The research team conducted individual semi-structured interviews with thirty-four clinicians spanning the entire training continuum, from medical students to postgraduate year one through five residents in internal medicine, and on to attending physicians in internal medicine and critical care medicine at McGill University-affiliated academic hospitals. The interviews were interpreted using applied thematic analysis, a rigorous qualitative method that allows researchers to identify recurring patterns in how participants describe their experiences. What emerged was a developmental arc, a story of how understanding of goals-of-care discussions transforms as clinicians gain experience and seniority.

The analysis organized its findings into four central themes that map the trajectory from novice to expert. The first traces a shift from concrete to abstract conceptualizations of what a goals-of-care discussion actually is. Less experienced trainees frequently conflated goals-of-care conversations with code status discussions, reducing a rich, patient-centered dialogue to a narrow question about resuscitation preferences. For these novices, the task was often perceived as a form to be completed, a checkbox in the admission paperwork rather than an exploration of what matters most to a patient facing serious illness. More senior clinicians, by contrast, described goals of care in abstract and contextual terms, framing these conversations as ongoing negotiations that integrate prognosis, patient values, family dynamics, and clinical uncertainty.

The second theme captures a parallel movement from performative to organic approaches. Early trainees described following scripted frameworks, reciting standardized phrases, and treating the conversation as a performance to be evaluated by a supervising attending. This performative orientation, while a reasonable starting point, left them rigid and easily thrown when a patient or family member deviated from the expected script. Experienced physicians described something fundamentally different: an organic, responsive conversation that flexes to the emotional and informational needs of the moment. They spoke of reading the room, pacing the disclosure of difficult information, and weaving goals-of-care discussions naturally into the fabric of clinical care rather than isolating them as discrete, formulaic events.

The third theme, from follower to leader in shared decision-making, addresses one of the most consequential differences between junior and senior clinicians. Novices were markedly less comfortable offering guidance and tended to position themselves as passive facilitators, presenting options without direction and hoping the patient would choose. This hesitation, the researchers suggest, may reflect both a lack of clinical confidence and an incomplete understanding of prognosis. Attending physicians, drawing on years of accumulated judgment, demonstrated a greater willingness to make recommendations, to share their expert opinion while still honoring patient autonomy, and to steer the conversation toward medically appropriate and patient-aligned decisions. This evolution from deference to directed guidance represents a core component of what experts mean by clinical judgment in serious illness communication.

The fourth theme concerns how learning itself happens, described as scaffolding between formal and informal development. Participants agreed almost universally that goals-of-care skills develop as a career-long endeavor, shaped far more by observation, feedback, and lived clinical experience than by structured instruction. Formal training on this topic was described as limited, fragmented, and often arriving too late. Trainees reported watching senior colleagues conduct these conversations, debriefing afterward with attendings when circumstances allowed, and gradually building competence through repetition and reflection. Yet the study found that many trainees were expected to lead goals-of-care discussions independently early in their training, before adequate scaffolding had been established, raising pointed concerns about patient care and trainee distress.

The implications of this developmental mismatch are significant. Internal medicine is, by the nature of its patient population, a specialty where goals-of-care conversations are frequently required. Hospitalized patients with advanced illness, uncertain prognoses, and complex family situations present these dilemmas daily. If junior physicians are being sent into these encounters with a conceptualization limited to code status and a performative, script-dependent approach, both patients and trainees are being underserved. Prior research cited by the authors, including studies of residents’ code status discussion skills and randomized trials of simulation-based communication training, has shown that these skills can be taught, but the new findings suggest that isolated interventions may not be enough. What is needed, the authors argue, is a structured, stage-specific, longitudinal curriculum that meets learners where they are in their development.

