capable patient Respect the refusal; verify capacity and address reversible causes of refusal (pain, fear, depression, misunderstanding)
Jehovah's Witness refusing transfusion Honor the specific refusal; ask what components and techniques are acceptable; a surrogate cannot authorize what the patient refused
Pregnant patient The pregnant patient with capacity decides; state law may restrict advance directive application in pregnancy
Family requesting that the patient not be told a diagnosis Ask the patient how much they want to know; information belongs to the patient
Conscientious objection by a clinician Permissible if care is transferred without abandonment
Resource allocation and triage Use pre-established, transparent, non-discriminatory crisis standards and a triage team separate from the treating clinicians, not bedside rationing
Disclosure of medical error Disclose promptly and honestly, with apology and remediation
Research in incapacitated patients Requires surrogate consent and IRB oversight, with special rules for exception from informed consent in emergency research