Transcript Outcome In Critically ill Cancer Patients
Can We Justify ICU Refusal for Cancer Patients ?
Elie AZOULAY, MD Medical ICU, Saint Louis Teaching Hospital Paris, France 14th ESICM Annual Congress Geneva, Switzerland 30 Sept-3 Oct 2001
Triage decisions to ICU
When evaluating a patient with a severe acute illness, the ICU physician must determine: (i) the diagnosis, prognosis, and treatment (ii) whether or not ICU admission is warranted (iii) and if it is, whether the patient, if competent, consents to ICU admission.
Triage decisions to ICU
The answer to the second question is a daily dilemma for ICU physicians. Its determinants have been reported as related to: (i) the number of beds available in the ICU (ii) patient characteristics and comorbidities (iii) and the characteristics of the acute illness (severity, reversibility, and predicted residuals and quality of life after ICU discharge)
SCCM pejorative diagnoses
Does the patient have any of the following? Refractory leukemia associated with multiple organ failure Persistent vegetative status or brain death without possibility of organ donation Acute respiratory failure associated with refractory leukemia I__I I__I I__I Chronic respiratory or cardiac failure, or metastatic cancer without therapeutic resource I__I JAMA 1994;271:1200-1203 Crit Care Med 1994;22:358-62
Recommendations
P a t i e n t ’ s o p i n i o n F a m i l y ’ s o p i n i o n G e n e r a l p r a c t i t i o n e r ’ s o p i n i o n Q O L a s e v a l u a t e d b y t h e f a m i l y Q O L a s e v a l u a t e d b y t h e p a t i e n t Q O L a s e v a l u a t e d b y t h e i n t e n s i v i s t R e l i g i o u s v a l u e s o f t h e p a t i e n t I C U a d m i s s i o n f o r a n i a t r o g e n i c e v e n t B u r d e n s a n d a d v a n t a g e s o f a n e w t r e a t m e n t I n v e s t i g a t i o n s m i g h t b e t t e r e x p l a i n t h e e v e n t E x p e c t e d c o s t o f t r e a t m e n t i f p a t i e n t a d m i t t e d B e d a v a i l a b l e i n a n o t h e r I C U S e v e r i t y o f u n d e r l y i n g d i s e a s e R e v e r s i b i l i t y o f u n d e r l y i n g d i s e a s e R e v e r s i b i l i t y o f a c u t e c o n d i t i o n T i m e t o o p t i m a l t r e a t m e n t P o t e n t i a l h a n d i c a p E x p e c t e d c h a n c e o f s u r v i v a l i f p a t i e n t a d m i t t e d C o n s e q u e n c e s f o r t h e f a m i l y S o c i a l c o n t e x t JAMA 1994;271:1200-1203 Crit Care Med 1994;22:358-62
Compliance with Triage-to-ICU Recommendations A 20 16 12 8 4 0 Number of recommendations observed
P=0.0003
Admission denied after patient examination Admission denied over the phone B 20 16 12 8 4 0 Number of recommendations observed
P<0.0001
Beds available Full unit
26 French ICUs 283 denied admissions
- age > 65 y - poor chronic health status - chronic severe respiratory and heart failure - metastatic disease without hope of remission - admission diagnosis Azoulay E. et al. Crit Care Med 2001; In press Sprung CL, Crit Care Med 27:1073-9, 1999
Cancer patients
ICU physicians are often reluctant to admit cancer patients because they require:
– –
a large amount of work costly resources
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in-depth knowledge of hematology by the ICU staff for little gain, since their outcome is frequently unfavorable.
“Only cancer patients with a chance of being cured, who agree to undergo supportive therapy, and those with best chances of benefiting from intensive care should be admitted by priority”.
Sculier Curr Opin Oncol 1991;3:656-662
Prognosis of Critically Ill Cancer Patients (CICP) From 1980 to 1995: The Collegial Break-Down
Overall CICP
Authors Lloyd-T Schuster Brunet Groeger N 60 % deaths Neutropenia Remission MV Renal Coma Score BMT Shock Liver MOF 78.3
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77 100 .
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260 57 1713 42 .
