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Differences in Utilization of Life Support and End-of-Life Care for Medical ICU Patients With Versus Without Cancer

Koff, Geoffrey MD1; Vaid, Urvashi MD, MS, FACP2; Len, Edward MD3; Crawford, Albert PhD, MBA, MSIS4; Oxman, David A. MD, FACP2

doi: 10.1097/CCM.0000000000002260
Online Clinical Investigations
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Objectives: To explore differences in the utilization of life support and end-of-life care between patients dying in the medical ICU with cancer compared with those without cancer.

Design: Retrospective review of 403 deaths or hospice transfers in the medical ICU from January 1, 2012, to June 30, 2013.

Setting: Urban tertiary care university hospital.

Patients: Consecutive medical ICU deaths or hospice transfers over an 18-month period.

Interventions: None.

Measurements and Main Results: One hundred eighty-two patients (45%) had a diagnosis of active cancer and 221 (55%) did not. Despite similar severity of illness, there were significant differences in the use of life support and end-of-life care. Patients without cancer had longer medical ICU length of stay (median, 5 vs 4 d; p = 0.0495), used mechanical ventilation more often and for longer (83.7% vs 70.9%, p = 0.002; 4 vs 3 d, p = 0.017), and initiated dialysis more frequently (26.7% vs 14.8%; p = 0.0038). Patients without active cancer had family meetings later (median, 3 vs 2 d; p = 0.001), less frequent palliative care consultation (17.6% vs 32.4%; p = 0.0006), and took longer to transition to do not resuscitate or comfort care (median, 4 vs 3 d; p = 0.048).

Conclusions: Among patients dying in the medical ICU, the diagnosis of active cancer influences the intensity of life support utilization and the quality of end-of-life care. Patients with active cancer use less life support and may receive better end-of-life care than similar patients without cancer. These differences are likely due to biases or misunderstandings about the trajectory of advanced nonmalignant disease among patients, families, and perhaps providers.

1Division of Pulmonary & Critical Care Medicine, Department of Medicine, Crozer-Chester Medical Center, Chester, PA.

2Division of Pulmonary and Critical Care Medicine, Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA.

3Division of Pulmonary & Critical Care Medicine, Department of Medicine, Rutgers/Robert Wood Johnson Medical Center, New Brunswick, NJ.

4Division of Pulmonary & Critical Care Medicine, Department of Medicine, College of Population Health, Thomas Jefferson University, Philadelphia, PA.

This work was performed at Thomas Jefferson University Hospital.

The authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: David Oxman, MD, FACP, Division of Pulmonary and Critical Care Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, E-mail: david.oxman@jefferson.edu

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