Analysis of causes of rejection of admission to the ICU of cancer patients

doi:10.15406/mojs.2023.11.00244

MOJ

eISSN: 2379-6162

Surgery

Mini Review Volume 11 Issue 3

Analysis of causes of rejection of admission to the ICU of cancer patients

Elena Cuenca Fito,¹

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Alejandro González Castro,² Inés Gómez Acebo,³ Noemí Vidal Vides¹

¹Intensive Care Medicine Service, University Hospital of A Coruña, Spain
²Department of Intensive Care Medicine Marqués de Valdecilla University Hospital, Spain
³Department of Medical and Surgical Sciences University of Cantabria, Santander, Spain

Correspondence:

Received: November 17, 2023 | Published: December 4, 2023

Citation: Fito EC, Castro AG, Acebo IG, et al. Analysis of causes of rejection of admission to the ICU of cancer patients. MOJ Surg. 2023;11(3):154-156. DOI: 10.15406/mojs.2023.11.00244

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Abstract

Introduction: Nowadays, there is a trend towards an "improved prognosis" in oncologic patients requiring intensive care. The limitation of admission to the ICU of oncological patients may be based on the consideration that in this particular situation, it may involve more suffering than benefit for the patient. The main objective of the study was to analyze the causes of refusal of admission to the ICU of patients with solid organ tumors in a tertiary hospital.

Materials and methods: We conducted a prospective study of patients with a diagnosis of solid organ tumor evaluated by the Intensive Care Medicine Department when suffering an acute event. A total of 215 patients were recruited, of whom 73 were admitted to the ICU and 42 were refused admission. The different causes of refusal of admission to the ICU were analyzed in these patients.

Results: The most frequent reason for refusing admission to the ICU was poor quality of life (90.48%, n=38), followed by considering ICU treatment futile (73.81%, n=31). In 78.57% (n=33) of the cases there was no disagreement with the consulting physician on the decision taken by the ICU team.

Conclusions: The most frequent cause of rejection in the ICU in our series of oncologic patients has been poor estimated quality of life. Age by itself has not been a frequent reason for rejecting such patients.

Keywords: ICU, oncology, urgent admission

Introduction

Today, there is a trend towards an "improved prognosis" in oncology patients requiring intensive care in the ICU, with a significant reduction in mortality rates.¹ One of the factors that has contributed to this improvement is early admission to the ICU, which has been identified as an independent factor influencing survival.²

The limitation of admission to the ICU for oncology patients may be based on the consideration that in this specific situation, it may involve more suffering than benefit for the patient.³

As Lecuyer and colleagues point out in their paper, taking a systematic approach of denying ICU admission to these patients would be simplistic. We conducted a prospective study of patients with a diagnosis of solid organ tumor evaluated by the Intensive Care Medicine Department when suffering an acute event. A total of 215 patients were recruited, of which 73 were admitted to the ICU and 42 were refused admission. The different causes of refusal of admission to the ICU were analyzed in these patients and are shown in Table 1.

Variable	Category	No ICU admission
Reason for not being admitted to the ICU, n(%)	Age	No	36(85,71)
		Yes	6(14,29)
	Severe chronic disease	No	24(57,14)
		Yes	18(42,86)
	Previous functional limitation	No	16(38,10)
		Yes	26(61,90)
	Estimated poor quality of life	No	4(9,52)
		Yes	38(90,48)
	Treatment futility	No	11(26,19)
		Yes	31(73,81)
	Living will	No	41(97,62)
		Yes	1(2,38)
	Patient refusal	No	40(95,24)
		Yes	2(4,76)
Patient informed, n(%)		Yes	40(95,24)
		Unknown	2(4,76)
Family is informed, n(%)		No	2(4,76)
		Yes	33(78,57)
		Unknown	7(16,67)
Recorded in the medical record, n(%)		No	4(9,52)
		Yes	38(90,48)
Disagreement with the consulting physician, n(%)		No	33(78,57)
		Yes	7(16,67)
		Unknown	2(4,76)

Table 1 Characteristics related to ICU admission refusal

The most frequent reason for refusing admission to the ICU was poor estimated quality of life (90.48%, n=38), followed by considering ICU treatment futile (73.81%, n=31), followed by a previous functional limitation in the patient 61.90% (n=26) and having a previous chronic disease 42.86% (n=18). As for age, 6 patients (14.29%) were not admitted for this reason. Only in 2.38% (n=1) was admission ruled out due to the patient's previous living will.

