ICU deaths in patients with advanced cancer: Criteria to decrease potentially inappropriate admissions and analysis of advance planning discussions.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 47-47
Author(s):  
Syed Sameer Nasir ◽  
Alva B Weir
Keyword(s):  
Life Expectancy ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Performance Status ◽  
Admission Criteria ◽  
Advanced Cancer Patients ◽  
Icu Admission ◽  
Post Procedure ◽  
Inappropriate Admissions ◽  
Advance Planning

47 Background: A significant number of advanced cancer admissions to intensive care unit (ICU) are inappropriate, as they do not prolonged survival. No clear consensus criteria for reasonable admissions of advanced cancer patients have been developed. Methods: We established four criteria for ICU admissions in advanced cancer patients: post procedure complication, recent cancer diagnosis, good performance status and life expectancy of > 6 months. We reviewed charts of all patients who died in the ICU at a university-affiliated hospital between 2005-2010. We then identified advanced cancer patients and looked for presence or absence of these criteria. We also reviewed evidence of advance planning discussions (APDs), prior to ICU admission to evaluate their benefit in preventing inappropriate admissions. Results: 421 deaths occurred in ICU between 2005-2010. 52 patients had advanced cancer. 27% were diagnosed with cancer one month or less prior to admission. 40% had ECOG performance status of 0-1. 27% had life expectancy of more than 6 months and 15% were admitted for post procedure complications. Overall, 37% did not satisfy any of our reasonable criteria at the time of ICU admission. In our chart review for evidence of APDs, 31% had completed APDs prior to ICU admission. 47% of patients who did not satisfy any of our reasonable admission criteria had APDs indicating desire for limited medical intervention. Patients lacking both reasonable admission criteria and APDs were 15%. Conclusions: Incorporating proposed admission criteria in ICU admission guidelines may prevent significant number of inappropriate, advanced cancer admissions to the ICU, thus avoiding ineffective, aggressive interventions and delay in timely access to high-quality hospice and palliative care. Our data confirms other data in suggesting that a simple increase in numbers of APDs would not likely change significantly the numbers of inappropriate ICU admissions. [Table: see text]

ICU deaths in advanced cancer patients: Reasonableness of ICU admissions.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 199-199
Author(s):  
Alva B Weir ◽  
Katheryn M Ryder ◽  
Harvey B. Niell ◽  
Muthia Muthia ◽  
Karen Clark
Keyword(s):  
Decision Making ◽  
Intensive Care ◽  
Life Expectancy ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Performance Status ◽  
Advanced Cancer Patients ◽  
Advanced Directives ◽  
Post Procedure ◽  
Large Databases

199 Background: Previous evaluations of care and outcomes for cancer patients who die in intensive care (ICU) settings have been limited to large databases. Little detailed information exists regarding the decision making in these eventually futile efforts. Reasonableness of admission has not been evaluated in detail. Methods: Previous evaluations of care and outcomes for cancer patients who die in intensive care (ICU) settings have been limited to large databases. Little detailed information exists regarding the decision making in these eventually futile efforts. Reasonableness of admission has not been evaluated in detail. Results: In our patients the mean duration of cancer awareness was 7.3 months. The majority (38) had expected duration of life prior to ICU of 6 months or less. Only 16 patients had documented discussions regarding treatment preferences or advanced directives prior to hospital admission. In establishing reasonableness of admission: 8 were post procedure complications; 21 had an ECOG performance status of 0-1 prior to admission; 14 had been notified of their incurable cancer for one month or less; an additional 3 patients had a life expectancy > 6 months. Of the 52 ICU deaths of patients with advanced cancers, 31 (60%) met our criteria for reasonableness of admission in spite of advanced cancer. Of the remaining 21 patients, 9 had advanced directives in place prior to hospitalization, but without specific decisions regarding ICU care. Only 23% of futile ICU admissions in advanced cancer patients lacked both advanced directives prior to hospital admission and reasonableness of ICU admission by the above criteria. Conclusions: The majority of patients with advanced cancer who die in the ICU in our medical center are reasonable admissions, as defined by recent diagnoses, good performance status, > 6 month life expectancy and admission for post procedure complications.

