No Exit: Identifying Avoidable Terminal Oncology Intensive Care Unit Hospitalizations

Abstract

Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care.

Outcomes of ICU Admission of Patients With Progressive Metastatic Gastrointestinal Cancer

“…While we did not analyze what proportion of our center’s total patients with cancer was represented by our cohort, recent data describe that approximately 1 in 20 patients with a solid tumor is admitted to an ICU within the first 2 years of their diagnosis, 9 and our study provides the site- and episode-specific information about such solid tumor ICU admissions that has been called for 10 in the wake of such cancer registry data research. 9 A different US institution recently presented the characteristics of their ICU admissions for patients with cancer and found that most deaths in the ICU consisted of advanced disease and/or poor clinical performance status, 11 that center’s experience agrees with our findings, and that the outcomes of patients with cancer in ICUs entail high morbidity and mortality. Those investigators’ findings also suggest that almost half of their ICU admissions were potentially avoidable, 11 although no specific criteria exist for such preventability of ICU admissions.…”

Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review

“…Reflecting dissatisfaction with simple variables, researchers have created complex variables (Table 5) in retrospective, prospective, and terminal hospitalization studies. 101e106 These variables have been created using interview data, medical records, and administrative data to capture the avoidability of hospitalizations 11 ; ED visits for chemotherapy toxicity 74 ; the number of transfers and transitions across care settings 12,13,100,107e110 ; hospital deaths of nursing home residents within three 101 or eight 111 days of hospital transfer; the deaths of terminally ill patients who had been transferred to the ICU and offered hemodialysis, vasopressors, or intubation 24 ; ICU deaths of patients with cancer after resuscitation and/or mechanical ventilation; and receipt of goal-concordant care. 102,112 2.…”

“…In addition, it will be important to understand the presence of variability in expert raters' judgments of the appropriateness of health care interventions. 144 For example, are intensivists more likely to view a hospitalization as potentially avoidable than oncologists or hospitalists 11 because they are more likely to be exposed to medical futility and thus more likely to experience moral distress? By reflecting the multidetermined nature of EoL interventions, future quality metrics will provide a more genuine depiction of the care provided in clinical settings.…”

“…Biases can be accounted for statistically, by adjusting for rater characteristics. 11 Artifacts can be minimized by design, using structured abstraction forms with evocative items or response options (e.g., anchoring vignettes). 169…”

“…Even the language used to describe EoL care is contested. Most individuals say they prefer to die peacefully at home, but many die in hospitals shortly after receiving treatments that have been described using value-laden terms, such as potentially avoidable, 11 burdensome, 12,13 inappropriate, 14e18 intensive, 19,20 unduly intensive, 21 futile, 22e24 wasteful, 25 and aggressive. 26e31 In this study, we use the neutral term discretionary to refer to interventions that typically confer benefits to patients but have limited or no evidence for their medical efficacy in particular clinical contexts.…”