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Toffart AC, Gonzalez F, Pierret T, Gobbini E, Terzi N, Moro-Sibilot D, Darrason M. Quels malades peuvent et doivent aller en réanimation ? Revue des Maladies Respiratoires Actualités 2021; 13:2S244-2S251. [PMID: 34659596 PMCID: PMC8512108 DOI: 10.1016/s1877-1203(21)00116-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- A.-C. Toffart
- UM Oncologie Thoracique, Service Hospitalo-Universitaire de Pneumologie et Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
- Université Grenoble 1 U 823-Institut pour l’Avancée des Biosciences-Université Grenoble Alpes, Grenoble, France
- Auteur correspondant. Adresse e-mail : (A.-C. Toffart)
| | - F. Gonzalez
- Unité de réanimation, Département Anesthésie-Réanimation, Institut Paoli Calmettes, Marseille, France
| | - T. Pierret
- UM Oncologie Thoracique, Service Hospitalo-Universitaire de Pneumologie et Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - E. Gobbini
- UM Oncologie Thoracique, Service Hospitalo-Universitaire de Pneumologie et Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - N. Terzi
- UM Médecine Intensive Réanimation, Pôle Urgences Médecine Aiguë, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - D. Moro-Sibilot
- UM Oncologie Thoracique, Service Hospitalo-Universitaire de Pneumologie et Physiologie, Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
- Université Grenoble 1 U 823-Institut pour l’Avancée des Biosciences-Université Grenoble Alpes, Grenoble, France
| | - M. Darrason
- Service de Pneumologie aigue spécialisée et cancérologie thoracique, Centre Hospitalier Lyon Sud, Lyon, France
- Institut de Recherches Philosophiques de Lyon, Université Lyon 3, Lyon, France
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Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C, Slowther A. Developing an intervention around referral and admissions to intensive care: a mixed-methods study. Health Serv Deliv Res 2019. [DOI: 10.3310/hsdr07390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BackgroundIntensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.ResultsInfluences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.LimitationsLimitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.ConclusionsDecision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.Future workFurther research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.Study registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.
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Affiliation(s)
- Chris Bassford
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mandy Ryan
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nicolas Krucien
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Agnieszka Ignatowicz
- Warwick Medical School, University of Warwick, Coventry, UK
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nadine Flowers
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Zoe Fritz
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Gavin Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sarah Quinton
- Warwick Medical School, University of Warwick, Coventry, UK
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Huayi Huang
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Turner
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mike Brooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aimee McCreedy
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Caroline Blake
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Slowther
- Warwick Medical School, University of Warwick, Coventry, UK
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Denis N, Timsit JF, Giaj Levra M, Sakhri L, Duruisseaux M, Schwebel C, Merle P, Pinsolle J, Ferrer L, Moro-Sibilot D, Toffart AC. Impact of systematic advanced care planning in lung cancer patients: A prospective study. Respir Med Res 2019; 77:11-17. [PMID: 31927479 DOI: 10.1016/j.resmer.2019.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/24/2019] [Accepted: 09/29/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND End-of-life (EOL) communication is crucial, particularly for cancer patients. While advanced care planning is still uncommon, we sought to investigate its impact on care intensity in case of organ failure in lung cancer patients. METHODS We prospectively included consecutive lung cancer patients hospitalised at the Grenoble University Hospital, France, between January 1, 2014 and March 31, 2016. Patients could be admitted several times and benefited from advanced care planning based on three care intensities: intensive care, maximal medical care, and exclusive palliative care. Patients' wishes were addressed. RESULTS Data of 739 hospitalisations concerning 482 patients were studied. During the three first admissions, 173 (25%) patients developed organ failure, with intensive care proposed to 56 (32%), maximal medical care to 104 (60%), and exclusive palliative care to 13 (8%). Median time to organ failure was 9 days [IQR 25%-75%: 3-13]. All patients benefited from care intensity that was either equal to or lower than the care proposed. Specific wishes were recorded for 158 (91%) patients, with a discussion about EOL conditions held in 116 (73%). CONCLUSIONS In case of organ failure, advanced care planning helps provide reasonable care intensity. The role of the patient's wishes as to the proposed care must be further investigated. CLINICAL TRIAL REGISTRATION The study was registered at www.ClinicalTrials.gov with the identifier NCT02852629.
