In the ICU, Patient's Values and Wishes Must Be Considered

WASHINGTON--Many of the patients who will die of cancer this yearwill receive care in the nation's intensive care units. Despiteheralded advances in drug research and medical technology, fewerthan one fourth of cancer patients admitted to an ICU survivefor 6 months, Mark S. Gelder, MD, said at the American CancerSociety National Conference on Gynecologic Cancers.

"We must reevaluate the role of the ICU in cancer patients,"said Dr. Gelder, assistant professor of gynecologic oncology,University of Florida College of Medicine, Gainesville. "Traditionally,the approach in the ICU was to do everything possible for thepatient. Today, as costs rise and societal and personal viewschange, this attitude is under attack."

Physicians must understand not only the patient's medical statusbut also his or her values and wishes, and those of the family,he said. But determining the patient's prognosis and decidingon appropriate levels of care once a patient is assigned to anICU may present problems.

Simplistic standards like age won't do, Dr. Gelder said. "What'syour definition of age? Biological age or chronological age? Ageis not a single criterion. Severity of illness and comorbid conditionsare more important." In fact, he said, the best predictorfor survival is preadmission functional status. Eighty percentof those who return to independent living get back to the samelevel after their stay in the ICU.

Prognostic systems employing logistic regression modeling techniqueshave been used to estimate the risk of death of patients in theICU, Dr. Gelder said. Systems such as APACHE, SAPS, and MPM attemptto classify groups of patients based on the severity of illnessearly in their ICU stay. "All three systems give an accurateestimate of the number of patients expected to die in a group,but not which individual patients will die," he said. "There'snothing wrong with incorporating these systems into a patient'sevaluation, but the physician's assessment and prediction of outcomesis as good or better than any scoring system."

Dealing with choice of treatment in the ICU requires close patient/physiciancommunication, he said. The physician must help patient and familyhave a full understanding of the patient's condition, prognosis,comorbidity, and options.

Unfortunately, many physicians do not discuss options becausethey believe that patients or families don't want to face thesefacts, will think the physician has given up on the patient, orwill demand unlimited futile therapy.

But, Dr. Gelder pointed out, studies show that patients do wantto discuss their prognosis and take an active role in decidinglevels of care and resuscitation, and that physicians and familiesare poor predictors of a patient's desires.

"Unilateral physician decisions without the patient or surrogate'spermission are fraught with problems," he said, "butcan be avoided with realistic, compassionate communications withpatients, families, and surrogates. Discussing these issues priorto a time of crisis will make decisions easier for all."