Discussion between clinicians and families about prognosis and goals was frequent but did not occasion decision-making moments. This study helps explain why communication interventions intended to maintain patient autonomy through facilitating surrogate participation in decisions have had limited impact.

A more comprehensive understanding of upstream factors that predispose courses of critical care is needed.

Following Extracorporeal Membrane Oxygenation (ECMO) initiation, care was escalated as complications mounted until the patient either could be decannulated or interventional options were exhausted.

We performed a focused ethnography in 2 cardiothoracic ICUs in 2 US academic hospitals. We conducted 380 hours of observation, 34 weekly interviews with families of 20 ECMO patients, and 13 interviews with unit clinicians from January to September 2018.

Qualitative analysis used an iterative coding process.

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