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Ashkenazi Headley 29 69 52 42 .
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Mechanical Ventilation
Authors Journal Snow Patients (N) JAMA 1979 180 Ewer JAMA 1986 46 Malignancy ICU Hospital Mortality Mortality Solid tumors 74 87 Peters Dees
Chest 1988
119
NJM 1990
49 Lung cancer 85 Hematologic / Both 67 87 82 76 Lee JAMA 1995 115 Tremblay CIM 1995 32 Both AML 77 99 97 99 Epner
J I M 1996
157 Hematologic / 83
Mechanical Ventilation + BMT
Authors Journal Patients (N) ICU Mortality Hospital Mortality Torecilla Crawford Afessa Paz
ICM 1988 ARRD 1992 Mayo C P 1992 Chest 1993
15 348 25 27 Rubenfeld Price Gruson D Jackson Huaringa
An Int Med 1996 AJRCCM 1998
159 48 Hematol Cell Ther 1998 41
BMT 1998
72
CCM 2000
60 83 79 93 96.7
/ 81.2
/ 63% 88 / / / 96 / 100 (+MOF) / / 83
Medical Futility
Schneiderman Ann Intern Med 1990;112:949-54 «...when physicians conclude (either through personal experience, experiences shared with colleagues, or published empirical data) that in the last 100 cases a medical treatment has been useless, they should regard that treatment as futile...physicians are entitled to withhold a procedure on this basis...and need not obtain consent from patients or family members»
End-Of-Life Decisions
Carlon GC. Crit Care Med. 1989;17:106-7 Just Say No …
Schuster D.P. Am Rev Respir Dis 1992;145:508-9 Everything that should be done--not everything that can be done.
G.D. Rubenfeld Ann Intern Med 1996;125;625-30 Withdrawing Life Support from Mechanically Ventilated Recipients of Bone Marrow Transplants
F Brunet Intensive Care Medicine 1990;16:291-7 Is ICU Justified for patients with Hematological Malignancies?
Can We Justify ICU Refusal for Cancer Patients ?
Yes, Of Course ...
Recent changes in prognosis
Authors Blot Groegger Azoulay Kress Staudinger Azoulay Hilbert Azoulay Darmon
Journal EJC 1997 JCO 1998 ICM 1999
AJRCCM 1999
CCM 2000 ICM 2000 CCM 2000 CCM 2001
Submitted
Patients
107 Mortality 55% 1693 42% 75 348 414 120 64 237 102 57% 41% 47% 58% 31.25% 43.7% 55%
Saint-Louis 12-bed ICU 1993-1999: all patients Number of patients 700 600 500 400 300 200 100 0 1993 1994 1995 1996 1997 1998 % deaths 30 25 20 5 0 15 10 1999
Saint-Louis 12-beds ICU 1990-1999: CICPs Number of patients 100 % deaths 1 80 60 40 20 0.2
0 1990 1991 1992 1993 1994 1995 1996 Year of ICU admission 1997 1998 1999 0 0.8
0.6
0.4
Targets of Improvements
Upstream triage of cancer patients
Improvement of hematological and oncological management:
– –
BMT Neutropenia
Improvement of ICU management:
– – –
Noninvasive mechanical ventilation G-CSF?
Dialysis
Patient Selection (1)
Myeloma patients Knaus scale C or D Stage III disease SAPS II score at admission Need for: Dialysis NIMV 30-day mortality 1992-1995 n=41 (%) 26 (66.5) 34 (83) 54 (38-70) 1996-1998 n=34 (%) 13 (38.2) 21 (62) 64 (43-82) 9 (22) 2 (5) 31 (75.6) 15 (44) 7 (20.6) 12 (35)
P
0.02
0.03
0.05
0.04
0.03
0.0008
Changing Use of ICU for Hematological Patients Azoulay et al. Intensive Care Medicine 1999;25:1395-1401
Patient Selection (2)
MV patients Complete remission
BMT Neutropenia SAPS II score at admission Need for:
Vasopressors Dialysis NIMV Conventional MV
End-of-life decision 30-day mortality 1991-1995 n=132 (%)
28 (21.2)
1996-1998 n=105 (%)
34 (32.3) 17 (12.8) 48 (36.6) 55 (38-70) 63 (47.7) 25 (18.9) 19 (14.4) 113 (85.6) 25 (18.9) 25 (23.8) 43 (40.9) 62 (43-82) 55 (52.4) 29 (27.7) 29 (27.6) 76 (72.4) 17 (16.2) 108 (81.8) 64 (60.9)
P
0.04 0.02
0.50
0.005
0.59 0.11
0.01 0.01
0.58
0.0003 Azoulay et al. Crit Care Med 2001;29:519-525
Targets for Improvements
Upstream triage of cancer patients
Improvement of hematological and oncological management:
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BMT
– –
G-CSF?
