Cancer Patient Characteristics Related to Prognosis in Patients with Metastatic Cancer Admitted to Intensive Care: The Importance of Advance Care Planning and Shared Decision Making

Dear Editor:

The physician orders for life-sustaining treatment (POLST) form apparently is used in the majority of U.S. patients throughout the country, as recently described by Hickman and Critser. ¹ The review clearly addresses issues of advance care planning, which is particularly applicable to patients with advanced cancer. Although the (proper) use of such a form may be required and/or helpful in clinical decision making (CDM) we are less well informed about the practical consequences in approach and outcome of the patient with or without a completed POLST form.

In a retrospective preliminary survey, we examined the survival among patients with various stages and types of cancer admitted to the intensive care unit (ICU) in a Dutch general teaching hospital. In addition, we assessed in whom do-not-resuscitate (DNR) orders were placed after discussion with the patient and family and to what extent it influenced the outcome.

Among the 25 patients examined, the hospital survival rate of those with metastasized cancer was 60% and their mean survival was 469 days after discharge (Table 1). Among age- and sex-matched patients without cancer, admitted to the ICU, these figures were 84% and 1262 days, respectively. Patients with stable disease or in partial response had a higher hospital discharge rate and survival as compared with those with progressive disease.

DNR orders were issued to half of the patients. Among the remaining patients it is unknown whether a DNR order was discussed or not. Survival tended to be higher among those who did not receive a DNR order. Although this may be predictable and suggest a proper selection of patients, it also clearly shows that in this population with metastasized cancer, the issue of DNR orders and advance care planning was neglected in too many cases. The discussion of DNR patients and advance care planning is dependent on many factors, among which is culture. A recent review shows that at present in a large number of patients, despite their sometimes poor prognosis, these issues are not discussed with them. ² We agree with Hickmann and Critser ¹ that standardization is an important goal to support patient-centered care. The use of the POLST form may be particularly helpful as it stimulates raising the issues among cancer patients in various stages. Future analysis after filling in the POLST form or other ways of documenting DNR issues and advance care planning, by following the disease course and (shared) CDM is likely to prove its value.

Due to major developments in cancer management, prognosis of cancer patients has further improved in the past two decades. ³ This should prompt us to alter the way we approach critically ill patients with (advanced) cancer. ICU survival has improved and hospital mortality has decreased among these patients. ⁴ Based on these studies, our preliminary analysis as well as disease-specific studies regarding both overall survival gains and quality of life, we should be able to recommend a DNR order or not and discuss advance care planning with patients. This is in view of the increased desire of SDM in patients undergoing palliative care, which is, among other reasons, due to changing attitudes in the community, increasing treatment options, and the wish by an increasing number of patients to control life. ⁵