Such a curriculum would look markedly different at each stage. For medical students and early residents, the priority would be building accurate conceptual foundations, decoupling goals of care from code status, and introducing frameworks that emphasize eliciting patient values before discussing interventions. For mid-level residents, deliberate practice with simulated patients and observed conversations with structured feedback could accelerate the shift from performative to organic approaches. For senior residents and early attendings, coaching on recommendation-giving and prognostic communication would support the transition to leadership in shared decision-making. The study’s participants themselves called for exactly this kind of sequenced, longitudinal design, echoing broader movements in medical education such as competency-based frameworks and longitudinal coaching programs that have been adopted in Canada and elsewhere.

The study also carries a broader message about the nature of expertise in medicine. Communication skills are often treated as soft skills, assumed to be absorbed along the way rather than rigorously taught. This research demonstrates that the growth from novice to expert in goals-of-care discussions follows a describable, predictable developmental progression, one that can be anticipated and supported rather than left to chance. The differences in conceptualization, approach, and decision-making role between junior and senior clinicians are not merely matters of personality or confidence. They reflect distinct cognitive and professional stages, each with its own learning needs. Recognizing this progression allows educators to design training that is developmentally attuned, rather than one-size-fits-all lectures delivered at a single point in training.

As populations age and chronic serious illness becomes an ever-larger share of medical practice, the ability to conduct skillful, compassionate goals-of-care conversations will only grow in importance. This study, funded by the Fédération des Médecins Résidents du Québec Research Grant and presented in preliminary form at the International Conference on Residency Education in Ottawa, provides a roadmap for how the medical education community might respond. By treating goals-of-care communication as a career-long developmental arc with structured support at every stage, training programs can ensure that physicians arrive at these pivotal bedside moments not as anxious novices clutching a script, but as confident, nuanced clinicians capable of guiding patients and families through the most consequential decisions of their lives.

Subject of Research: How internal medicine physicians develop goals-of-care discussion skills across the training continuum

Article Title: How Internal Medicine Physicians Learn to Conduct Goals-of-Care Discussions: A Qualitative Study Across the Training Continuum

Article References: Lee, C. B., Snell, L., Li, K. X., Jayaraman, D., & Nugus, P. (2026). How Internal Medicine Physicians Learn to Conduct Goals-of-Care Discussions: A Qualitative Study Across the Training Continuum. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10696-w

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10696-w

Keywords: goals of care, internal medicine, medical education, communication skills, qualitative study, shared decision-making, code status, residency training, palliative care, clinical judgment, longitudinal curriculum, physician development

The historical record explains why skepticism took root. Studies conducted in the 1980s and 1990s reported in-hospital mortality approaching 90 percent among patients with acute myeloid leukemia who required invasive mechanical ventilation. Against such figures, many clinicians questioned whether intensive care offered anything more than a prolonged and painful death. Yet the evidence landscape has steadily transformed. Refinements in patient selection, combined with sweeping advances in supportive care, have progressively improved outcomes, and more recent studies report in-ICU mortality rates of approximately 45 percent for critically ill patients with acute leukemia. That trajectory, from near-certain fatality to a coin-flip chance of survival, represents one of the quiet revolutions in hematology and intensive care.

A major new analysis has now brought unprecedented statistical weight to this transformation. An individual participant data meta-analysis by Chean and colleagues, published in Intensive Care Medicine, examines the outcomes of critically ill adults with acute leukemia using data from 2,003 patients treated in 55 intensive care units across 19 countries, with an inclusion period spanning more than two decades, from January 2000 to July 2023. The scale and duration of the study fill a long-standing knowledge gap created by earlier single-center investigations and limited sample-size analyses that focused mainly on patients younger than 60 years, a group that no longer reflects the real-world demographics of the disease.

What distinguishes this meta-analysis methodologically is its use of the individual participant data approach. Unlike conventional meta-analyses that rely on aggregated results extracted from published papers, an IPD meta-analysis goes back to the raw data of each contributing study and reanalyzes them. This allows researchers to improve both the quantity and quality of the evidence, to include information that was never reported in the original publications, and to standardize analyses and outcome definitions across studies. The method demands that investigators contact the corresponding author of every included trial or cohort, an arduous process that explains why such analyses remain relatively rare but carry exceptional authority when completed.

