Outcomes of ICU patients with and without perceptions of excessive care: a comparison between cancer and non-cancer patients

Abstract Background Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer. Methods This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer. Results Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p < 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60–1.72 and HR 0.87, 95% CI 0.49–1.54) and TLDs (HR 0.81, 95% CI 0.33–1.99 and HR 0.70, 95% CI 0.27–1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58–3.15 and 1.66, 95% CI 1.28–2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups. Conclusions The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.

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

Intensive Care Medicine Experimental ◽

10.1186/2197-425x-3-s1-a651 ◽

2015 ◽

Vol 3 (S1) ◽

Author(s):

M Tavares ◽

I Neves ◽

F Coelho ◽

O Afonso ◽

A Martins ◽

...

Keyword(s):

Intensive Care Unit ◽

Decision Making ◽

Intensive Care ◽

End Of Life ◽

Cancer Patients ◽

End Of Life Decision ◽

Life Decision

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Multicenter outcome study of cancer patients admitted to the intensive care unit: a probability of mortality model.

Journal of Clinical Oncology ◽

10.1200/jco.1998.16.2.761 ◽

1998 ◽

Vol 16 (2) ◽

pp. 761-770 ◽

Cited By ~ 162

Author(s):

J S Groeger ◽

S Lemeshow ◽

K Price ◽

D M Nierman ◽

P White ◽

...

Keyword(s):

Intensive Care Unit ◽

Logistic Regression ◽

Intensive Care ◽

Hospital Mortality ◽

Cancer Patients ◽

The United States ◽

Categorical Variables ◽

Allogeneic Bone ◽

Icu Admission ◽

Hospital Survival

PURPOSE To develop prospectively and validate a model for probability of hospital survival at admission to the intensive care unit (ICU) of patients with malignancy. PATIENTS AND METHODS This was an inception cohort study in the setting of four ICUs of academic medical centers in the United States. Defined continuous and categorical variables were collected on consecutive patients with cancer admitted to the ICU. A preliminary model was developed from 1,483 patients and then validated on an additional 230 patients. Multiple logistic regression modeling was used to develop the models and subsequently evaluated by goodness-of-fit and receiver operating characteristic (ROC) analysis. The main outcome measure was hospital survival after ICU admission. RESULTS The observed hospital mortality rate was 42%. Continuous variables used in the ICU admission model are PaO2/FiO2 ratio, platelet count, respiratory rate, systolic blood pressure, and days of hospitalization pre-ICU. Categorical entries include presence of intracranial mass effect, allogeneic bone marrow transplantation, recurrent or progressive cancer, albumin less than 2.5 g/dL, bilirubin > or = 2 mg/dL, Glasgow Coma Score less than 6, prothrombin time greater than 15 seconds, blood urea nitrogen (BUN) greater than 50 mg/dL, intubation, performance status before hospitalization, and cardiopulmonary resuscitation (CPR). The P values for the fit of the preliminary and validation models are .939 and .314, respectively, and the areas under the ROC curves are .812 and .802. CONCLUSION We report a disease-specific multivariable logistic regression model to estimate the probability of hospital mortality in a cohort of critically ill cancer patients admitted to the ICU. The model consists of 16 unambiguous and readily available variables. This model should move the discussion regarding appropriate use of ICU resources forward. Additional validation in a community hospital setting is warranted.

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An Analysis of Arguments for and Against Euthanasia and Assisted Suicide: Part One

Cambridge Quarterly of Healthcare Ethics ◽

10.1017/s0963180100006733 ◽

1996 ◽

Vol 5 (1) ◽

pp. 62-76 ◽

Cited By ~ 4

Author(s):

David C. Thomasma

Keyword(s):

United States ◽

Intensive Care Unit ◽

Intensive Care ◽

Cancer Patients ◽

Critically Ill ◽

Assisted Suicide ◽

The United States ◽

Hospital Intensive Care Unit ◽

Return Home ◽

Life Prolongation

In advanced technological societies there is growing concern about the prospect of protracted deaths marked by incapacitation, intolerable pain and indignity, and invasion by machines and tubing. Life prolongation for critically ill cancer patients in the United States, for example, literally costs a fortune for very little benefit, typically from $82,845 to $189,339 for an additional year of life. Those who return home after major interventions live on average only 3 more months; the others live out their days in a hospital intensive care unit.

