Cancer Patients Dying in the Intensive Care Units and Access to Palliative Care

Abstract

Background:

In France, cancer has become the leading cause of death. Intensive care units (ICU) focus on survival, which may not be an appropriate setting to provide palliative care (PC) as needed by cancer patients and families.

Objective:

To describe the cancer patients who died in the ICU in 2010 in a French academic medical center.

Design:

Retrospective study

Measurements:

We reviewed medical records of all cancer patients who died in the ICU in 2010. The information collected from electronic medical records included patient sociodemographics and clinical characteristics, PC service referral, and the date of first contact with PC.

Results:

Among the 536 cancer patients who died in 2010, 42 (8%) died in the ICU. The cancers were hematological (21%), gastrointestinal (21%) and head and neck (21%). One patient had a PC referral versus 45% in the total population (p < 0.001) and the referral was the same day as the death. Eight (19%) patients had chemotherapy during their last month of life and 2 during the ICU hospitalization. Seventy-four per cent of patient admissions to the ICU related directly to malignancy. The mean time between diagnosis of cancer and death was 2.3 years (standard deviation, 4.4).

Conclusions

: Our work highlights the need for early PC in the illness trajectory of cancer patients to prevent the transfer of dying patients to the ICU. More studies are needed to understand the decision making leading to such transfers.

Introduction

End-of-life (EoL) care is a major step in the course of a cancer patient's illness that requires specific skills to enable improved quality of life, comfort, and optimum family support.¹ Most cancer patients die after a long illness causing progressive deterioration,² but some may occasionally experience a sudden deterioration leading to a transfer to the intensive care unit (ICU).

EoL management in the ICU is often not appropriate³: Cancer patients have a high prevalence of pain and other symptoms such as dyspnea or nausea that are sometimes underestimated.^4–6 Communication with patients and their families is difficult for ICU teams,^6–8 who feel unprepared when facing EoL situations.⁹ The teams whose primary mission and main objective is survival can struggle to cope with a cancer patient at the palliative stage.^3,10 Admissions to the ICU in the last month of life are further indicators of poor quality of care.^11–15

Involving palliative care (PC) teams in the course of the cancer patient's illness has shown a significant impact on the quality of EoL management and even recently improved survival.^16–18 Despite recent research, PC teams are often involved too late in the treatment of cancer patients.^19,20

The goal of this retrospective study was to describe the cancer patients who died in the ICU in 2010 and the factors associated with this last hospitalization.

Method

We reviewed the medical records of all cancer patients who died in the ICU in an academic medical center between January 1 and December 31, 2010. Our Institutional Review Board approved this retrospective study.

The information collected from electronic medical records included patient demographics and clinical characteristics, ICU hospitalization length, record of advance directives and healthcare proxy, PC service referrals, and the date of the patient's first contact with PC.

Statistical analyses

Before analysis, the database was anonymized. Categorical variables were expressed as number (n) and percentage. Quantitative variables were expressed as mean ± standard deviation (SD) when the distribution was normal, or median and minimum and maximum when the distribution was not normal. Categorical variables were compared using the chi-square test or Fisher's exact test when the conditions of application of chi-square test were not met. Quantitative variables were compared between groups using Student's t test after verification of equality of variances when data were normally distributed, and with the nonparametric test of Wilcoxon when the hypothesis of normality of distribution was not verified. The test of the difference was considered statistically significant at 5% (p < 0.05). Statistical analyses were conducted using SAS version 9.1.3 (SAS Institute, Inc., NC).

Results

Among the 536 cancer patients who died in 2010 (total population), 42 (8%) died in the ICU. Twenty-six (62%) patients were male with a mean age of 68 (SD; 16). The most common types of cancer were hematological (21%), gastrointestinal (21%), and head and neck (21%). The number of metastatic patients were lower in the ICU than in the referral population (36% vs. 62%, p = 0.067). The mean length of stay was lower in the ICU (14 days [SD; 13] vs. 16.5 [SD; 17]) (p = 0.657) (Table 1).