ICU Deaths in Patients With Advanced Cancer

2016 ◽  
Vol 34 (2) ◽  
pp. 173-179 ◽  
Author(s):  
Syed Sameer Nasir ◽  
Muthiah Muthiah ◽  
Kathryn Ryder ◽  
Karen Clark ◽  
Harvey Niell ◽  
...  
Keyword(s):  
Life Expectancy ◽  
Advanced Cancer ◽  
Medical Center ◽  
Performance Status ◽  
Health Science ◽  
Admission Criteria ◽  
Science Center ◽  
Ecog Performance Status ◽  
Incurable Cancer ◽  
Post Procedure

Background: A significant number of advanced cancer admissions to the intensive care unit (ICU) are inappropriate in that they do not result in prolonged survival. No clear consensus criteria for reasonable admissions of advanced cancer patients have been developed. Method: We established four criteria for reasonable admissions to ICU in patients who suffered from advanced, incurable cancer: post procedure complication, recent notification of cancer, ECOG performance status of 0-1, and life expectancy of more than 6 months. Based on these criteria, we reviewed the charts of all patients who died in the ICU at the University of Tennessee Health Science Center (UTHSC) affiliated Veteran’s Affairs Medical Center between 10/2005 and 10/2010. We identified patients with advanced, incurable cancer and performed an in depth review of their charts. Results: In the 421 charts of patients who died in our ICU between October 2005 and October 2010 we identified 52 patients admitted to the ICU with advanced, incurable cancer. 14 patients were diagnosed with cancer one month or less prior to admission. 21 patients had ECOG performance status of 0-1. 14 patients had life expectancy of more than 6 months and 8 patients were admitted for post procedure complication. 47% of patients who did not satisfy any of our reasonable admission criteria had APDs. Conclusions: Incorporating proposed admission criteria in ICU admission guidelines may prevent 37% of inappropriate, advanced cancer admissions to the ICU. A simple increase in numbers of APDs would not likely change significantly the numbers of inappropriate ICU admissions.

scholarly journals Palliative Care and COVID-19 Pandemic: Retrospective Study of Factors Associated With Infection and Death at an Oncological Palliative Care Reference Center

2021 ◽  
pp. 104990912098696
Author(s):  
Livia Costa de Oliveira ◽  
Karla Santos da Costa Rosa ◽  
Ana Luísa Durante ◽  
Luciana de Oliveira Ramadas Rodrigues ◽  
Daianny Arrais de Oliveira da Cunha ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Palliative Care ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Karnofsky Performance Status ◽  
Performance Status ◽  
Tumor Type ◽  
Advanced Cancer Patients ◽  
Factors Associated ◽  
Reactive Protein

Background: Advanced cancer patients are part of a group likely to be more susceptible to COVID-19. Aims: To describe the profile of advanced cancer inpatients to an exclusive Palliative Care Unit (PCU) with the diagnosis of COVID-19, and to evaluate the factors associated with death in these cases. Design: Retrospective cohort study with data from advanced cancer inpatients to an exclusive PCU, from March to July 2020, with severe acute respiratory syndrome. Diagnostic of COVID-19 and death were the dependent variables. Logistic regression analyses were performed, with the odds ratio (OR) and 95% confidence interval (CI). Results: One hundred fifty-five patients were selected. The mean age was 60.9 (±13.4) years old and the most prevalent tumor type was breast (30.3%). Eighty-three (53.5%) patients had a diagnostic confirmation of COVID-19. Having diabetes mellitus (OR: 2.2; 95% CI: 1.1-6.6) and having received chemotherapy in less than 30 days before admission (OR: 3.8; 95% CI: 1.2-12.2) were associated factors to diagnosis of COVID-19. Among those infected, 81.9% died and, patients with Karnofsky Performance Status (KPS) < 30% (OR: 14.8; 95% CI 2.7-21.6) and C-reactive protein (CRP) >21.6mg/L (OR: 9.3; 95% CI 1.1-27.8), had a greater chance of achieving this outcome. Conclusion: Advanced cancer patients who underwent chemotherapy in less than 30 days before admission and who had diabetes mellitus were more likely to develop Coronavirus 2019 disease. Among the confirmed cases, those hospitalized with worse KPS and bigger CRP were more likely to die.

