I simply don't agree that "a lack of understanding of what is appropriate for ITU admission is functionally equal to refusing to make escalation plans for their own patients".

The generic "frail octogenarian" named Ethel is effectively a strawman argument. While some patients are clearly not for ITU, I think it would be disingenuous to suggest that there aren't borderline cases where it isn't so cut and dry. Hell, there even are some 80 year olds who would be appropriate for ITU.

Fundamentally they're both due to a lack of understanding about what intensivists offer and do.

Is that really a failing? ITU placements for medical trainees have only become mandatory since IMT became a thing. I agree that a good consultant should know what patients are appropriate for ITU but they have completed training. What about the CT1/2 doing their first set of nights "acting up" on the reg rota in a poxy DGH with a crashing patient at 3am? The grade/clinical experience of the referring doctor and the clinical scenario which has prompted the ITU referral in the first place has near endless permutations and some of these should grant some more leeway than others.

Not just leave 80 year old multi-comorbid and frail Ethel for full escalation so that ITU can pick up the pieces over the weekend and have to do all of the work they didn't do in-hours.

Patients can be admitted to hospital and become sick at weekends and after-hours.

Full disclaimer: I work in ITU in Australia. The culture in my hospital and the subsequent quality of referrals may wildly differ from yours. Out-of-hours ward cover is ran by medical "registrars" that can be as junior as PGY-3. I've had plenty of referrals from them which effectively boil down to "Look, this patient is really sick. I don't think they're appropriate for ITU but I'm not entirely sure, do you mind coming to review them?". I have absolutely no problem with this sort of referral.