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An Analysis of Patients Transferred to a Tertiary Oncological Intensive Care Unit for Defined Procedures

American Journal of Critical Care ◽

10.4037/ajcc2015174 ◽

2015 ◽

Vol 24 (3) ◽

pp. 241-247 ◽

Cited By ~ 1

Author(s):

Sunil Kamat ◽

Sanjay Chawla ◽

Prabalini Rajendram ◽

Stephen M. Pastores ◽

Natalie Kostelecky ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cancer Patients ◽

Signs And Symptoms ◽

The United States ◽

Outcome Data ◽

Lengths Of Stay ◽

Intensive Care Unit Transfer ◽

Tumor Bleeding ◽

Oncological Center

Background Up to 50 000 intensive care unit interhospital transfers occur annually in the United States. Objective To determine the prevalence, characteristics, and outcomes of cancer patients transferred from an intensive care unit in one hospital to another intensive care unit at an oncological center and to evaluate whether interventions planned before transfer were performed. Methods Data on transfers for planned interventions from January 2008 through December 2012 were identified retrospectively. Demographic and clinical variables, receipt of planned interventions, and outcome data were analyzed. Results Of 4625 admissions to an intensive care unit at the oncological center, 143 (3%) were transfers from intensive care units of other hospitals. Of these, 47 (33%) were transfers for planned interventions. Patients’ mean age was 57 years, and 68% were men. At the time of intensive care unit transfer, 20 (43%) were receiving mechanical ventilation. Interventions included management of airway (n = 19) or gastrointestinal (n = 2) obstruction, treatment of tumor bleeding (n = 12), chemotherapy (n = 10), and other (n = 4). A total of 37 patients (79%) received the planned interventions within 48 hours of intensive care unit arrival; 10 (21%) did not because their signs and symptoms abated. Median intensive care unit and hospital lengths of stay at the oncological center were 4 and 13 days, respectively. Intensive care unit and hospital mortality rates were 11% and 19%, respectively. Deaths occurred only in patients who received interventions. Conclusions Interhospital transfers of cancer patients to an intensive care unit at an oncological center are infrequent but are most commonly done for direct interventional care. Most patients received planned interventions soon after transfer.

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Effect of socioeconomic deprivation and the appointment of Welfare Attorneys

Scottish Medical Journal ◽

10.1258/smj.2011.011183 ◽

2011 ◽

Vol 56 (4) ◽

pp. 220-222

Author(s):

M G Booth ◽

E O'neil ◽

C Haddow ◽

B Cook ◽

J Kinsella

Keyword(s):

Intensive Care Unit ◽

Decision Making ◽

Intensive Care ◽

Socioeconomic Deprivation ◽

Socioeconomically Disadvantaged ◽

Icu Patients ◽

The Public ◽

Educational Package ◽

Scottish Population ◽

Lack Of Knowledge

Most patients in intensive care unit (ICU) lack decision-making ability. The Adults with Incapacity (Scotland) Act 2000 allows someone to appoint a Welfare Attorney (WA) to act on their behalf should they lose capacity. Scotland has areas of major socioeconomic deprivation associated with lower life-expectancy and with a lack of knowledge about and consequently difficulty accessing services. The effect of socioeconomic deprivation on WA registration was investigated. A complete list of registered WAs was categorized by deprivation. The Public Guardian, Scotland indicated whether patients admitted to ICU at Glasgow Royal (April 2006-May 2009) had a WA registered. All Scottish ICU admissions (2004-2008) were categorized by deprivation. Twelve of 1152 ICU patients at Glasgow Royal had a WA. Of 165,997 WAs registered, 5984 were in the most deprived and 27,970 in the most affluent areas. Overall, 3.9% of the Scottish population had a WA (1.4% in the most, 6.5% in the least deprived population decile). In conclusion, the uptake of WAs was low, especially in deprived areas. The reasons could include a lack of knowledge, not anticipating the need for a WA or not being confident in the process. Any educational package needs to target the most socioeconomically disadvantaged.

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Acinetobacterinfections: a growing threat for critically ill patients

Epidemiology and Infection ◽

10.1017/s0950268807009478 ◽

2007 ◽

Vol 136 (8) ◽

pp. 1009-1019 ◽

Cited By ~ 45

Author(s):

M. E. FALAGAS ◽

E. A. KARVELI ◽

I. I. SIEMPOS ◽

K. Z. VARDAKAS

Keyword(s):

United States ◽

Intensive Care Unit ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Relative Frequency ◽

