We deal with this all the time. Most often, the topic comes up in a crisis and usually the decision is to treat aggressively. The AACN newsletter had an article recently that discussed a study which looked at the availability of critical care beds having an impact on whether palliative versus critical care is offered to patients. In other words, if the unit is full, grandma gets comfort care which so often is the better choice. We know that if the individual needing a unit bed was young or even younger than ancient, a unit bet would miraculously come available because some chronically ill, high maintenance, never going to get better person would get downgraded and moved out.