Table 1.

Patients' Characteristics

	ICU patients (n = 42)	Total population (n = 536)	p
Sex, male	26 (62%)	333 (62%)	0.99^*
Age in years, mean (SD)	69 (16)	68 (14)	0.5^**
Cancer type
Hematological	9 (21%)	73 (14%)	0.239^*
Gastrointestinal	9 (21%)	101 (19%)	0.737^*
Head and neck	9 (21%)	43 (8%)	0.011^*
Lung	6 (14%)	118 (22%)	0.332^*
Breast	2 (5%)	28 (5%)	0.825^*
Genitourinary	7 (17%)	81 (15%)	0.817^*
Metastatic cancer	15 (36%)	335 (62%)	0.067^*
Last hospitalization length in days, mean (SD)	14 (13)	16.5 (17)	0.657^**
Palliative care referral
Patients followed	1 (2%)	240 (45%)	<0.001^***
Mean interval between initial palliative care intervention and death in days (SD)	1	73 (188)	<0.001^**
Chemotherapy
In the last year of life	12 (29%)	217 (40%)	0.299^*
In the last month of life	8 (19%)	124 (23%)	0.625^*

Chi-square test.

Wilcoxon test.

***

Fisher's exact test.

ICU, intensive care unit; SD, standard deviation.

One patient had a PC referral out of the 42 cancer patients who died in the ICU versus 45% in the total population (p < 0.001), and the referral was the same day as the death. Patients who died in the ICU had a mean of 3.6 hospitalizations (SD; 5) during their last year of life. Eight (19%) patients had chemotherapy during their last month of life and 2 (with hematologic disease) during the ICU hospitalization.

Table 2 focuses on the pattern of care in the ICU. The most common causes for ICU admission were postchemotherapy septic shock (33%) and acute respiratory distress (29%). Patients had more than three antecedents for 55% of patients. Seventy-four percent of patients were admitted to the ICU for reasons directly related to their malignancy. Mean time between diagnosis of cancer and death for patients admitted to intensive care was 2.3 years (SD; 4.4). Sixty-nine percent of them had received chemotherapy (24% two or more lines of chemotherapy). A Pluridisciplinary Consultative Meeting is recorded in 31% of cases with a decision of PC for 5% of patients and the pursuit of “curative” treatment for 26% of patients. A decision to withdraw the intensive treatment was made for 76% of patients, with a delay of 2.2 days on average (SD; 3) between the decision and death. No advance directives were recorded; one healthcare proxy was recorded.

Table 2.

Intensive Care Unit Hospitalization Characteristics

	ICU patients (n = 42)
Reason for hospitalization
Cardiorespiratory arrest	4 (10%)
Septic shock	14 (33%)
Other shock	8 (19%)
Surgical complication	4 (10%)
Acute respiratory distress	12 (29%)
Medical diseases reported
<2	34 (81%)
3 or more	23 (55%)
Direct relation between hospitalization and cancer	31 (74%)
Mean interval between diagnosis and death, in years (SD)	2.3 (4.4)
Treatments received
Chemotherapy	29 (69%)
1	19 (45%)
2 or more	10 (24%)
in ICU	2 (5%)
Pluridisciplinary consultative meeting the month before death	13 (31%)
Treatment pursued	11 (26%)
Supportive care	2 (5%)
Advance directives found	0
Proxy person found	1 (2%)
Patients' will (LATA)	6 (14%)
LATA medical decision	32 (76%)
Mean interval between LATA decision and death, in days (SD)	2.2 (3)
Proxy meeting	37 (88%)
Proxy support proposed	5 (12%)
Psychologist	3 (7%)
Social worker	2 (5%)

LATA, withholding and withdrawing life-sustaining treatment.

Discussion

Many patients with incurable diseases or cancers die in intensive care in poor conditions.^9,11,21,22 Our aim was to focus on cancer patients who had died in the ICU in the hospital.