The United States ◽

Considerable Proportion ◽

Southern Europe ◽

Icu Patients

SUMMARYThere has been increasing concern regarding the rise ofAcinetobacterinfections in critically ill patients. We extracted information regarding the relative frequency ofAcinetobacterpneumonia and bacteraemia in intensive-care-unit (ICU) patients and the antimicrobial resistance ofAcinetobacterisolates from studies identified in electronic databases.Acinetobacterinfections most frequently involve the respiratory tract of intubated patients andAcinetobacterpneumonia has been more common in critically ill patients in Asian (range 4–44%) and European (0–35%) hospitals than in United States hospitals (6–11%). There is also a gradient in Europe regarding the proportion of ICU-acquired pneumonias caused byAcinetobacterwith low numbers in Scandinavia, and gradually rising in Central and Southern Europe. A higher proportion ofAcinetobacterisolates were resistant to aminoglycosides and piperacillin/tazobactam in Asian and European countries than in the United States. The data suggest thatAcinetobacterinfections are a growing threat affecting a considerable proportion of critically ill patients, especially in Asia and Europe.

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Incidence of pressure injury in an oncological intensive care unit

Revista Brasileira de Enfermagem ◽

10.1590/0034-7167-2018-0356 ◽

2019 ◽

Vol 72 (6) ◽

pp. 1490-1495

Author(s):

Rafael Tavares Jomar ◽

Rubens Pelágio de Jesus ◽

Marcos Pelágio de Jesus ◽

Bárbara Rocha Gouveia ◽

Eriane Nascimento Pinto ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Longitudinal Study ◽

Enteral Nutrition ◽

Cancer Patients ◽

Incidence Rate ◽

Cumulative Incidence ◽

Pressure Injury ◽

Sedative Drugs ◽

Tumour Characteristics

ABSTRACT Objective: to investigate the incidence of pressure injury in cancer patients of an intensive care unit. Method: A longitudinal study with 105 patients admitted to an oncological intensive care unit. The incidence rate was calculated as the number of events per 100 patient-days. Cumulative incidence was calculated both globally and according to selected characteristics, and submitted to hypothesis tests. Results: incidence rate per 100 patient-days was 1.32, and global cumulative incidence was 29.5%. A higher incidence was observed in patients with chronic diseases who had at least one episode of diarrhea, received enteral nutrition, and took vasoactive or sedative drugs for a prolonged period of time. Regarding type of tumour and antineoplastic treatments, no differences in incidence were observed. Conclusion: A high cumulative global incidence of pressure lesion was reported in cancer patients admitted to the intensive care unit, although tumour characteristics and antineoplastic treatments did not affect incidence.

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Factors associated with survival of patients with solid Cancer alive after intensive care unit discharge between 2005 and 2013

BMC Cancer ◽

10.1186/s12885-020-07706-3 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Hubert Gheerbrant ◽

Jean-François Timsit ◽

Nicolas Terzi ◽

Stéphane Ruckly ◽

Mathieu Laramas ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cancer Patients ◽

Solid Cancer ◽

Factors Associated ◽

Icu Admission ◽

Icu Discharge ◽

Treatment Limitation ◽

Anticancer Treatment ◽

Ecog Ps

Abstract Background At intensive care unit (ICU) admission, the issue about prognosis of critically ill cancer patients is of clinical interest, especially after ICU discharge. Our objective was to assess the factors associated with 3- and 6-month survival of ICU cancer survivors. Methods Based on the French OutcomeRea™ database, we included solid cancer patients discharged alive, between December 2005 and November 2013, from the medical ICU of the university hospital in Grenoble, France. Patient characteristics and outcome at 3 and 6 months following ICU discharge were extracted from available database. Results Of the 361 cancer patients with unscheduled admissions, 253 (70%) were discharged alive from ICU. The main primary cancer sites were digestive (31%) and thoracic (26%). The 3- and 6-month mortality rates were 33 and 41%, respectively. Factors independently associated with 6-month mortality included ECOG performance status (ECOG-PS) of 3–4 (OR,3.74; 95%CI: 1.67–8.37), metastatic disease (OR,2.56; 95%CI: 1.34–4.90), admission for cancer progression (OR,2.31; 95%CI: 1.14–4.68), SAPS II of 45 to 58 (OR,4.19; 95%CI: 1.76–9.97), and treatment limitation decision at ICU admission (OR,4.00; 95%CI: 1.64–9.77). Interestingly, previous cancer chemotherapy prior to ICU admission was independently associated with lower 3-month mortality (OR, 0.38; 95%CI: 0.19–0.75). Among patients with an ECOG-PS 0–1 at admission, 70% (n = 66) and 61% (n = 57) displayed an ECOG-PS 0–2 at 3- and 6-months, respectively. At 3 months, 74 (55%) patients received anticancer treatment, 13 (8%) were given exclusive palliative care. Conclusions Factors associated with 6-month mortality are almost the same as those known to be associated with ICU mortality. We highlight that most patients recovered an ECOG-PS of 0–2 at 3 and 6 months, in particular those with a good ECOG-PS at ICU admission and could benefit from an anticancer treatment following ICU discharge.

