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Predicting outcomes for critically ill patients is an important aspect of discussions with families in the intensive care unit. Our objective was to evaluate clinical intensive care unit survival predictions and their consequences for mechanically ventilated patients.Prospective cohort study. Fifteen tertiary care centers.Consecutive mechanically ventilated patients ≥18 yrs of age with expected intensive care unit stay ≥72 hrs.We recorded baseline characteristics at intensive care unit admission. Daily we measured multiple organ dysfunction score (MODS), use of advanced life support, patient preferences for life support, and intensivist and bedside intensive care unit nurse estimated probability of intensive care unit survival.The 851 patients were aged 61.2 (±17.6, mean ± SD) yrs with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 21.7 (±8.6). Three hundred and four patients (35.7%) died in the intensive care unit, and 341 (40.1%) were assessed by a physician at least once to have a <10% intensive care unit survival probability. Independent predictors of intensive care unit mortality were baseline APACHE II score (hazard ratio, 1.16; 95% confidence interval, 1.08–1.24, for a 5-point increase) and daily factors such as MODS (hazard ratio, 2.50; 95% confidence interval, 2.06–3.04, for a 5-point increase), use of inotropes or vasopressors (hazard ratio, 2.14; 95% confidence interval, 1.66–2.77), dialysis (hazard ratio, 0.51; 95% confidence interval, 0.35–0.75), patient preference to limit life support (hazard ratio, 10.22; 95% confidence interval, 7.38–14.16), and physician but not nurse prediction of <10% survival. The impact of physician estimates of <10% intensive care unit survival was greater for patients without vs. those with preferences to limit life support (p < .001) and for patients with less vs. more severe organ dysfunction (p < .001). Mechanical ventilation, inotropes or vasopressors, and dialysis were withdrawn more often when physicians predicted <10% probability of intensive care unit survival (all p s < .001).Physician estimates of intensive care unit survival <10% are associated with subsequent life support limitation and more powerfully predict intensive care unit mortality than illness severity, evolving or resolving organ dysfunction, and use of inotropes or vasopressors.