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Affiliation(s)
- N Denis
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - J-F Timsit
- Department of medical and infectious resuscitation, hôpital Bichat Claude Bernard, 75018 Paris, France
| | - M Giaj Levra
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - L Sakhri
- Department of oncology, Institut Daniel Hollard, groupe hospitalier mutualiste, 38000 Grenoble, France
| | - M Duruisseaux
- Department of pneumology, hôpital Louis Pradel, Institut de Cancérologie des Hospices Civils de Lyon, 69500 Bron, France
| | - C Schwebel
- Pôle urgences médecine aiguë, department of intensive care and resuscitation, centre hospitalier universitaire Grenoble Alpes, 38000 Grenoble, France; Laboratoires des pharmaceutiques biocliniques U 1039, université Grenoble Alpes, 38700 La Tronche, France
| | - P Merle
- UMR Inserm 1240, department of pneumology, CHU G Montpied, 63000 Clermont-Ferrand, France
| | - J Pinsolle
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - L Ferrer
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - D Moro-Sibilot
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France; Inserm U 1209/CNRS UMR 5309, Centre de Recherche UGA, Institut pour l'Avancée des Biosciences, 38700 La Tronche, France
| | - A-C Toffart
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France; Inserm U 1209/CNRS UMR 5309, Centre de Recherche UGA, Institut pour l'Avancée des Biosciences, 38700 La Tronche, France.
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Collart C, Moro-Sibilot D, Maignan M, Schwebel C, Giaj Levra M, Ferrer L, Paquier C, Viglino D, Toffart AC. [Emergency room management of patients with lung cancer and organ failure]. Rev Mal Respir 2019; 36:672-678. [PMID: 31255316 DOI: 10.1016/j.rmr.2019.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 03/23/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND When patients with lung cancer present to the emergency department with organ failure the question of admission to intensive care has to be considered. Our aim is to describe the process leading to the proposed management. METHODS Retrospectively, all patients admitted to the emergency room between December 2010 and January 2015 with a diagnosis of ICD-10 C34.9 (lung cancer) were reviewed. Those with at least one organ failure were included. RESULTS The records of 561 patients were reviewed, 79 (14%) had at least one organ failure. The majority of these patients received maximal medical care (59%), 25% exclusive palliative care, and 15% intensive care. Performance status, metastatic status and efficacy of anti-tumor treatment were recorded in the emergency medical record in 20%, 66% and 74% of cases, respectively. An opinion was obtained from the oncologist in 44% of cases and from the intensivist in 41% of cases. No external advice was provided in 27% of cases. CONCLUSION In the majority of cases, the decision on the intensity of care to be provided to patients with lung cancer and organ failure was made in a collective manner.
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Affiliation(s)
- C Collart
- Service d'accueil des urgences, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - D Moro-Sibilot
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - M Maignan
- Service d'accueil des urgences, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France; Inserm U1042, laboratoire hypoxie physiopathologie, université Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - C Schwebel
- Clinique universitaire de médecine intensive et réanimation, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France; Inserm U1039, biocliniques radiopharmaceutiques, université Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - M Giaj Levra
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - L Ferrer
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - C Paquier
- Service d'accueil des urgences, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - D Viglino
- Service d'accueil des urgences, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France; Inserm U1042, laboratoire hypoxie physiopathologie, université Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - A-C Toffart
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble-Alpes, 38043 Grenoble cedex 9, France; Inserm U 1209, CNRS UMR 5309, centre de recherche UGA, institut pour l'avancée des biosciences, 38700 La Tronche, France.