How long do I have? Observational study on communication about life expectancy with advanced cancer patients

2017 ◽  
Vol 100 (10) ◽  
pp. 1820-1827 ◽  
Author(s):  
I. Henselmans ◽  
E.M.A. Smets ◽  
P.K.J. Han ◽  
H.C.J.C. de Haes ◽  
H.W.M.van Laarhoven
Keyword(s):  
Life Expectancy ◽  
Observational Study ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Advanced Cancer Patients

scholarly journals Home Artificial Nutrition in Advanced Cancer

1997 ◽  
Vol 90 (11) ◽  
pp. 597-603 ◽  
Author(s):  
Loris Pironi ◽  
Enrico Ruggeri ◽  
Stephan Tanneberger ◽  
Stefano Giordani ◽  
Franco Pannuti ◽  
...  
Keyword(s):  
Enteral Nutrition ◽  
Parenteral Nutrition ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Performance Status ◽  
Artificial Nutrition ◽  
Utilization Rate ◽  
Karnofsky Performance Score ◽  
Advanced Cancer Patients ◽  
At Home

Attitudes to home artificial nutrition (HAN) in cancer vary greatly from country to country. A 6-year prospective survey of the practice of HAN in advanced cancer patients applied by a hospital-at-home programme in an Italian health district was performed to estimate the utilization rate, to evaluate efficacy in preventing death from cachexia, maintaining patients at home without burdens and distress and improving patients' performance status, and to obtain information about costs. Patients were eligible for HAN when all the following were present: hypophagia; life expectancy 6 weeks or more, suitable patient and family circumstances; and verbal informed consent. From July 1990 to June 1996, 587 patients were evaluated; 164 were selected for HAN (135 enteral and 29 parenteral) and were followed until 31 December 1996. The incidence of HAN per million inhabitants was 18.4 in the first year of activity and 33.2–36.9 in subsequent years, being 4–10 times greater than rates reported by the Italian HAN registers. On 31 December 1996, 158 patients had died because of the disease and 6 were on treatment. Mean survival was 17.2 weeks for those on enteral nutrition and 12.2 weeks for those on parenteral nutrition. Prediction of survival was 72% accurate. 95 patients had undergone 155 readmissions to hospital, where they spent 15–23% of their survival time. Burdens due to HAN were well accepted by 124 patients, an annoyance or scarcely tolerable in the remainder. The frequency of major complications of parenteral nutrition was 0.67 per year for catheter sepsis and 0.16 per year for deep vein thrombosis. Karnofsky performance score increased in only 13 patients and body weight increased in 43. The fixed direct costs per patient-day (in European Currency Units) were 14.2 for the nutrition team, 18.2 for enteral nutrition and 61 for parenteral nutrition. The results indicate that definite entry criteria and local surveys are required for the correct use of HAN in advanced cancer patients, that HAN can be applied without causing additional burdens and distress, and that its costs are not higher than hospital costs.

The Importance of a Home Care Program for Patients with Advanced Cancer Pain

1985 ◽  
Vol 71 (5) ◽  
pp. 449-454 ◽  
Author(s):  
Vittorio Ventafridda ◽  
Marcello Tamburini ◽  
Silvana Selmi ◽  
Luigi Valera ◽  
Franco De Conno
Keyword(s):  
Home Care ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Performance Status ◽  
Care Program ◽  
Pain Clinic ◽  
Advanced Cancer Patients ◽  
Sample Group ◽  
Significant Difference ◽  
Quality Of Life Index

At the Pain Clinic of the National Cancer Institute of Milan, a special Home Care Program has been set up to assist advanced cancer patients with pain and their families during their remaining survival. The Home Care Unit comprises a team of physicians, nurse clinicians, psychologists and many volunteers who are active both in the hospital and at the patient's home. This entire operation provides a continuous relationship between the family, the patient and the Home Care Unit. This Home Care Program, which is one of a kind with other forms of treatment for advanced cancer patients (i.e. hospices), has produced interesting results. Out of a sample group of 50 patients, 33 were monitored at home by the Home Care Unit while 17 had their families to do the monitoring. Over a six-week period the following results were reported: a) Improvement of psycho-emotional factors such as anxiety, weakness and mood for both patients and their families who entered the Home Care Program. b) The Quality of Life Index remained unchanged for the sample group that entered the Home Care Program whereas it deteriorated for patients monitored by their families. c) A decrease in the Integrated Pain Score for both groups; however, results showed a statistically significant difference in favor of patients on the Home Care Program. d) The Performance Status decreased by very little over the study period, and there was little difference between the two groups. These results confirm the need for a Home Care Program which must go hand in hand with the Pain Clinic as an effective way to control Total Pain.

