End-of-life decision making for cancer patients in an intensive care unit

Introduction

Patients with advanced malignances are at a high risk of developing complications that lead to an Intensive Care Unit (ICU) admission. Despite improvements in ICU-level care, mortality rates for some patients remain especially high. Limitation of therapy is an integral component of high-quality care of cancer patients in the ICU.

Objectives

Describe the practice and analyze associated factors of life-sustaining treatment in the 8-bed ICU of a cancer specialized center.

Methods

Retrospective surveillance of adult patients (aged more than 18 years) admitted to the ICU from January/2010 to December/2014. For patients with more than one admission, only the last one was analyzed. Patients were divided into two groups: withdrawing or withholding life support (WWLS), and full life support, as suggested in the literature. Predictive factors of WWLS were identified using multivariate logistic regression analysis.

Results

Among 1511 patients admitted to ICU, 1309 (86,6%) had solid tumors and 202 (13,4%) had some kind of hematological malignancy. A small group had received stem-cell transplant (4,9%). The median age was 62 (18, minimum and 90, maximum) years and 58% were male. Thirteen percent (196/1511) of patients had limitation of therapy (WWLS). We observed no difference in the annual prevalence during the study period (p=0,631). Primary reasons for the decision concerned malignancy status namely refractoriness to therapy and progressive disease. Hospital mortality was 39% (590/1511) and 33,2% of deaths occurred after WWLS. WWLS was independently associated with age, surgical status, length of mechanical ventilation, length of stay, APACHE score and organ failure (table 1).

Table 1 Multivariate logistic regression analysis.

Conclusions

End-of-life practice has been a routine in our center during the last 5 years (13% of admissions). As demonstrated previously in general ICU, clinical parameters seem to be major determinants of WWLS decisions in cancer patients. Consensus statements may help physicians in the difficult task of end-of-life decision making.