In this paper, we describe how hospital culture and institutional structures either encourage or discourage the escalation of high-intensity, potentially non-beneficial life-sustaining care near the end of life. We conducted 113 semi-structured, in-depth interviews with hospital-based clinicians and administrators across three academic hospitals in California and Washington. We found that hospital policies, practices, protocols, and resources could either promote or thwart the American default towards high-intensity end-of-life care. These findings highlight the importance of the intentional design of hospital policies and its impact on the provision of potentially non-beneficial, life-sustaining treatments.