Can We Justify ICU Refusal for Cancer Patients ?

1. 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

2. 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.

3. 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)

4. SCCM pejorative diagnoses JAMA 1994;271:1200-1203 Crit Care Med 1994;22:358-62

5. Recommendations JAMA 1994;271:1200-1203 Crit Care Med 1994;22:358-62

6. Compliance with Triage-to-ICU Recommendations Number of recommendations observed 20 16 P=0.0003 12 Admission denied after patient examination A Admission denied over the phone 8 4 26 French ICUs 283 denied admissions - age > 65 y - poor chronic health status - chronic severe respiratory and heart failure - metastatic disease without hope of remission - admission diagnosis 0 Number of recommendations observed 20 P<0.0001 16 12 Beds available B Full unit 8 4 0 Azoulay E. et al. Crit Care Med 2001; In press Sprung CL, Crit Care Med 27:1073-9, 1999

7. Cancer patients • 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. • “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;3:656-662

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

9. Overall CICP Authors N % deaths Neutropenia Remission MV Renal Coma Score BMT Shock Liver MOF Lloyd-T 60 78.3 + + . . . + . . . . . . + . . . . + Schuster 77 100 . . . . . . . + . . + Brunet 260 57 . . + + + + . + . + . Groeger 1713 42 . Ashkenazi 29 69 . + . . . . . . . . . + . . . + . . + Headley 52 42

10. Mechanical Ventilation

11. Mechanical Ventilation + BMT

12. Medical Futility Schneiderman Ann Intern Med 1990;112:949-54 «...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»

13. End-Of-Life Decisions • Carlon GC. Crit Care Med. 1989;17:106-7 Just Say No … • Schuster D.P. Am Rev Respir Dis 1992;145:508-9 Everything that should be done--not everything that can be done. • G.D. Rubenfeld Ann Intern Med 1996;125;625-30 Withdrawing Life Support from Mechanically Ventilated Recipients of Bone Marrow Transplants • F Brunet Intensive Care Medicine 1990;16:291-7 Is ICU Justified for patients with Hematological Malignancies?

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

15. Recent changes in prognosis

16. Saint-Louis 12-bed ICU 1993-1999: all patients Number of patients % deaths 700 30 600 25 500 20 400 15 300 10 200 5 100 0 0 1993 1994 1995 1996 1997 1998 1999

17. Saint-Louis 12-beds ICU 1990-1999: CICPs % deaths Number of patients 100 1 80 0.8 0.6 60 40 0.4 20 0.2 0 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Year of ICU admission

18. 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

19. Patient Selection (1) 1992-1995 1996-1998 P Myeloma patients n=41 (%) n=34 (%) Knaus scale C or D 26 (66.5) 13 (38.2) 0.02 Stage III disease 34 (83) 21 (62) 0.03 SAPS II score at admission 54 (38-70) 64 (43-82) 0.05 Need for : Dialysis 9 (22) 15 (44) 0.04 NIMV 2 (5) 7 (20.6) 0.03 30-day mortality 31 (75.6) 12 (35) 0.0008 Changing Use of ICU for Hematological Patients Azoulay et al. Intensive Care Medicine 1999;25:1395-1401

20. Patient Selection (2) MV patients Azoulay et al. Crit Care Med 2001;29:519-525

21. 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

22. Cumulative Survival 1.00 Neutropenia .80 .60 .40 N S .20 0.00 0.00 5.00 10.00 15.00 20.00 25.00 30.00 Cumulative Survival 1.00 Autologous BMT .80 .60 .40 N S .20 0.00 0.00 5.00 10.00 15.00 20.00 25.00 30.00 Time (days) from admission Neutropenia and BMT

23. Neutropenia

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

25. 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

26. 1 ,8 Noninvasive mechanical ventilation ,6 ,4 Conventional mechanical ventilation ,2 0 0 5 10 15 20 25 30 Time (days) from admission Survival in two matched groups of 48 patients treated with and without NIMV Cumulative survival Crude mortality 21/48 (43.7%) 34/48 (70.8%) ARR: 0.27 (0.08-0.46) NNT: 4 (2-12) Azoulay et al. Crit Care Med 2001;29:519-525

27. Hilbert et al. N Engl J Med 2001 15;344:481-487

28. Acute Renal Failure and dialysis Cumulative Survival 1.00 .80 Dialysis .60 .40 N S .20 0.00 0.00 5.00 10.00 15.00 20.00 25.00 30.00 Time (days) from admission

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

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

31. 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;355:2112-8 • 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

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

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

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