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Patients on palliative chemo more likely to undergo intensive care

Publish date: March 14, 2014
By
Amy Karon

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Prevent 'ICU to nowhere'

This study has provided evidence of the risk of strategic failure for those receiving disease-directed treatment for advanced cancer. In my practice as a surgeon wearing my other hat as a palliative medicine consultant in a critical care unit, I frequently see the "red flag" of ongoing cytotoxic chemotherapy for patients with advanced cancer now admitted for critical illness. Rarely, in my experience, has an ICU admission contributed much in the way of future quality of life or survival. Even more rarely has there been a previous detailed discussion with health care providers about the rainy day scenario of how to manage a grave complication of treatment or an illness. In the name of hope we often avoid the inevitable with tedious negotiations about tactical distractions - more consultants, more scans, more procedures. Adding to the confusion is the gulf separating critical care from oncology. Their respective worldviews are strikingly different.

The study also raises two other questions: What do we mean when we say "terminal"? Do we really understand the difference between palliative treatment and noncurative treatment? The current consensus definition of "palliative" emphasizes quality of life as the primary goal of care and sees life prolongation as a secondary benefit. Dr. Thomas Miner, an oncologic surgeon, framed it well: "Palliative treatment is not the opposite of cure; it has its own distinct indications and goals and should be evaluated independently" (Ann. Surg. Oncol. 2002;9:696-703). To prevent the tragic outcome for oncology patients of "ICU to nowhere," patients, families, and practitioners should consider taking the time and resources such as a palliative care team to have the strategic discussion much earlier in the course of oncologic illness.

Geoffrey P. Dunn, M.D., an ACS Fellow based in Erie, Pa., is chair of the American College of Surgeons Surgical Palliative Care Task Force.


 

FROM BMJ

Cancer patients who received palliative chemotherapy at the end of life were significantly more likely to undergo intensive medical care and to die in an ICU, according to researchers.

These patients were also significantly more likely to be referred late to hospice care compared with terminal patients who did not receive palliative chemotherapy, said Dr. Holly Prigerson of Weill Cornell Medical College, New York, and her associates.

The prospective, multicenter cohort study enrolled 386 adults with metastatic cancers refractory to at least one chemotherapy regimen. Patients were terminally ill at enrollment. In all, 216 (56%) were receiving palliative chemotherapy when they enrolled a median of 4 months before death.

Dr. Holly Prigerson

Fourteen percent of patients receiving palliative chemotherapy underwent mechanical ventilation, cardiopulmonary resuscitation, or both in the week before death, compared with 2% of patients not receiving palliative chemotherapy. The adjusted difference in risk was 10.5%. Since events were rare, adjusted risk differences were calculated and reported instead of odds ratios, as odds ratios might have exaggerated actual risk, the investigators noted.

Patients receiving palliative chemotherapy were less likely to acknowledge that their illness was terminal (35% vs. 49%, P = .04) and to report having discussed their end-of-life wishes with a physician (37% vs. 48%, P = .03. They were also less likely to have completed a do-not-resuscitate order compared with patients not receiving palliative chemotherapy (36% vs. 49%, P less than .05), the investigators reported (BMJ 2014 [doi: 10.1136/bmj.g1219]).

There was no significant difference in overall survival between patients who received palliative chemotherapy and those who did not (hazard ratio 1.11), the investigators said.

The findings show that "end of life discussions may be particularly important for patients receiving palliative chemotherapy, who should be informed by data on the likely outcomes associated with its use," the researchers said.

The study was nonrandomized, and therefore patients who received palliative chemotherapy could have differed in terms of unmeasured factors such as disease duration, the investigators noted. They recommended larger studies to confirm their findings.

The authors received research support from the National Institute of Mental Health, the National Cancer Institute, the American Cancer Society, and the Conquer Cancer Foundation. No authors reported conflicts of interest.

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