The findings confirm what many specialists hoped but could not previously prove with such rigor: ICU mortality has decreased over time among patients requiring mechanical ventilation. The authors of the accompanying editorial, Guillaume Berton and Norbert Vey of Aix-Marseille University and Institut Paoli-Calmettes in Marseille, attribute this trend to improvements on two fronts simultaneously. On the hematology side, new chemotherapy regimens have emerged, while supportive care has advanced dramatically through antimicrobial prophylaxis and improved management of febrile neutropenia, the dangerous fever that strikes patients whose infection-fighting white cells have been wiped out by both disease and treatment.

Perhaps the most striking demographic shift documented in the analysis is the changing age profile of patients reaching the ICU. The proportion of patients older than 65 years admitted to intensive care nearly doubled over the study period, rising from 18 percent before 2010 to 33 percent after 2010. This is not a coincidence of referral patterns but a direct consequence of therapeutic innovation. For decades, elderly patients with acute leukemia were often offered palliative care because intensive cytotoxic chemotherapy, the gold standard for younger patients, was considered too toxic for bodies with diminished functional reserves. That paradigm has been upended by non-intensive approaches, most notably the combination of hypomethylating agents with the BCL-2 inhibitor venetoclax, which has demonstrated a median overall survival of 14.7 months and has become the standard of care for AML patients ineligible for intensive chemotherapy.

The therapeutic revolution extends further. Although the Chean meta-analysis excluded post-transplant ICU admissions, advances in allogeneic stem-cell transplantation now allow this potentially curative procedure to be offered to increasingly older patients, with evidence supporting matched sibling, unrelated, and haploidentical donor options in those over 60. Together, these developments signal that treatment for older AML patients has moved decisively from palliative approaches to strategies with curative intent, and the resulting lengthening of survival will only reinforce the role of intensive care in this population. But with more therapeutic possibilities come new dilemmas, above all patient selection, which must rest on a careful evaluation of frailty and is tightly interwoven with the triage decisions made before ICU admission is even offered.

The meta-analysis also delivered a finding that unsettles prior assumptions: older age, defined as above 65 years, emerged as an adverse predictor of in-ICU mortality. This contrasts with earlier studies that had reported in-ICU mortality rates for elderly patients similar to those of younger cohorts. The editorial authors suggest the discrepancy may reflect variable levels of expertise among the participating centers, illustrated by differences in outcomes according to the national economic level of the countries involved. Such disparities may influence not only the quality of intensive care management but also which patients are selected for admission in the first place, raising uncomfortable questions about equity of access to critical care for older patients with leukemia.

The stakes of that triage question are amplified by what happens after patients leave the unit. A recent report highlighted in the editorial found that a significant proportion of AML patients require modifications to their antileukemic treatment following ICU discharge, altering their long-term prognosis, with older age increasing this risk. In other words, the ICU episode does not exist in isolation; it can derail the optimal cancer therapy on which survival ultimately depends. Conversely, one important limitation of the Chean analysis is that treatment response was not considered, even though response is a major determinant of survival and of the success of organ failure management. Future studies, the editorial argues, should incorporate modern response criteria, including the residual disease assessments now routinely used in hematology practice.

Finally, the editorial closes with a human dimension that data alone cannot capture: patients’ own wishes. Goals-of-care discussions are key to determining the most appropriate management strategy for critically ill patients with cancer, yet they remain relatively infrequent in practice, a gap that demands further research. Meanwhile, the treatment landscape continues to accelerate. More potent antileukemic agents are inducing deeper and longer responses, but each advance carries novel toxicities: venetoclax can trigger tumor lysis syndrome, targeted molecular therapies against FLT3, IDH, and menin can provoke differentiation syndrome causing respiratory, hemodynamic, and renal failure, and the spread of immunotherapy brings risks exemplified by cytokine release syndrome and immune cell-associated neurotoxicity seen with T-cell engagers and CAR T cells in acute lymphoblastic leukemia. As these therapies expand, the editorial concludes, more than ever a continuous close collaboration between intensivists and hematologists is paramount to ensure proper management of these increasingly complex, increasingly survivable patients.

