{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T12:51:37Z","timestamp":1792155097010,"version":"4.4.0"},"reference-count":25,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T00:00:00Z","timestamp":1791936000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["J Intensive Care Med"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The 2026 joint SCCM\/ESICM Delphi consensus identified vasopressor intensity as a defining feature of refractory septic shock, yet its relationship to real-world goals-of-care documentation remains unclear.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>We assessed the association between escalating vasopressor intensity and documented surrogate goals-of-care markers among septic shock decedents.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Retrospective cohort study of adult septic shock decedents in MIMIC-IV (2008-2022) requiring vasopressors \u22656\u2005h and surviving \u226524\u2005h after initiation. Vasopressor intensity was quantified by peak norepinephrine equivalent (NEE) dose during ICU stay and stratified as: 0.01\u20130.50 (stratum 1), &gt;0.50\u20130.99 (stratum 2), and \u22651.00\u2005\u00b5g\/kg\/min (stratum 3). The primary outcome was death without documented surrogate goals-of-care markers, defined as having neither a documented do-not-resuscitate (DNR) order nor documented palliative care involvement.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The final cohort included 2458 patients: stratum 1 (n\u2009=\u20091033), stratum 2 (n\u2009=\u2009909), and stratum 3 (n\u2009=\u2009516). Death without documented goals-of-care markers increased across strata (23.8%, 28.3%, 31.2%; p-for-trend=0.001). After multivariable adjustment, stratum 3 patients remained more likely than stratum 1 to die without documented goals-of-care markers (aOR 1.32; 95% CI 1.02-1.69; p\u2009=\u20090.03). Palliative care documentation declined progressively with increasing vasopressor intensity (59.2%, 52.0%, 46.9%; p-for-trend&lt;0.001), accompanied by lower rates of integrated DNR\/palliative care documentation (47.0%, 40.0%, 36.4%; p-for-trend&lt;0.001). Patients exceeding the Delphi-proposed refractory shock threshold (NEE &gt;0.50\u2005\u00b5g\/kg\/min) were more likely to die without documented goals-of-care markers than those below the threshold (29.3% vs 23.8%; p\u2009=\u20090.002).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Higher vasopressor intensity was paradoxically associated with a greater likelihood of death without documented goals-of-care markers and with lower palliative care documentation. These findings suggest a disconnect between escalating physiologic severity and documentation of surrogate goals-of-care markers in refractory septic shock and warrant further evaluation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/08850666261490895","type":"journal-article","created":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T15:33:08Z","timestamp":1791991988000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Escalating Vasopressor Intensity and the Goals-of-Care Documentation Gap in Septic Shock: Relevance to the Proposed Refractory Shock Threshold"],"prefix":"10.1177","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9901-926X","authenticated-orcid":false,"given":"Imran","family":"Khalid","sequence":"first","affiliation":[{"name":"Department of Critical Care, King Faisal Specialist Hospital & Research Centre"},{"name":"Department of Medicine, Wayne State University, Detroit, MI, USA"},{"name":"Alfaisal University, College of Medicine, Riyadh, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9778-6403","authenticated-orcid":false,"given":"Javier","family":"Diaz-Mendoza","sequence":"additional","affiliation":[{"name":"Department of Medicine, Henry Ford Health System"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5314-8987","authenticated-orcid":false,"given":"Manahil","family":"Imran","sequence":"additional","affiliation":[{"name":"Department of Critical Care, King Faisal Specialist Hospital & Research Centre"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-2471-833X","authenticated-orcid":false,"given":"Raafey","family":"Imran","sequence":"additional","affiliation":[{"name":"Department of Critical Care, King Faisal Specialist Hospital & Research Centre"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2244-8397","authenticated-orcid":false,"given":"Muhammad Ali","family":"Akhtar","sequence":"additional","affiliation":[{"name":"Department of Medicine, Hurley Medical Center"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-6236-2939","authenticated-orcid":false,"given":"Basel Ghurm","family":"Alshehri","sequence":"additional","affiliation":[{"name":"Department of Critical Care, King Faisal Specialist Hospital & Research Centre"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-8920-5219","authenticated-orcid":false,"given":"Amir","family":"Iqbal","sequence":"additional","affiliation":[{"name":"Department of Medicine, Wayne State University, Detroit, MI, 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