Team Approach Lowers ICU Care for Terminal Cancer

Roxanne Nelson

November 27, 2012

A pain-and-palliative-care-team approach can help decrease the use of intensive care services for cancer patients nearing the end of their lives, according to a new study.

A comprehensive approach to palliative care, with regular feedback for providers, reduced intensive care unit (ICU) utilization during patients' terminal hospitalizations, commented lead author Allen Ray Sing Chen, MD, PhD, MHS, associate professor of oncology and pediatrics at Johns Hopkins University, Baltimore, Maryland. "More patients chose to avoid resuscitation, fewer patients died after prolonged ventilation, and survival to discharge did not change."

Dr. Chen presented the findings of his study at a press briefing held ahead of the 2012 Quality Care Symposium, which will take place November 30 through December 1 in San Diego, California.

"Advanced life support and care are essential for patients undergoing treatment with curative intent [but] are much less likely to help patients in terminal stages, and we wondered if we can help patients make important decisions about levels of care," Dr. Chen said.

Because the use of intensive care services does not improve outcomes in patients with terminal disease, the cancer center at John Hopkins established the Harry J. Duffey Family Pain and Palliative Care Program in 2007, he explained, and one important goal was to help physicians improve communication with patients about end-of-life issues.

The multidisciplinary team comprises 2 nurses, a social worker, a palliative care physician, a pharmacist, a nutritionist, and a chaplain, and provides inpatient consultation clinic, didactic sessions, and support for family meetings to discuss and document goals of care.

In addition, Johns Hopkins also provides education on palliative care for medical students and residents and consultation services for the faculty.

Services Reduced

Dr. Chen and colleagues hypothesized that if this effort were effective, the result would be a reduction in the use of ICU services in patients who die in their center. They studied trends for 4 years, from January 2008 through December 2011, and all deaths were tabulated with their code status and presented at the morbidity and mortality review held twice per quarter.

The use of ICU services was identified from billing data and confirmed by chart review, and ICU patient survival to hospital discharge was tracked on the safety dashboard.

During the study period, 525 oncology patients died while hospitalized in the cancer center. Among those who died, the authors noted a gradual increase in no-code status, the election of comfort care, or withdrawal of ICU support, from 81% to 95% (odds ratio 1.14 per quarter, P < .0001). "And this was highly significant," Dr. Chen said.

The number of patients who received long courses of mechanical ventilation (more than 14 days) decreased from about 10% to 5% and that was highly significant (P < .05), he pointed out. There was no decrease in the survival-to-discharge rate among patients who received ICU care.

Dr. Chen explained that the cost implications have not yet been studied, although that is in the works. But without a doubt, reducing ICU services will decrease costs. "There is no doubt that ICU management is among the most expensive care we can provide and figures run several thousand a day," he said.

He noted that their team has also identified factors that are predictive of the need for critical care, and "now the objective is to facilitate the discussion" about this, and those objectives are under way.

This study shows that support can be provided to patients and families to help them avoid invasive and futile care at end of life, commented Jyoti Patel, MD, American Society of Clinical Oncology Cancer Communications Committee member, who moderated the briefing.

"This study has implications [for] patients and their families and it is also important for physicians," said Dr. Patel, who is an oncologist on the medical staff at Northwestern Memorial Hospital, Chicago, Illinois, and is the director of the Aerodigestive Malignancy program of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. "This can decrease [these] high resource maneuvers that do not improve quality of life."

2012 Quality Care Symposium: Abstract 1. To be presented November 30, 2012.