Physicians’ predictions of long-term survival and functional outcomes do not influence the decision to admit patients with advanced disease to intensive care: A prospective study

Abstract

Background: Long-term survival and functional outcomes should influence admission decisions to intensive care, especially for patients with advanced disease. Aim: To determine whether physicians’ predictions of long-term prognosis influenced admission decisions for patients with and without advanced disease. Design: A prospective study was conducted. Physicians estimated patient survival with intensive care and with care on the ward, and the probability of 4 long-term outcomes: leaving hospital alive, survival at 6 months, recovery of functional status, and recovery of cognitive status. Patient mortality at 28 days was recorded. We built multivariate logistic regression models using admission to the intensive care unit (ICU) as the dependent variable. Setting/participants: ICU consultations for medical inpatients at a Swiss tertiary care hospital were included. Results: Of 201 evaluated patients, 105 (52.2%) had an advanced disease and 140 (69.7%) were admitted to the ICU. The probability of admission was strongly associated with the expected short-term survival benefit for patients with or without advanced disease. In contrast, the predicted likelihood that the patient would leave the hospital alive, would be alive 6 months later, would recover functional status, and would recover initial cognitive capacity was not associated with the decision to admit a patient to the ICU. Even for patients with advanced disease, none of these estimated outcomes influenced the admission decision. Conclusions: ICU admissions of patients with advanced disease were determined by short-term survival benefit, and not by long-term prognosis. Advance care planning and developing decision-aid tools for triage could help limit potentially inappropriate admissions to intensive care.

Outcome of cancer patients considered for intensive care unit admission in two university hospitals in the Netherlands: the danger of delayed ICU admissions and off-hour triage decisions

“…ICU denial rate in our study was higher than in studies including general patients [31][32][33][34][35], patients with advanced disease [36] or hematological patients [37]. In our study, short-term mortality of patients with immediate ICU admission (i.e., ICU mortality, hospital mortality or 30-day mortality) was variable when compared to other studies reporting similar [29,[38][39][40] or lower mortality [26,30,41].…”

One-year Mortality of Cancer Patients with an Unplanned ICU Admission: A Cohort Analysis Between 2008 and 2017 in the Netherlands

“…However, ICU admissions of patients are often determined by short-term survival benefit, and not by long-term prognosis. 35 In addition, physicians do not always communicate adequately about the prognosis and benefits of treatments toward patients and relatives. [36][37][38] Ideally, oncologists and hematologists discuss long-term outcomes after an ICU admission with patients and relatives well before an ICU admission, in order to manage expectations.…”

Time-limited trial – searching for rational solutions in the functioning of intensive care units

“…It is necessary to discuss the balance of risks and benefits, limit unnecessary or harmful therapies, and adjust the scope and methods of treatment to the set goal. It is necessary to jointly define the rational limits of therapy in each case to reduce suffering that does not bring any benefit [8].…”

“…It has been unequivocally proven that we deal with overtreatment in patients with advanced diseases and poor prognosis. Intensive therapy in these cases is associated with minimal benefit and prolonged suffering [8].…”