Regarding the communication of the decision, it was observed that in 95.24% (n=40) of the occasions the patients and in 78.57% (n=33) the families were informed about the decision not to be admitted to the ICU.

In 90.48% (n=38) of the cases the decision not to admit the patient to the ICU was recorded, while in 9.52% (n=4) the decision was not recorded. In 78.57% (n=33) of the cases there was no disagreement with the consulting physician on the decision taken by the ICU team.

Table 2 shows the relationship between the variables related to refusal of admission to the ICU and mortality at 3 months. We found that of all these variables, only the futility of treatment reached significant differences; in these patients there was a 9-fold greater probability of death at 3 months (OR=9.05 [95%CI= 1.41-58.17]). Although the results are not statistically significant, higher mortality was also observed in those where the cause of refusal of admission to the ICU was considered to be poor quality of life (p=0.09). The same occurred when we found disagreement with the consulting physician (p=0.06).

Variable

Category

a/n

Reason for not being
admitted to the ICU,
n(%)

Age

Yes

71/173
5/6

1(ref.) 0.73 (0.05-10.40)

.0,816

Severe chronic disease

Yes

14/18

0.88 (0.16-4.85)

0,884

Estimated poor quality of life

Yes

23/26

4.12 (0.67-25.31)

0,126

Previous functional
limitation

Yes

31/38

7.70 (0.71-83.24)

0,093

Treatment futility

Yes

27/31

9.05 (1.41-58.17)

0,020

Living will

Yes

1/1

1.00 (1.00-1.00)

Patient refusal

Yes

2/2

1.00 (1.00-1.00)

Patient informed, n(%)

Yes

33/40

1(ref.)

Family is informed, n(%)

Yes

28/33

1.75 (0.05-58.38)

0,753

Recorded in the medical record, n(%)

Yes

31/38

3.67 (0.29-46.29)

0,315

Disagreement with family, n(%)

29/34

1(ref.)

Unknown

8-Apr

0.23 (0.04-1.34)

0,101

Disagreement with the consulting n(%)

29/33

1(ref.)

Yes

4/7

0.12 (0.01-1.09)

0,060

Unknown

0/2

1.00 (1.00-1.00)

Table 2 Relationship between variables related to ICU admission refusal and 3-month mortality

Multiple factors should be considered when deciding whether or not to admit cancer patients to the ICU.⁴ Guidelines for the admission of cancer patients to the ICU should be based on shared decisions between oncologists and intensive care specialists, thus ensuring a complete and adequate evaluation of each case. As Joynt et al. describe in their paper, refusal of ICU admission is a frequent situation and depends on multiple factors including age, mortality probability scales and the availability of ICU beds.⁵

Multicenter studies are needed to help identify predictors of death in this group of patients. Soares et al propose the ASSESS approach, a five-step framework for the comprehensive assessment of ICU cancer patients. These factors encompass the selection criteria for ICU admission, the medical condition at the time of ICU admission, the typology of life-sustaining treatments required, and the degree of organ dysfunction at admission. They also encompass overall long-term and disease-free survival and quality of life.⁶

Communication with the patient and family is a crucial part of the process, the role of the intensivist is to provide both the highest quality clinical care and appropriate advice to the patient and their loved ones regarding prognosis, treatment options and preferences.⁷

Conclusion

In conclusion, in our study the most frequent cause of rejection in the ICU in our series of oncologic patients was poor quality of life. Age by itself has not been a frequent reason for rejecting these patients. We should avoid lumping all cancer patients into the same group and should adopt a multidisciplinary and personalized approach.