You are the ICU Consultant managing Paul, a 22-year-old male who was admitted to your ICU yesterday with septic shock and multi-organ failure secondary to severe community acquired pneumonia. He had been well until the 24 hours prior to his admission.
Currently he is on 100 ug/min of noradrenaline, vasopressin at 0.04 units/min, hydrocortisone 200 mg/d, is invasively ventilated, on CVVHDF, and on a 50% dextrose infusion. He is receiving blood products for bleeding from multiple sites. He is on appropriate antibiotics. His vasopressor doses and lactate (currently 13) are rapidly rising.
The consensus of your ICU specialist colleagues is that he will be unsupportable and die within the next 12 hours, and there are no further therapeutic options.
His relatives have just arrived and are waiting to speak to you.
Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.