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Gorham J, Ameye L, Paesmans M, Berghmans T, Sculier JP, Meert AP. [Lung cancer: Prognosis in intensive care depends mainly on the acute complication]. Rev Mal Respir 2019; 36:333-341. [PMID: 30898468 DOI: 10.1016/j.rmr.2018.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 05/14/2018] [Indexed: 11/17/2022]
Abstract
INTRODUCTION It has been demonstrated in unselected populations of cancer patients that prognosis in intensive care is essentially dependent on the extent of the acute physiological disturbance caused by the complication precipitating the admission. By contrast, the prognosis after hospital discharge remains dependent on the characteristics of the underlying neoplasm. The aim of our study was to confirm whether this general finding was the case in a specific population of lung cancer patients, since there are no data on this patient group in the literature. PATIENTS AND METHODS We conducted a retrospective study including all patients with lung cancer admitted to our ICU between September 1, 2008 and December 31, 2013. RESULTS During this period, 180 different patients with lung cancer were admitted into ICU. The simplified acute physiology score II (SAPS II) (OR 1.07 ; 95% CI 1.04-1.11), respiratory failure (OR 4.00; 95% CI 1.76-9.07) and the presence of therapeutic limitations were the 3 factors independently affecting hospital mortality in multivariate analysis. Considering only patients discharged alive from the hospital, the presence of metastases (HR 2.30; 95% CI 1.44-3.65) and limitations on therapy (HR 5,89; IC 95% 3,11-11,14) were the two statistically independent prognostic factors for overall survival. CONCLUSION In this population of lung cancer patients admitted into ICU, independent predictors of hospital mortality are determined by the physiological perturbations induced by the acute presenting complication. After recovery from this, prognosis is again determined by the characteristics of the underlying cancer.
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Affiliation(s)
- J Gorham
- Service des soins intensifs et urgences oncologiques & oncologie thoracique, Institut Jules-Bordet, rue Héger Bordet, 1000 Bruxelles, Belgique.
| | - L Ameye
- Data Centre, Institut Jules-Bordet, rue Héger-Bordet, 1000 Bruxelles, Belgique
| | - M Paesmans
- Data Centre, Institut Jules-Bordet, rue Héger-Bordet, 1000 Bruxelles, Belgique
| | - T Berghmans
- Service des soins intensifs et urgences oncologiques & oncologie thoracique, Institut Jules-Bordet, rue Héger Bordet, 1000 Bruxelles, Belgique
| | - J-P Sculier
- Service des soins intensifs et urgences oncologiques & oncologie thoracique, Institut Jules-Bordet, rue Héger Bordet, 1000 Bruxelles, Belgique
| | - A-P Meert
- Service des soins intensifs et urgences oncologiques & oncologie thoracique, Institut Jules-Bordet, rue Héger Bordet, 1000 Bruxelles, Belgique
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Song JH, Kim S, Lee HW, Lee YJ, Kim MJ, Park JS, Kim YJ, Yoon HI, Lee JH, Lee JS, Lee CT, Cho YJ. Effect of intensivist involvement on clinical outcomes in patients with advanced lung cancer admitted to the intensive care unit. PLoS One 2019; 14:e0210951. [PMID: 30759088 PMCID: PMC6373899 DOI: 10.1371/journal.pone.0210951] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/06/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose Intensive care unit (ICU)-related mortality for lung cancer is ranked highest among the solid tumors and little information exists on the role of intensivists on clinical outcomes. This study aimed to elucidate the intensivist’s contribution toward clinical outcomes. Materials and methods Data of advanced lung cancer patients, including stage IIIB or IV non-small cell lung cancer and extensive-stage small cell lung cancer, admitted to the ICU from 2005 to 2016 were analyzed. Multivariate logistic regression was performed to determine variables associated with ICU and in-hospital mortality. Autoregressive integrated moving average (ARIMA) for time-series was used to assess the intensivist’s impact. Results Of 264 patients, 85 (32.2%) were admitted to the ICU before and 179 (67.8%) after organized intensive care introduction in 2011. Before and after 2011, the changes observed were as follows: ICU mortality rate, 43.5% to 40.2%, respectively (p = 0.610); hospital mortality rate, 82.4% to 65. 9% (p = 0.006). The duration of ICU and hospital stay decreased after 2011 (14.5±16.5 vs. 8.3 ± 8.6, p < 0.001; 36.6 ± 37.2 vs. 22.0 ± 19.6, p < 0.001). On multivariate analysis, admission after 2011 was independently associated with decreased hospital mortality (Odds ratio 0.42, 95% confidence interval 0.21–0.77, p = 0.006). In ARIMA models, intensivist involvement was associated with significantly reduced hospital mortality. (Estimate -17.95, standard error 5.31, p = 0.001) Conclusion In patients with advanced lung cancer, organized intensive care could contribute to improved clinical outcomes.
