Selection criteria for intensive care unit referral of lung cancer patients: a pilot study

Abstract

The decision-making process for the intensity of care delivered to patients with lung cancer and organ failure is poorly understood, and does not always involve intensivists. Our objective was to describe the potential suitability for intensive care unit (ICU) referral of lung cancer in-patients with organ failures.We prospectively included consecutive lung cancer patients with failure of at least one organ admitted to the teaching hospital in Grenoble, France, between December 2010 and October 2012.Of 140 patients, 121 (86%) were evaluated by an oncologist and 49 (35%) were referred for ICU admission, with subsequent admission for 36 (73%) out of those 49. Factors independently associated with ICU referral were performance status ⩽2 (OR 10.07, 95% CI 3.85–26.32), nonprogressive malignancy (OR 7.00, 95% CI 2.24–21.80), and no explicit refusal of ICU admission by the patient and/or family (OR 7.95, 95% CI 2.39–26.37). Factors independently associated with ICU admission were the initial ward being other than the lung cancer unit (OR 6.02, 95% CI 1.11–32.80) and an available medical ICU bed (OR 8.19, 95% CI 1.48–45.35).Only one-third of lung cancer patients with organ failures were referred for ICU admission. The decision not to consider ICU admission was often taken by a non-intensivist, with advice from an oncologist rather than an intensivist.

Perception of prognosis of cancer patients by non-oncologists

“…For example, a recent cohort of 49, 515 metastatic patients with acute coronary syndrome documented a percutaneous coronary intervention (PCI) for only 24.9% of ST elevation myocardial infarction (STEMI) and 9.6% for non‐STEMI . In addition, while both short term and long term prognosis of cancer patients admitted to intensive care units has considerably improved, many patients are not considered as candidates for intensive care, or admitted after a detrimental delay . We are unaware of reports of less dramatic interventions, but it is likely that cancer patients are undertreated by physicians who consider them to have a very poor prognosis.…”

“…Such an awareness might have direct practical implications; physicians who have a pessimistic view of the prognosis of cancer patients might prefer palliative care over investigation and treatment of medical conditions which might influence both quality of life and survival. Cancer patients might receive insufficient therapy during acute hospital admissions and might not be admitted to intensive care units, if the treating physicians believe they have dismal prognosis anyway. A perception of dismal prognosis, sometimes referred to as “therapeutic nihilism”, might turn into one through misconception .…”

Admitting lung cancer patients to intensive care for organ dysfunction: a complex decision process

“…It is also important to consider that the prognosis of lung cancer patients surviving to the ICU stay is relatively poor, with a 6-month mortality rate of 73%, and only two-thirds of those receiving further anticancer treatment survive [8]. In this issue of the European Respiratory Journal, the article by TOFFART et al [9] reflects this situation, with hospital mortality of ∼60% for patients admitted to ICU and a 1-year survival after discharge from the ICU of 12%. Using a population similar to common descriptions, the authors asked how the decisions for referral of lung cancer patients to ICU were taken.…”

“…but also subjective constraints of a philosophical, psychological or religious nature in their decision. TOFFART et al [9] reported on 140 consecutive lung cancer patients with at least one organ dysfunction admitted to a single general hospital during a 23-month period. What is the main information provided by that prospective pilot study?…”

“…To approach this major point, the physician needs to have an adequate knowledge of lung cancer behaviour, prognosis and treatment but also to offer a therapeutic project at hospital discharge. This is the pivotal role of the ( pneumo)oncologists who, in the study by TOFFART et al [9], were involved in 86% of the decisions. Intensivists only regain importance when considering the final decision for ICU admission.…”