LIMITING CARE IN CRITICALLY ILL PATIENTS WITH MALIGNANCY: A REVIEW OF 150 CONSECUTIVE MORTALITIES

Abstract

PURPOSE: Describe differences in care between patients with hematologic or solid tumor malignancy who expired after admission to a Medical Intensive Care Unit (MICU) in an academic center. METHODS: All mortalities in the MICU at Rush University Medical Center over a 2 year period were reviewed. Data collected included: time of admission and death, therapies withheld or withdrawn at the end of life, and code status upon admission. RESULTS: A total of 150 patients with active malignances (84 with solid tumor and 66 with hematologic malignancy) expired in the MICU during the study period. Most (89.3%) patients admitted to the MICU were full code upon admission. Most patients who died (87.3%) had their care limited or withdrawn. Hematologic malignancy patients were more likely to be full code upon MICU admission (OR 6.4, p = 0.007), have a longer MICU median length of stay in hours (101.5 vs. 71.5 p = 0.047), and be terminally extubated (OR 7.73, p = 0.009) than were solid malignancy patients. CONCLUSION: The vast majority of cancer patients who died in the MICU were full code on admission. Patients with hematologic malignancies were more likely to be full code on admission, supported for a longer time, and more likely to undergo terminal extubation than patients with solid malignancies. CLINICAL IMPLICATIONS: Advance directives with cancer patients should be addressed earlier during the course of their illness. It appears patients with hematologic malignancies requiring ICU care were treated more aggressively both prior to transfer (full code status) and in the MICU (longer time of support before death). However once the decision was made to withdraw care, life sustaining therapies were more aggressively withdrawn (higher rate of terminal extubation). This may reflect practice differences between oncologists and hematologists. These findings may be useful in addressing medical care both before transfer and anticipating medical practice after transfer. Although curative treatment of cancer is often the primary goal of the patient and treating physician, there may be an opportunity to discuss transition to palliative care earlier.