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Affiliation(s)
- Jin Hwa Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Ihwa-dong, Jongno-gu, Seoul, South Korea
| | - Sooyeon Kim
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
| | - Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Ihwa-dong, Jongno-gu, Seoul, South Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
| | - Mi-jung Kim
- Medical Oncology, International St. Mary's Hospital, College of Medicine, Catholic Kwandong University,Seo-gu, Incheon, South Korea
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
| | - Ho Il Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
| | - Jong Seok Lee
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
- * E-mail: ,
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Abstract
Decision-making by intensivists around accepting patients to intensive care units is a complex area, with often high-stakes, difficult, emotive decisions being made with limited patient information, high uncertainty about outcomes and extreme pressure to make these decisions quickly. This is exacerbated by a lack of clear guidelines to help guide this difficult decision-making process, with the onus largely relying on clinical experience and judgement. In addition to uncertainty compounding decision-making at the individual clinical level, it is further complicated at the multi-speciality level for the senior doctors and surgeons referring to intensive care units. This is a systematic review of the existing literature about this decision-making process and the factors that help guide these decisions on both sides of the intensive care unit admission dilemma. We found many studies exist assessing the patient factors correlated with intensive care unit admission decisions. Analysing these together suggests that factors consistently found to be correlated with a decision to admit or refuse a patient from intensive care unit are bed availability, severity of illness, initial ward or team referred from, patient choice, do not resuscitate status, age and functional baseline. Less research has been done on the decision-making process itself and the factors that are important to the accepting intensivists; however, similar themes are seen. Even less research exists on referral decision and demonstrates that in addition to the factors correlated with intensive care unit admission decisions, other wider variables are considered by the referring non-intensivists. No studies are available that investigate the decision-making process in referring non-intensivists or the mismatch of processes and pressure between the two sides of the intensive care unit referral dilemma.
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Affiliation(s)
- Fiona R James
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Nicola Power
- Department of Psychology, Lancaster University, UK
| | - Shondipon Laha
- Critical Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
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Zerbib Y, Rabbat A, Fartoukh M, Bigé N, Andréjak C, Mayaux J, De Prost N, Misset B, Lemiale V, Bruneel F, Maizel J, Ricome S, Jacobs F, Bornstain C, Dupont H, Baudin F, Azoulay E, Pène F; Groupe de Recherche sur la Réanimation Respiratoire en Onco-Hématologie (GRRR-OH). Urgent Chemotherapy for Life-Threatening Complications Related to Solid Neoplasms. Crit Care Med 2017; 45:e640-8. [PMID: 28398925 DOI: 10.1097/CCM.0000000000002331] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Solid neoplasms can be directly responsible for organ failures at the time of diagnosis or relapse. The management of such specific complications relies on urgent chemotherapy and eventual instrumental or surgical procedures, combined with advanced life support. We conducted a multicenter study to address the prognosis of this condition. DESIGN A multicenter retrospective (2001-2015) chart review. SETTING Medical and respiratory ICUs. PATIENTS Adult patients who received urgent chemotherapy in the ICU for organ failure related to solid neoplasms were included. The modalities of chemotherapy, requirements of adjuvant instrumental or surgical procedures, and organ supports were collected. Endpoints were short- and long-term survival rates. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred thirty-six patients were included. Lung cancer was the most common malignancy distributed into small cell lung cancer (n = 57) and non-small cell lung cancer (n = 33). The main reason for ICU admission was acute respiratory failure in 111 patients (81.6%), of whom 89 required invasive mechanical ventilation. Compression and tissue infiltration by tumor cells were the leading mechanisms resulting in organ involvement in 78 (57.4%) and 47 (34.6%) patients. The overall in-ICU, in-hospital, 6-month, and 1-year mortality rates were 37%, 58%, 74%, and 88%, respectively. Small cell lung cancer was identified as an independent predictor of hospital survival. However, this gain in survival was not sustained since the 1-year survival rates of small cell lung cancer, non-small cell lung cancer, and non-lung cancer patients all dropped below 20%. CONCLUSIONS Urgent chemotherapy along with aggressive management of organ failures in the ICU can be lifesaving in very selected cancer patients, most especially with small cell lung cancer, although the long-term survival is hardly sustainable.