Neutropenia
Improvement of ICU management:
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Noninvasive mechanical ventilation
–
Dialysis
Neutropenia and BMT
Cumulative Survival 1.00
.80
.60
.40
.20
0.00
0.00
5.00
10.00
15.00
20.00
25.00
30.00
Neutropenia N S Cumulative Survival 1.00
.80
.60
.40
.20
0.00
0.00
5.00
10.00
15.00
20.00
25.00
Time (days) from admission 30.00
Autologous BMT N S
Neutropenia
Authors Johnson Bouchama Blot Guiguet Gruson Hilbert Darmon Journal
CCM 1986 ICM 1999
26 60 Eur J C 1996 107
CCM 1998 CCM 2000 CCM 2000
94 93 64
Submitted
102 Patients ICU Mortality 69.2% 85% 55% 60% 71% 31.2 % 55%
Effect of G-CSF on neutropenia duration
ICU admission may be helpful even if prolonged neutropenia is expected ...
Darmon M et al. Submitted
Targets for Improvements
Upstream triage of cancer patients
Improvement of hematological and oncological management:
–
BMT
– –
G-CSF?
Neutropenia
Improvement of ICU management:
–
Noninvasive mechanical ventilation
–
Dialysis
Survival in two matched groups of 48 patients treated with and without NIMV
Cumulative survival 1 ,8 ,6 ,4 ,2 0
0 5
Noninvasive mechanical ventilation Conventional mechanical ventilation
10 15 20 25
Time (days) from admission
30
Crude mortality 21/48 (43.7%) 34/48 (70.8%) ARR: 0.27 (0.08-0.46) NNT: 4 (2-12) Azoulay et al. Crit Care Med 2001;29:519-525
Hilbert et al. N Engl J Med 2001 15;344:481-487
Acute Renal Failure and dialysis
Cumulative Survival 1.00
.80
Dialysis .60
.40
N S .20
0.00
0.00
5.00
10.00
15.00
20.00
25.00
30.00
Time (days) from admission
Can We Justify ICU Refusal for Cancer Patients ?
Yes … But,
Conclusion : Patient selection, not routine denial
Cancer patients are a heterogeneous group.
Improvements in both intensive care and oncohematological management have stripped classic predictors of ICU mortality of much of their value.
Allo-BMT patients remain poor candidates for ICU admission, above all when they need intensive management
The doctrine of ‘double effect’ in triage ?
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Opening widely the filter for ICU admission may avoid depriving patients from a chance to recover, but may allow physicians to perform more end of-life decisions Cuttini M, Lancet. 2000;355:2112-8
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Do we have (need) more beds to admit everyone for a selected period to better estimate the reversibility of the disease, or should we only take into account malignancy and comorbidities?
We above all need to clear a double talk Sulmasy DP, Arch Intern Med 1999;159:545-50
Everything that should be done...
When patients, oncohematologists and ICU physicians feel that ICU admission is reasonable, all potentially effective treatment methods should be used in the ICU.
Triage to the ICU using a multiplidiscinary method should place CICPs on the same level of priority as any other patient with other comorbidities
Is ICU selection by intensivists still a dilemma for cancer patients ?
ICU ADMISSION?
ICU physicians Hematologists and oncologists Patients and family members Multiple step selection … Are guidelines necessary?
For whom?
Studies are ongoing ...
Social context
Need for Guidelines?
Guidelines are important because they offer a basis for discussion.
However, doctors need to know when they should transgress guidelines.