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

Abstract

@ERSpublicationsWith adequate selection, intensive care and mechanical ventilation should not be considered futile in lung cancer http://ow.ly/E3lB1Physicians in charge of patients with lung cancer not only face the cancer itself but also major comorbidities due to tobacco exposure. In addition to complications of lung cancer and anticancer treatments, chronic obstructive pulmonary disease exacerbations and cardiovascular disease, for example, are situations that can potentially lead patients with lung cancer to emergency wards and, finally, intensive care units (ICUs). Lung cancer represents up to 15-20% of ICU admissions in cancer patients. The reasons for ICU admission are primarily respiratory problems, with pneumonia being the leading cause, and sepsis and shock as the second and third aetiologies.During recent decades, the poor prognosis of cancer patients, both with haematological and with solid tumours, has prompted the decision for the ICU to refuse admission to these patients. Much progress in critical care has moved this common attitude from a nihilistic approach to a complex process for selecting patients before referring cancer patients to the ICU. It has been clearly demonstrated that the prognosis of cancer patients during their ICU stay is mainly dependent upon acute physiological disturbances induced by the complication that led the patient to the ICU [1, 2]. However, after recovery, the prognosis is again determined by the characteristics of the underlying oncological disease. These conclusions are of value in unselected oncology populations [2] and in specific groups of cancer patients requiring invasive mechanical ventilation[3], noninvasive ventilation [4] or renal replacement therapy [1,5].Along with the overall improvement in the prognosis of ICU cancer patients, the same trend was observed for lung cancer [5], with hospital mortality ranging from 24% to 65% [6,7]. 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.Decision for ICU admission is certainly a complex process in which multiple stakeholders (medical oncologists, pneumologists, intensivists, general practitioners, patients and their relatives) are involved. They have to consider objective (cancer stage and status, general conditions and comorbidities, etc.) 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...