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Meert AP, Grigoriu B, Licker M, Van Schil PE, Berghmans T. Intensive care in thoracic oncology. Eur Respir J 2017; 49:49/5/1602189. [DOI: 10.1183/13993003.02189-2016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/06/2017] [Indexed: 01/21/2023]
Abstract
The admission of lung cancer patients to intensive care is related to postprocedural/postoperative care and medical complications due to cancer or its treatment, but is also related to acute organ failure not directly related to cancer.Despite careful preoperative risk management and the use of modern surgical and anaesthetic techniques, thoracic surgery remains associated with high morbidity, related to the extent of resection and specific comorbidities. Fast-tracking processes with timely recognition and treatment of complications favourably influence patient outcome. Postoperative preventive and therapeutic management has to be carefully planned in order to reduce postoperative morbidity and mortality.For patients with severe complications, intensive care unit (ICU) mortality rate ranges from 13% to 47%, and hospital mortality ranges from 24% to 65%. Common predictors of in-hospital mortality are severity scores, number of failing organs, general condition, respiratory distress and the need for mechanical ventilation or vasopressors. When considering long-term survival after discharge, cancer-related parameters retain their prognostic value.Thoracic surgeons, anesthesiologists, pneumologists, intensivists and oncologists need to develop close and confident partnerships aimed at implementing evidence-based patient care, securing clinical pathways for patient management while promoting education, research and innovation. The final decision on admitting a patient with lung to the ICU should be taken in close partnership between this medical team and the patient and his or her relatives.
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Abstract
Advances in cancer treatment and patient survival are associated with increasing number of these patients requiring intensive care. Over the last 2 decades, there has been a steady improvement in the outcomes of critically ill patients with cancer. This review provides data on the use of the intensive care unit (ICU) and short and long-term outcomes of critically ill patients with cancer, the ICU system practices that influence patients outcomes, and the role of the different clinical variables in predicting the prognosis of these patients.
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Affiliation(s)
- Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R- 3 Hudson, Detroit, MI 48201, USA.
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Goldvaser H, Milman Y, Dujovni T, Stern A, Mahamid M, Hanovich E, Zivony A, Shochat T, Yerushalmi R, Gafter-Gvili A, Brenner B, Shepshelovich D. Perception of prognosis of cancer patients by non-oncologists. Int J Clin Pract 2016; 70:1027-1032. [PMID: 28032432 DOI: 10.1111/ijcp.12909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 10/07/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Data are lacking regarding the perception of cancer patients' prognosis by physicians who are not oncologists. METHODS This was a multicenter survey of seven university-affiliated hospitals, assessing physicians' perception of the median survival of patients with seven advanced malignancies. The study cohort included physicians from all 73 internal medicine, surgery, emergency medicine and critical care departments in the participating hospitals. Family practitioners were contacted through email. Physicians' specialty, age, professional status and hospital type (secondary vs tertiary) were noted. The primary end-point was defined as the percentage of answers with a pessimistic error of more than a year in perception of prognosis as compared with current literature. The secondary end-point was defined as any pessimistic answer. RESULTS Four hundred and eighty-eight physicians filled the questionnaire, including 429 hospital physicians and 59 family practitioners. Perception of prognosis was pessimistic when compared with current literature, with 37% and 59% of the answers meeting the primary and the secondary end-points, respectively. Younger age, resident status and work at a secondary hospital were associated with pessimistic perception (P<.001 for all variables). Pessimistic outlook was similar for all specialties and for most malignancies, including those with considerable cure rates such as Hodgkin's lymphoma and germ cell tumour. CONCLUSION Non-oncologists are considerably over pessimistic regarding their perception of the cancer patients' prognosis. A pessimistic perception of prognosis might cause undertreatment and therefore affect both patients' quality of life and their actual survival. Education regarding cancer therapy and its benefits should be emphasised for non-oncologists involved in cancer patient care.