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Hidden Obligatory Fluid Intake in Critical Care Patients

Journal of Intensive Care Medicine ◽

10.1177/0885066615625181 ◽

2016 ◽

Vol 32 (3) ◽

pp. 223-227 ◽

Cited By ~ 4

Author(s):

Muhammad Umair Bashir ◽

Anan Tawil ◽

Vishnu R. Mani ◽

Umer Farooq ◽

Michael A. DeVita

Keyword(s):

Intensive Care Unit ◽

Decision Making ◽

Critical Care ◽

Medical Records ◽

Critical Care Unit ◽

Fluid Intake ◽

Icu Patients ◽

Critical Care Admission ◽

The Mean ◽

Critical Care Patients

Introduction: In addition to the fluid intake in the form of intravenous maintenance or boluses in intensive care unit (ICU) patients, there are sources of fluids that may remain unrecognized but contribute significantly to the overall fluid balance. We hypothesized that fluids not ordered as boluses or maintenance infusions—“hidden obligatory fluids”—may contribute more than a liter to the fluid intake of a patient during any random 24 hours of critical care admission. Methods: Patients admitted to the Harlem Hospital ICU for at least 24 hours were included in this study (N = 98). Medical records and nursing charts were reviewed to determine the sources and volumes of various fluids for the study patients. Results: The mean hidden obligatory volume for an ICU patient was calculated to be 978 mL (standard deviation [SD]: 904, median: 645) and 1571 mL (SD: 1023, median: 1505), with enteral feeds compared to the discretionary volume of 2821 mL (SD: 2367, median: 2595); this obligatory fluid volume was affected by a patient’s need for pressor support and renal replacement therapy. Conclusion: Hidden obligatory fluids constitute a major source of the fluid intake among patients in a critical care unit. Up to 1.5 L should be taken into account during daily decision making to effectively regulate their volumes.

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Decision-Making Processes in Surrogates of Cancer Patients in a Taiwan Intensive Care Unit

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17124443 ◽

2020 ◽

Vol 17 (12) ◽

pp. 4443 ◽

Cited By ~ 1

Author(s):

Wan-Na Sun ◽

Hsin-Tien Hsu ◽

Nai-Ying Ko ◽

Yu-Tung Huang

Keyword(s):

Intensive Care Unit ◽

Decision Making ◽

Intensive Care ◽

Cancer Patients ◽

Medical Center ◽

Medical Decision ◽

Confined Space ◽

Asian Populations ◽

Decision Making Processes ◽

Purposive Sample

Background: Few studies in Asian countries have explored the emotional entanglements and conflicts that surrogates often experience during the medical decision-making process. This study was to explore decision-making processes in surrogates of cancer patients in a Taiwan intensive care unit (ICU). This qualitative study surveyed a purposive sample of surrogates (n = 8; average age, 48 years) of cancer patients in the ICU of a medical center in Taiwan. A phenomenological methodology was used, and a purposive sample of surrogates of cancer patients were recruited and interviewed during the first three days of the ICU stay. Results: Based on the interview results, four themes were generalized through text progression: (1) Use love to resist: internal angst. This theme was related to the reflexive self -blame, the feelings of inner conflict, and the reluctance to make healthcare decisions, which surrogates experienced when they perceived suffering by the patient. (2) Allow an angel to spread love among us: memories and emotional entanglements. Memories of the patient caused the surrogate to experience emotional entanglements ranging from happiness to sadness and from cheerfulness to anger. (3) Dilemmas of love: anxiety about ICU visitor restrictions. The confined space and restricted visiting hours of the ICU limited the ability of surrogates to provide emotional support and to share their emotions with the patient. (4) Suffocating love: entanglement in decision-making. Emotional entanglements among family members with different opinions on medical care and their struggles to influence decision-making often prevented surrogates from thinking logically. Conclusions: Expression of emotions by ICU surrogates is often restrained and implicit, particularly in Asian populations. These results can help health professionals understand the psychological shock and inner conflict experienced by surrogates and provide a useful reference for improving their communications with surrogates.

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