Can We Justify ICU Refusal for Cancer Patients ? Elie AZOULAY, MD Medical ICU, Saint Louis Teaching Hospital Paris, France 14th ESICM Annual Congress Geneva, Switzerland 30 Sept-3 Oct 2001

Triage decisions to ICU When evaluating a patient with a severe acute illness, the ICU physician must determine: (i) the diagnosis, prognosis, and treatment (ii) whether or not ICU admission is warranted (iii) and if it is, whether the patient, if competent, consents to ICU admission.

Triage decisions to ICU The answer to the second question is a daily dilemma for ICU physicians. Its determinants have been reported as related to: (i) the number of beds available in the ICU (ii) patient characteristics and comorbidities (iii) and the characteristics of the acute illness (severity, reversibility, and predicted residuals and quality of life after ICU discharge)

SCCM pejorative diagnoses JAMA 1994;271: Crit Care Med 1994;22:358-62

Recommendations JAMA 1994;271: Crit Care Med 1994;22:358-62

Cancer patients u ICU physicians are often reluctant to admit cancer patients because they require: –a large amount of work –costly resources –in-depth knowledge of hematology by the ICU staff for little gain, since their outcome is frequently unfavorable. for little gain, since their outcome is frequently unfavorable. u “Only cancer patients with a chance of being cured, who agree to undergo supportive therapy, and those with best chances of benefiting from intensive care should be admitted by priority”. Sculier Curr Opin Oncol 1991;3:

Prognosis of Critically Ill Cancer Patients (CICP) From 1980 to 1995: The Collegial Break-Down

Overall CICP AuthorsN% deaths NeutropeniaRemissionMVRenalComaScoreBMTShockLiverMOF Lloyd-T Schuster Brunet Groeger Ashkenazi Headley

Mechanical Ventilation

Mechanical Ventilation + BMT

Medical Futility Schneiderman Ann Intern Med 1990;112: «...when physicians conclude (either through personal experience, experiences shared with colleagues, or published empirical data) that in the last 100 cases a medical treatment has been useless, they should regard that treatment as futile...physicians are entitled to withhold a procedure on this basis...and need not obtain consent from patients or family members»

End-Of-Life Decisions â Carlon GC. Crit Care Med. 1989;17:106-7 Just Say No … â Schuster D.P. Am Rev Respir Dis 1992;145:508-9 Everything that should be done--not everything that can be done. â G.D. Rubenfeld Ann Intern Med 1996;125; Withdrawing Life Support from Mechanically Ventilated Recipients of Bone Marrow Transplants â F Brunet Intensive Care Medicine 1990;16:291-7 Is ICU Justified for patients with Hematological Malignancies?

Can We Justify ICU Refusal for Cancer Patients ? Yes, Of Course...

Recent changes in prognosis

Saint-Louis 12-bed ICU : all patients Number of patients % deaths

Year of ICU admission Number of patients Saint-Louis 12-beds ICU : CICPs

Targets of Improvements ¬ Upstream triage of cancer patients ­ Improvement of hematological and oncological management: –BMT –Neutropenia ® Improvement of ICU management: –Noninvasive mechanical ventilation –G-CSF? –Dialysis

Patient Selection (1) n=41 (%) n=34 (%) P Knaus scale C or D Stage III disease 26 (66.5) 34 (83) 13 (38.2) 21 (62) SAPS II score at admission 54 (38-70) 64 (43-82) 0.05 Need for : Dialysis NIMV 9 (22) 2 (5) 15 (44) 7 (20.6) day mortality 31 (75.6) 12 (35) Changing Use of ICU for Hematological Patients Azoulay et al. Intensive Care Medicine 1999;25: Myeloma patients

Patient Selection (2) MV patients Azoulay et al. Crit Care Med 2001;29:

Targets for Improvements ¬ Upstream triage of cancer patients ­ Improvement of hematological and oncological management: –BMT –G-CSF? –Neutropenia ® Improvement of ICU management: –Noninvasive mechanical ventilation –Dialysis

Neutropenia and BMT Neutropenia Autologous BMT N S Cumulative Survival Time (days) from admission

Neutropenia

Effect of G-CSF on neutropenia duration Darmon M et al. Submitted ICU admission may be helpful even if prolonged neutropenia is expected...

Targets for Improvements ¬ Upstream triage of cancer patients ­ Improvement of hematological and oncological management: –BMT –G-CSF? –Neutropenia ® Improvement of ICU management: –Noninvasive mechanical ventilation –Dialysis

Survival in two matched groups of 48 patients treated with and without NIMV Cumulative survival 21/48 (43.7%) 34/48 (70.8%) Crude mortality ARR: 0.27 ( ) NNT: 4 (2-12) Azoulay et al. Crit Care Med 2001;29:

Hilbert et al. N Engl J Med ;344:

Acute Renal Failure and dialysis Dialysis N S Cumulative Survival Time (days) from admission

Can We Justify ICU Refusal for Cancer Patients ? Yes … But,

Conclusion : Patient selection, not routine denial u Cancer patients are a heterogeneous group. u Improvements in both intensive care and oncohematological management have stripped classic predictors of ICU mortality of much of their value. u Allo-BMT patients remain poor candidates for ICU admission, above all when they need intensive management

The doctrine of ‘double effect’ in triage ? –Opening widely the filter for ICU admission may avoid depriving patients from a chance to recover, but may allow physicians to perform more end-of-life decisions Cuttini M, Lancet. 2000;355: –Do we have (need) more beds to admit everyone for a selected period to better estimate the reversibility of the disease, or should we only take into account malignancy and comorbidities? We above all need to clear a double talk Sulmasy DP, Arch Intern Med 1999;159:545-50

Everything that should be done... u When patients, oncohematologists and ICU physicians feel that ICU admission is reasonable, all potentially effective treatment methods should be used in the ICU. u Triage to the ICU using a multiplidiscinary method should place CICPs on the same level of priority as any other patient with other comorbidities

Is ICU selection by intensivists still a dilemma for cancer patients ? Patients and family members Hematologists and oncologists ICUphysicians ICU ADMISSION? Multiple step selection … Are guidelines necessary? For whom? Studies are ongoing... Social context Social context

Need for Guidelines? u Guidelines are important because they offer a basis for discussion. u However, doctors need to know when they should transgress guidelines.