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Affiliation(s)
- Hadar Goldvaser
- Davidoff Center, Rabin Medical Center, Institute of Oncology, Beilinson Hospital, Petach Tikva, Israel
| | - Yonatan Milman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Dujovni
- Pediatric Oncology Unit, Emek Medical Center, Afula, Israel
| | - Anat Stern
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | | | | | - Amir Zivony
- Department of Family Medicine, Rabin Medical Center, Petach Tikva, Israel
| | - Tzippy Shochat
- Statistical Consulting Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Rinat Yerushalmi
- Davidoff Center, Rabin Medical Center, Institute of Oncology, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Gafter-Gvili
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Medicine A, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Baruch Brenner
- Davidoff Center, Rabin Medical Center, Institute of Oncology, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Shepshelovich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Medicine A, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
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Fisher R, Dangoisse C, Crichton S, Whiteley C, Camporota L, Beale R, Ostermann M. Short-term and medium-term survival of critically ill patients with solid tumours admitted to the intensive care unit: a retrospective analysis. BMJ Open 2016; 6:e011363. [PMID: 27797987 PMCID: PMC5073479 DOI: 10.1136/bmjopen-2016-011363] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Patients with cancer frequently require unplanned admission to the intensive care unit (ICU). Our objectives were to assess hospital and 180-day mortality in patients with a non-haematological malignancy and unplanned ICU admission and to identify which factors present on admission were the best predictors of mortality. DESIGN Retrospective review of all patients with a diagnosis of solid tumours following unplanned admission to the ICU between 1 August 2008 and 31 July 2012. SETTING Single centre tertiary care hospital in London (UK). PARTICIPANTS 300 adult patients with non-haematological solid tumours requiring unplanned admission to the ICU. INTERVENTIONS None. PRIMARY AND SECONDARY OUTCOMES Hospital and 180-day survival. RESULTS 300 patients were admitted to the ICU (median age 66.5 years; 61.7% men). Survival to hospital discharge and 180 days were 69% and 47.8%, respectively. Greater number of failed organ systems on admission was associated with significantly worse hospital survival (p<0.001) but not with 180-day survival (p=0.24). In multivariate analysis, predictors of hospital mortality were the presence of metastases (OR 1.97, 95% CI 1.08 to 3.59), Acute Physiology and Chronic Health Evaluation II (APACHE II) Score (OR 1.07, 95% CI 1.01 to 1.13) and a Glasgow Coma Scale Score <7 on admission to ICU (OR 5.21, 95% CI 1.65 to 16.43). Predictors of worse 180-day survival were the presence of metastases (OR 2.82, 95% CI 1.57 to 5.06), APACHE II Score (OR 1.07, 95% CI 1.01 to 1.13) and sepsis (OR 1.92, 95% CI 1.09 to 3.38). CONCLUSIONS Short-term and medium-term survival in patients with solid tumours admitted to ICU is better than previously reported, suggesting that the presence of cancer alone should not be a barrier to ICU admission.
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Affiliation(s)
- Richard Fisher
- Department of Critical Care, King's College London, Guy's & St Thomas’ Hospital NHS Foundation Trust, London, UK
- Department of Critical Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Carole Dangoisse
- Department of Critical Care, King's College London, Guy's & St Thomas’ Hospital NHS Foundation Trust, London, UK
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Siobhan Crichton
- Division of Health and Social Care Research, King's College London, London, UK
| | - Craig Whiteley
- Department of Critical Care, King's College London, Guy's & St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Luigi Camporota
- Department of Critical Care, King's College London, Guy's & St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Richard Beale
- Department of Critical Care, King's College London, Guy's & St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas’ Hospital NHS Foundation Trust, London, UK
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13
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Sakhri L, Saint-Raymond C, Quetant S, Pison C, Lagrange E, Hamidfar Roy R, Janssens JP, Maindet-Dominici C, Garrouste-Orgeas M, Levy-Soussan M, Terzi N, Toffart AC. [Limitations of active therapeutic and palliative care in chronic respiratory disease]. Rev Mal Respir 2016; 34:102-120. [PMID: 27639947 DOI: 10.1016/j.rmr.2016.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 06/29/2016] [Indexed: 11/16/2022]
Abstract
The issue of intensive and palliative care in patients with chronic disease frequently arises. This review aims to describe the prognostic factors of chronic respiratory diseases in stable and in acute situations in order to improve the management of these complex situations. The various laws on patients' rights provide a legal framework and define the concept of unreasonable obstinacy. For patients with chronic obstructive pulmonary disease, the most robust decision factors are good knowledge of the respiratory disease, the comorbidities, the history of previous exacerbations and patient preferences. In the case of idiopathic pulmonary fibrosis, it is necessary to know if there is a prospect of transplantation and to assess the reversibility of the respiratory distress. In the case of amyotrophic lateral sclerosis, treatment decisions depend on the presence of advance directives about the use of intubation and tracheostomy. For lung cancer patients, general condition, cancer history and the tumor treatment plan are important factors. A multidisciplinary discussion that takes into account the patient's medical history, wishes and the current state of knowledge permits the taking of a coherent decision.
