177 Q5. For all classes of obesity, the goal of the EN regimen should not exceed 65%–70% of target energy requirements as measured by IC. If IC is unavailable, we suggest using the weight-based equation 11–14 kcal/kg actual body weight per day for patients with BMI in the range of 30–50 and 22–25 kcal/kg ideal body weight per day for patients with BMI >50. We suggest that protein should be provided in a range from 2.0 g/kg ideal body weight per day for patients with BMI of 30–40 up to 2.5 g/kg ideal body weight per day for patients with BMI ≥40. Q6. If available, an enteral formula with low caloric density and a reduced NPC:N should be used in the adult obese ICU patient. While an exaggerated immune response in obese patients implicates potential benefit from immune-modulating formulas, lack of outcome data precludes a recommendation at this time. Q7. Additional monitoring is suggested to assess worsening of hyperglycemia, hyperlipidemia, hypercapnia, fluid overload, and hepatic fat accumulation in the obese critically ill patient receiving EN. Q8. The obese ICU patient with a history of bariatric surgery should receive supplemental thiamin prior to initiating dextrose-containing IV fluids or nutrition therapy. In addition, evaluation for and treatment of micronutrient deficiencies such as calcium, thiamin, vitamin B12, fat-soluble vitamins (A, D, E, K), and folate, along with the trace minerals iron, selenium, zinc, and copper, should be considered. R. NUTRITION THERAPY END-OF-LIFE SITUATIONS R1. ANH (artificial nutrition and hydration) is not obligatory in cases of futile care or end-of-life situations. The decision to provide ANH should be based on evidence, best practices, clinical experience and judgment; effective communication with the patient, family, and/or authorized surrogate decision maker; and respect for patient autonomy and dignity. Reference: McClave SA, et al. JPEN J Parenter Enteral Nutr. 2016;40(2):159-211. Used with permission of SCCM and A.S.P.E.N. If no grade is listed after the guideline, it is ungraded; based on expert consensus.