Subject of Research: Intensive care unit access and outcomes for critically ill adults with acute leukemia

Article Title: Beyond classical boundaries: rethinking ICU access in acute leukemia

Article References: Berton, G., & Vey, N. (2026). Beyond classical boundaries: rethinking ICU access in acute leukemia. Intensive Care Medicine. https://doi.org/10.1007/s00134-026-08623-y

Image Credits: AI Generated

DOI: 10.1007/s00134-026-08623-y

Keywords: acute leukemia, intensive care unit, acute myeloid leukemia, ICU mortality, mechanical ventilation, venetoclax, hypomethylating agents, allogeneic stem-cell transplantation, tumor lysis syndrome, individual participant data meta-analysis, elderly patients, goals of care

The scale of the problem remains staggering. Sepsis, the life-threatening organ dysfunction caused by a dysregulated host response to infection, continues to rank among the leading causes of death worldwide, accounting for millions of deaths each year despite major advances in recognition and management. Global estimates of hospital-treated sepsis underscore the enormous incidence and mortality burden, and the economic consequences extend far beyond the acute hospital stay. Survivors frequently require prolonged rehabilitation, recurrent healthcare use and long-term nursing support, and many lose their independence entirely. Epidemiological studies from Germany, for example, have documented the substantial costs and care dependency that follow sepsis hospitalization, painting a picture of a condition whose true burden is measured in years, not days.

Crucially, mortality statistics capture only part of that burden. A growing body of evidence shows that increasing numbers of sepsis survivors experience persistent cognitive impairment, physical disability, psychological distress and markedly reduced quality of life. Landmark follow-up studies of patients who survived acute respiratory distress syndrome, a condition closely intertwined with sepsis in the intensive care unit, revealed functional disability persisting five years after critical illness, while systematic reviews have shown that many critical illness survivors struggle to return to employment, with lasting psychosocial consequences. These findings suggest that success in sepsis care should be measured not only by survival but by the quality and meaning of that survival for patients and their families, including the often-overlooked burden carried by caregivers, who face psychological, physical, social and financial challenges of their own.

The editorial also emphasizes a clinical reality that is frequently obscured by the language of emergency medicine: sepsis is not always an isolated and reversible disease process. For some patients, it represents a transient physiological insult from which meaningful recovery is expected. For others, it may be the final manifestation of advanced malignancy, severe frailty, end-stage organ failure or another life-limiting condition. In such situations, aggressive organ support and life-sustaining therapies may prolong life without achieving outcomes that patients would consider acceptable. Recognizing this heterogeneity, the authors argue, is essential when defining treatment goals and evaluating whether ongoing interventions remain appropriate. A one-size-fits-all approach that maximizes physiological parameters in every patient risks delivering care that is technically successful but profoundly misaligned with individual values.

To address this, the authors propose viewing sepsis and septic shock as a trajectory rather than a single event. During the acute phase, which generally covers the first several hours after recognition and extends through the first 24 to 72 hours, survival remains the primary objective. Early recognition, rapid diagnosis and prompt initiation of evidence-based therapies are essential, and the campaign’s guidelines have extensively addressed this phase over the last 25 years. Patients and families should be involved in decision-making whenever possible, even though this is often difficult during the initial stages of critical illness, when both families and clinicians typically prioritize survival. Still, the editorial stresses that even in the acute phase clinicians should consider whether initiating life-sustaining treatment is consistent with the patient’s wishes and values, a point of particular ethical weight because not starting treatment is often perceived as less difficult than withdrawing it later.