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Affiliation(s)
- L Sakhri
- Institut de cancérologie Daniel-Hollard, groupe hospitalier Mutualiste, 38000 Grenoble, France
| | - C Saint-Raymond
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble, 38000 Grenoble, France
| | - S Quetant
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble, 38000 Grenoble, France
| | - C Pison
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble, 38000 Grenoble, France; Laboratoire de bioénergétique fondamentale et appliquée, Inserm 1055, 38400 Saint-Martin-d'Hères, France; Université Grenoble Alpes, 38400 Saint-Martin-d'Hères, France
| | - E Lagrange
- Pôle psychiatrie, neurologie et rééducation neurologique, clinique de neurologie, CHU de Grenoble, 38000 Grenoble, France
| | - R Hamidfar Roy
- Pôle urgences médecine aiguë, clinique de réanimation médicale, CHU de Grenoble, 38000 Grenoble, France
| | - J-P Janssens
- Service de pneumologie, hôpital Cantonal universitaire, Genève, Suisse
| | - C Maindet-Dominici
- Pôle anesthésie réanimation, centre de la douleur, CHU de Grenoble, 38000 Grenoble, France
| | - M Garrouste-Orgeas
- Service de médecine intensive et de réanimation, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France
| | - M Levy-Soussan
- Unité mobile d'accompagnement et de soins palliatifs, hôpital universitaire Pitié-Salpêtrière, 75006 Paris, France
| | - N Terzi
- Université Grenoble Alpes, 38400 Saint-Martin-d'Hères, France; Pôle psychiatrie, neurologie et rééducation neurologique, clinique de neurologie, CHU de Grenoble, 38000 Grenoble, France; Inserm U1042, université Grenoble Alpes, HP2, CHU de Grenoble, 38000 Grenoble, France
| | - A-C Toffart
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble, 38000 Grenoble, France; Université Grenoble Alpes, 38400 Saint-Martin-d'Hères, France; Institut pour l'avancée des biosciences, centre de recherche UGA, Inserm U 1209, CNRS UMR 5309, 38000 Grenoble, France.
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Klein KR, Burkle FM Jr, Swienton R, King RV, Lehman T, North CS. Qualitative Analysis of Surveyed Emergency Responders and the Identified Factors That Affect First Stage of Primary Triage Decision-Making of Mass Casualty Incidents. PLoS Curr 2016; 8:ecurrents. [PMID: 27651979 DOI: 10.1371/currents.dis.d69dafcfb3ad8be88b3e655bd38fba84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Introduction: After all large-scale disasters multiple papers are published describing the shortcomings of the triage methods utilized. This paper uses medical provider input to help describe attributes and patient characteristics that impact triage decisions. Methods: A survey distributed electronically to medical providers with and without disaster experience. Questions asked included what disaster experiences they had, and to rank six attributes in order of importance regarding triage. Results: 403 unique completed surveys were analyzed. 92% practiced a structural triage approach with the rest reporting they used “gestalt”.(gut feeling) Twelve per cent were identified as having placed patients in an expectant category during triage. Respiratory status, ability to speak, perfusion/pulse were all ranked in the top three. Gut feeling regardless of statistical analysis was fourth. Supplies were ranked in the top four when analyzed for those who had placed patients in the expectant category. Conclusion: Primary triage decisions in a mass casualty scenario are multifactorial and encompass patient mobility, life saving interventions, situational instincts, and logistics.
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Meert AP, Berghmans T, Sculier JP. Admitting lung cancer patients to intensive care for organ dysfunction: a complex decision process. Eur Respir J 2016; 45:308-9. [PMID: 25653261 DOI: 10.1183/09031936.00198714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Anne-Pascale Meert
- Service des Soins Intensifs et Urgences Oncologiques & Oncologie Thoracique, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Berghmans
- Service des Soins Intensifs et Urgences Oncologiques & Oncologie Thoracique, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Paul Sculier
- Service des Soins Intensifs et Urgences Oncologiques & Oncologie Thoracique, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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Toffart AC, Duruisseaux M, Sakhri L, Giaj Levra M, Moro-Sibilot D, Timsit JF. Indications de réanimation en oncologie thoracique. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/s1877-1203(16)30039-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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