The management of critically ill patients with limited survival prospects presents increasingly ethical, operational, and clinical complexities within Intensive Care Medicine [1]. Mortality within the first 24 hours of intensive care unit (ICU) admission, although a relatively small subset of ICU deaths, often signals late recognition of deterioration, disproportional escalation of measures, and complex decision-making processes [2]. Our recent audit [3] revealed that 7.7% of ICU admissions in our unit resulted in death within 24 hours, accounting for nearly one in four ICU deaths in a one-year time frame. These patients had an average age of 75 years old with a significant proportion of patients categorized as vulnerable or frail (Clinical Frailty Score - CFS ≥4). These results underscore the need for systemic improvements in the identification and management of patients at risk of rapid deterioration.

The literature consistently supports the association between prolonged ward stays and increased mortality following ICU admission [4,5]. This pattern often reflects institutional limitations in staffing, monitoring, and early warning activation. Rapid Response Teams (RRTs) have been shown to reduce hospital mortality by facilitating early interventions for deteriorating patients [6]. The implementation of these teams is essential, as is the training of healthcare professionals in wards to identify and promptly recognize early signs of clinical deterioration or patients at risk of deterioration [6]. To operationalize frailty-adjusted triage in real-time hospital settings, we propose the systematic use of the CFS, validated as a strong predictor of poor ICU outcomes [7,8], in combination with Early Warning Scores (e.g., NEWS2, MEWS) to detect early deterioration [6], and simplified prognostic tools suitable for ward environments (e.g., quick SOFA, modified SAPS II). Availability of these instruments in Rapid Response Team assessments or initial hospital admission protocols would enable structured registration, automated electronic alerts, and timely multidisciplinary discussions when high short-term mortality risk is detected.

However, implementation may be limited by resource variability across healthcare systems, the need for training and awareness among non-intensivist professionals, integration with electronic health records, and the influence of cultural and ethical differences on early treatment limitation decisions [9,10]. Despite these challenges, standardizing such tools in pre-ICU workflows could improve triage accuracy, reduce non-beneficial ICU admissions, and support earlier palliative care integration, ultimately promoting a more ethical and efficient use of critical care resources.

Our audit found that 70.6% of early ICU deaths involved treatment limitation within 24 hours of admission. A pressing ethical concern may arise: should these patients have been admitted to ICU in the first place? When is escalation of treatments truly appropriate, and who decides? The ETHICUS Study and subsequent European Society of Intensive Care Medicine (ESICM) guidelines advocate for the early integration of ethics consultation and palliative care principles [9,10]. Proportionality of care, patient autonomy, and the avoidance of non-beneficial interventions must guide ICU decision-making, especially when time is limited [10]. In acute and time-sensitive ICU contexts, feasible ethical deliberation models include rapid-consultation institutional ethics committees, which can provide input within hours as recommended by the ESICM guidelines [10], and advance care planning (ACP) protocols that ensure patient values and treatment preferences are documented and accessible in the electronic health record [9,10]. Short, structured meetings at the bedside—bringing together ICU staff, primary teams, and palliative care specialists—can facilitate proportionality-of-care assessments under tight time constraints. Embedding palliative care principles directly into ICU admission criteria further supports decisions when prognosis is poor and escalation may be non-beneficial [10,11]. The integration of ACP documentation with prompt ethical consultation seems to provide the most effective balance between timely action and informed, values-driven decision-making in acute care environments [9–11].

Early mortality in the ICU transcends clinical outcomes, imposing significant emotional and ethical burdens on both patients’ families and healthcare professionals. The progression of critical illness and swift decision-making processes frequently shorten opportunities for comprehensive family involvement in end-of-life care discussions, which may contribute to heightened emotional distress [10]. Integration of palliative care principles into ICU protocols, especially for patients with higher predicted short-term mortality, should become standard practice [11]. Addressing these multifaceted issues requires future research to focus on the creation of advanced predictive tools for early ICU mortality. Such tools should encompass patient-specific factors including frailty, existing comorbidities, and relevant biomarkers that reflect disease severity. Emerging work in artificial intelligence (AI)-driven risk stratification and dynamic clinical modeling shows promise in forecasting short-term mortality [12]. Although our observations stem from a single Portuguese tertiary ICU, key findings—such as the link between frailty, delayed deterioration recognition, and early ICU mortality—mirror patterns reported in multicenter studies from both European [2,4,7] and non-European settings [6,8]. The proposed strategies, aligned with international guidelines [10], have broad conceptual applicability but may require adaptation in low-resource contexts, where ICU capacity, rapid response systems, and end-of-life care frameworks differ. In such environments, simplified triage tools, task-shifting, and integration of community-based palliative services may be more feasible. Multicenter, cross-national collaborations—including low- and middle-income countries—would strengthen the external validity and global relevance of these recommendations.

We consider fundamental to highlight the importance of thorough pre-admission assessments, early recognition of clinical deterioration, integration of palliative care within the ICU, and ethical deliberation in end-of-life decisions. Addressing these challenges can significantly improve the quality of care for critically ill patients while promoting the responsible and efficient use of ICU resources. Future research must prioritize predictive accuracy, ethical clarity, and compassionate care. In doing so, we can transform the first 24 hours in the ICU from a period of loss to a window of meaningful intervention.