Use of parenteral nutrition in patients with advanced cancer

2008 ◽  
Vol 33 (1) ◽  
pp. 102-106 ◽  
Author(s):  
Isaac Soo ◽  
Leah Gramlich
Keyword(s):  
Parenteral Nutrition ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Bowel Obstruction ◽  
Karnofsky Performance Status ◽  
Performance Status ◽  
Intestinal Failure ◽  
Advanced Cancer Patients ◽  
End Stage ◽  
Northern Alberta

The purpose of this study is to describe patient-related variables in a cohort of advanced cancer patients (ACPs) enrolled in a home parenteral nutrition (HPN) program. This study reviewed the cohort of ACPs enrolled in the Northern Alberta Home Total Parenteral Nutrition Program (NAHTPNP). Thirty-eight ACPs received HPN during the study period, 24% of all patients admitted for PN. Of these, 27 (71%) were female. Mean age was 48.76 y (SD 13.8 y). Bowel obstruction was the most common indication for initiating HPN (84%, 32) and ovarian cancer was the most common malignancy (34%, 13). Patients who began HPN with a Karnofsky performance status (KPS) of greater than 50 (median of 70) were found to have a longer duration of life (median: 6 months) compared with patients who began HPN with a KPS of 50 or below (median = 50; median 3 months; p = 0.01; two-tailed). There was no difference in survival between malignancy type (p = NS). Advanced cancer is the fastest growing indication for enrollment in the HPN program. ACP demonstrated a 3% average annual increase proportionate to all indications for HPN starts, accounting for 7%–48% of HPN starts from 1999–2006. HPN is an increasingly used therapy for patients with advanced cancer, most commonly for intestinal failure in the setting of bowel obstruction. Initiation of HPN at a higher KPS was associated with a longer duration of life. Further studies are needed to validate the use of TPN in end-stage cancer patients.

Outcomes of prognostic disclosure: Effects on advanced cancer patients’ prognostic understanding, mental health, and relationship with their oncologist.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. 9519-9519 ◽  
Author(s):  
Andrea Catherine Enzinger ◽  
Baohui Zhang ◽  
Tracy A. Balboni ◽  
Deborah Schrag ◽  
Holly Gwen Prigerson
Keyword(s):  
Psychological Distress ◽  
Life Expectancy ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Psychological Symptoms ◽  
Substantial Improvement ◽  
Wilcoxon Test ◽  
Advanced Cancer Patients ◽  
Incurable Cancer ◽  
Symptoms Of Depression

9519 Background: Many oncologists are reluctant to discuss life expectancy with advanced cancer patients. We examined the frequency of prognostic disclosure and its impact on patients’ prognostic understanding, the patient-doctor relationship, and psychological distress. Methods: Coping with Cancer was an NCI-funded, multi-site prospective cohort of 726 patients with advanced incurable cancer, enrolled 2002-2008. At baseline, patients were asked if their oncologist had ever discussed prognosis, and if so what estimate was communicated. Patients also estimated their prognosis. The therapeutic alliance scale measured patient-doctor relationship, and the McGill QOL instrument assessed symptoms of depression and anxiety. Multivariable analyses (MVA) assessed relationships between prognostic disclosure and psychological symptoms, controlling for confounds. Results: Among this cohort of terminally ill patients (median survival 4mos), most (72%) wanted to be told their life expectancy. Only 19.8% (104/525) of patients had received a prognostic estimate from their oncologist (median estimate 6mos; IQR 6-15mos). When queried about factors informing their prognostic understanding, 85.9% of patients cited personal or religious beliefs; only 11.7% cited a physician’s estimate. Of the 299 patients willing to estimate their life expectancy, patients who had been previously informed of their prognosis were substantially more realistic in their own estimate (median 12mos v 48mos, Wilcoxon test p<0.001). Moreover, patients’ and oncologists’ prognostic estimates were significantly correlated (ρ=0.49, p<0.001). Prognostic disclosure was not associated with poor patient-doctor relationship rating (Fisher’s Exact, p=0.625), nor was it associated with depressive symptoms (β 0.06, p=0.242) or anxiety (β 0.06, p=0.234) in MVA. Conclusions: Few advanced cancer patients are informed of their life expectancy, although most want this information. Prognostic disclosure is associated with substantial improvement in patients’ prognostic understanding, without compromising the patient-doctor relationship or increasing psychological distress.