Gender and age are similar to the total population (cancer patients who died in our hospital in 2010) and is not a factor associated to ICU admission.²³

The number of metastatic patients was lower than in the total population, but hematological disease is not classified as metastatic, and head and neck cancers often have local progression. These results suggest that metastatic disease status is a limiting factor for the transfer in the ICU and trigger PC referral.^24,25 For hematological patients the metastatic status is not a useful indicator. Nevertheless, the deterioration of these patients is inevitable.^2,26 The literature recommends early collaboration between oncohematology and PC,^23,27–29 but it still seems difficult for oncohematologists to determine when to integrate PC teams in the course of patient care.^30–32

In our study, the ICU admission was a consequence of the cancer treatment for 74% of patients (postchemotherapy septic shock, postoperative complications). The patients were mostly frail, highlighting the need to assess a patient's general condition before ICU admission.²⁶ Despite algorithms used by resuscitation teams, the final admission decision remains intensivist dependent and relying on the specific patient situation, such as the bone marrow transplantation for example.³³

Twenty-five percent of patients who died in the ICU had received more than two lines of chemotherapy. This defines an advanced cancer and should be a criterion for a nonadmission to the ICU. Two patients with hematological diseases received chemotherapy in the ICU. Most patients die after resuscitation chemotherapy.^34,35 American Society of Clinical Oncology (ASCO) has developed misuse of chemotherapy criteria, including an estimated life expectancy of less than one month.^12,36 Earle found an increasing proportion of patients receiving chemotherapy within 14 days before death,¹³ which was about 19% of patients in our study. These findings suggest that it is difficult for oncohematologists and intensivists to identify terminal stage.^37,38 Early PC referral would improve the identification of this stage^39–41 and decrease the number of chemotherapy at the end of life.^40,42

Cancer patients often suffer from difficult symptoms whose intensity often increases at the end of life.⁴³ Symptom management is essential and requires validated and adapted tools.⁴⁴ Palliative care teams (PCT) are seldom involved in the ICU (9% of PCT interventions in 2010).^27,43 One reason is the very short time between ICU admission and patient's death. The ICU settings is often poorly adapted to patients and their families.²² Physicians and team have little time to spend with families, and psychologist or social worker availability is random. Families were not often able to discuss about their loved one's condition with intensivists.⁴⁵ Integrating PC teams in ICU would be useful in the overall care of cancer patients and their families.⁴⁶

There is a significant gap between patient's status and therapeutic decisions^47,48: Patients are too ill to participate in decisions, families are not sufficiently prepared for the death of their loved one and their expectations are often “unrealistic.”³ The intensivists describe a feeling of failure when a patient dies.⁴⁹ Finally, ICU teams emphasize the difficulty in confirming when “the end is really there”.⁵⁰

Our study found an average time of 2.3 years between the diagnosis of cancer and the patient's death and only 1 of the 42 patients involved was referred to PC, and it was the day he died. Implementation of PC teams has been suggested to improve PC impact: referring every patient diagnosed with metastatic cancer to PC teams,^51,52 integrating PCT with emergency rooms.^21,46

We found no advance directives in medical records and only one patient had a healthcare proxy person recorded. These results highlight the need for discussion about the end-of-life preferences.

The retrospective nature of our monocentric study is the first limitation of this work. Lack of data, such as explanation for ICU transfer, trusted person, advance directives, or withholding treatment decisions, are the most significant limitations. A prospective study interviewing the physicians involved in the decision is needed to understand the decision making about ICU referral versus palliative referral.

Conclusion

Our work highlights the need for improving the integration of our PC team in the ICU and other settings, such as oncology surgery or hematology. Integrating PC early in the illness trajectory of cancer patients enables discussion about end of life with patients and families, offers an expertise for the terminal stage diagnosis, and can prevent transfers of dying patients to the ICU.^32,53

Footnotes

Acknowledgment

The authors thank Avril Jackson and Léa Monsarrat for editing.

Author Disclosure Statement

No competing financial interests exist.

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