The acute phase is followed by a period of ongoing critical illness that may last for days or weeks, depending on the patient’s clinical course. During this stage, clinicians must reassess prognosis, treatment options and the balance between the burden of interventions and the likelihood of meaningful recovery. Patient goals and values should be revisited as clinical circumstances evolve, linking medical interventions to outcomes that are meaningful to patients rather than focusing solely on survival. The authors point to the concept of goal-directed health care, which redefines health and health care in the era of value-based medicine, and to consensus frameworks from other acute specialties, such as stroke, that have already embedded goal-concordant care into quality improvement standards. Such an approach, they argue, may strengthen therapeutic relationships, support shared decision-making and improve adherence to treatment plans.

Culture, communication and belief systems occupy a central place in this vision. Cultural identity encompasses not only ethnicity, language and religion but also family structures, values and beliefs about illness, death and healthcare itself. Care plans should address patients’ preferences, life goals and cultural context, and healthcare systems may need culturally specific resources to bridge communication gaps and support equitable care. The editorial cites the multinational ETHICATT study, which demonstrated that religion and religiosity significantly influence end-of-life decisions and patient autonomy in intensive care units across different countries, and in some settings religious beliefs may also shape the legal and ethical dimensions of end-of-life decision-making. Effective, structured communication is presented as fundamental throughout the entire course of sepsis, ensuring that patients and families are informed, heard and able to participate in decisions aligned with the patient’s goals and values.

Yet the evidence suggests this component of care remains underdeveloped. Research on sepsis hospitalizations has documented persistent deficits in the identification of patient goals and in the delivery of goal-concordant care after discharge. Prognostic uncertainty, time pressures and the traditional focus on physiological stabilization contribute to delayed conversations about treatment preferences. Policy statements from the American College of Critical Care Medicine and the American Thoracic Society have established shared decision-making as a standard in intensive care, and practical guidance on evidence-based ICU family conferences and the fine-tuning of family partnerships in decision-making provide clinicians with tested frameworks. Evidence also indicates that involving palliative care specialists can improve communication, facilitate decision-making and reduce potentially non-beneficial interventions without compromising quality of care, including for older adults hospitalized with septic shock. The editorial’s conclusion is unambiguous: communication should be considered a core component of high-quality sepsis management rather than an adjunct to it.

As patients enter the recovery phase, attention must shift toward functional outcomes, quality of life and psychological well-being, with comprehensive rehabilitation and follow-up programs recognized as essential components of recovery after sepsis. The authors acknowledge that the 2026 Surviving Sepsis Campaign guidelines have already moved in this direction, including Good Practice Statements in areas where high-certainty evidence is difficult to generate, and offering recommendations on goals-of-care discussions, advance directives, time-limited trials, palliative care and long-term outcomes. But they argue that future guidelines should go further, giving greater prominence to outcomes such as functional independence, cognitive performance, psychological well-being and caregiver burden. Where evidence is limited, recommendations may appropriately be informed by professional standards, ethical principles, patient values and societal goals, a stance the authors insist does not weaken evidence-based medicine but increases its transparency. The future of sepsis care, they conclude, lies not in departing from evidence-based medicine but in expanding it toward value-informed, goal-centred care, in which survival remains vital but is recognized as only one of several outcomes patients may value, alongside dignity, meaningful relationships, freedom from prolonged suffering and symptom control.

Subject of Research: Patient-centred, goal-concordant sepsis care within the Surviving Sepsis Campaign guidelines

Article Title: Surviving Sepsis Campaign beyond survival: aligning sepsis care with patient goals

Article References: Kesecioglu, J., Metaxa, V., & Azoulay, E. (2026). Surviving Sepsis Campaign beyond survival: aligning sepsis care with patient goals. Intensive Care Medicine. https://doi.org/10.1007/s00134-026-08590-4

Image Credits: AI Generated

DOI: 10.1007/s00134-026-08590-4

Keywords: sepsis, septic shock, Surviving Sepsis Campaign, intensive care, shared decision-making, palliative care, goals of care, patient-centred care, post-sepsis morbidity, critical illness recovery, end-of-life care, clinical guidelines