Differences in performance status assessments between palliative care specialists, nurses, and oncologists.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 19-19
Author(s):  
YuJung Kim ◽  
Yi Zhang ◽  
Ji Chan Park ◽  
David Hui ◽  
Gary B. Chisholm ◽  
...  
Keyword(s):  
Palliative Care ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Performance Status ◽  
Well Being ◽  
Assessment Tools ◽  
Advanced Cancer Patients ◽  
Care Clinic ◽  
Edmonton Symptom Assessment Scale ◽  
Ecog Ps

19 Background: The Eastern Cooperative Oncology Group (ECOG) performance status (PS) is one of the most commonly used assessment tools among oncologists and palliative care specialists caring advanced cancer patients. However, the inter-observer difference between the oncologist and palliative care specialist has never been reported. Methods: We retrospectively reviewed the medical records of all patients who were first referred to an outpatient palliative care clinic in 2013 and identified 278 eligible patients. The ECOG PS assessments by palliative care specialists, nurses, and oncologists, and the symptom burden measured by Edmonton Symptom Assessment Scale (ESAS) were analyzed. Results: According to the pairwise comparisons using Sign tests, palliative care specialists rated the ECOG PS grade significantly higher than oncologists (median 0.5 grade, P<0.0001) and nurses also rated significantly higher (median 1.0 grade, P<0.0001). The assessments of palliative care specialists and nurses were not significantly different (P=0.10). Weighted kappa values for inter-observer agreement were 0.26 between palliative care specialists and oncologists, and 0.61 between palliative care specialists and nurses. Palliative care specialists’ assessments showed a moderate correlation with fatigue, dyspnea, anorexia, feeling of well-being, and symptom distress score measured by ESAS. The ECOG PS assessments by all three groups were significantly associated with survival (P<0.001), but the assessments by oncologists could not distinguish survival of patients with PS 2 from 3. Independent predictors of discordance in PS assessments between palliative care specialists and oncologists were the presence of an effective treatment option (odds ratio [OR] 2.39, 95% confidence interval [CI] 1.09-5.23) and poor feeling of well-being (≥4) by ESAS (OR 2.38, 95% CI 1.34-4.21). Conclusions: ECOG PS assessments by the palliative care specialists and nurses were significantly different from the oncologists. Systematic efforts to increase regular interdisciplinary meetings and communications might be crucial to bridge the gap and establish a best care plan for each advanced cancer patients.

Advanced cancer patients’ changes in terminal illness understanding (TIU) and their psychological well-being.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 11617-11617
Author(s):  
Login S. George ◽  
Megan Johnson Shen ◽  
Paul K. Maciejewski ◽  
Andrew S. Epstein ◽  
Holly Gwen Prigerson
Keyword(s):  
Life Expectancy ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Psychological Symptoms ◽  
Treatment Decision ◽  
Well Being ◽  
Advanced Cancer Patients ◽  
Psychological Well Being ◽  
Change Scores

11617 Background: Although accurate TIU is necessary for informed treatment decision-making, clinicians worry that patients’ recognition of the terminal nature of their illness may lower psychological well-being. This study examines if such recognition is associated with lowered psychological well-being, that persists over time. Methods: Data came from 87 advanced cancer patients, with a life expectancy of less than 6 months. Patients were assessed pre and post an oncology visit to discuss cancer restaging scan results, and again one month later (follow-up). TIU was assessed at pre and post as the sum of four indicator variables — understanding of terminal nature of illness, curability, stage, and life-expectancy — and a TIU change score was computed (post minus pre). Psychological well-being (psychological symptoms subscale, McGill questionnaire) was assessed at pre, post, and follow-up, and two change scores were computed (post minus pre; follow-up minus post). Results: Changes toward more accurate TIU was associated with a corresponding decline in psychological well-being ( r = -0.33, p < .01), but thereafter was associated with subsequent improvements in psychological well-being ( r = .40, p < .001). This pattern persisted even after adjustment for relevant demographic factors, prognostic discussion, scan results, and physical well-being change. TIU change scores ranged from positive to negative, with some participants showing improvements in TIU ( n = 19), some showing decrements in TIU ( n = 14), and others showing stable TIU ( n = 54). Among patients with improved TIU, psychological well-being initially decreased, but subsequently recovered [7.03 (2.23) to 6.30 (1.80), to 7.63 (2.08)]; the stable TIU group showed relatively unchanged well-being [7.34 (2.37) to 7.45 (2.32), to 7.36 (2.66)], and the less accurate TIU group showed an initial improvement followed by a subsequent decline [6.30 (2.62) to 7.36 (2.04), to 5.63 (3.40)]. Conclusions: Improved TIU may be associated with initial decrements in psychological well-being, followed by patients rebounding to baseline levels. Concerns about psychological harm may not need to be a deterrent to having prognostic discussions with patients.

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