Escalating Vasopressor Intensity and the Goals-of-Care Documentation Gap in Septic Shock: Relevance to the Proposed Refractory Shock Threshold

Background 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. Objectives We assessed the association between escalating vasopressor intensity and documented surrogate goals-of-care markers among septic shock decedents. Methods Retrospective cohort study of adult septic shock decedents in MIMIC-IV (2008-2022) requiring vasopressors ≥6 h and surviving ≥24 h after initiation. Vasopressor intensity was quantified by peak norepinephrine equivalent (NEE) dose during ICU stay and stratified as: 0.01–0.50 (stratum 1), >0.50–0.99 (stratum 2), and ≥1.00 µg/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. Results The final cohort included 2458 patients: stratum 1 (n = 1033), stratum 2 (n = 909), and stratum 3 (n = 516). 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 = 0.03). Palliative care documentation declined progressively with increasing vasopressor intensity (59.2%, 52.0%, 46.9%; p-for-trend<0.001), accompanied by lower rates of integrated DNR/palliative care documentation (47.0%, 40.0%, 36.4%; p-for-trend<0.001). Patients exceeding the Delphi-proposed refractory shock threshold (NEE >0.50 µg/kg/min) were more likely to die without documented goals-of-care markers than those below the threshold (29.3% vs 23.8%; p = 0.002). Conclusion 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.