Advance care planning and terminal intensive care unit admissions for cancer patients: We can do better.

Abstract

e23000 Background: Terminal oncology intensive care unit (ICU) admissions are associated with high healthcare costs and decreased quality of life. Chemotherapy can be given in non-curative settings to optimize symptom control, but use of it at the end of life does not improve longevity. In addition, goals of care are too often not addressed for patients at high risk of death. Methods: We carried out a retrospective review identifying patients of a large academic cancer center who were admitted to and expired in an ICU between January 1, 2017 to December 31, 2018. Results: 120 patients met inclusion criteria. Median age was 58 years. Only 15.0% (n = 18) of all patients had advance directives. The majority of patients (94.1%, n = 113) were FULL CODE on admission. Median duration of admission was 10 days. Median time to death from ICU admission was 7.5 days. 65.0% (n = 78) of all patients were intubated, while 15.0% (n = 15) received CPR. 58.3% (n = 70) of the study population had solid malignancies; of note, 97.1% (n = 68) of these patients were metastatic at presentation and had a median ECOG performance status of 2. Patients with metastatic solid tumors typically have a more indolent course of progression compared to patients with hematologic malignancies. However, only 23.5% (n = 16) had discussed goals of care or code status with their outpatient oncologists, despite many seeing them within the last month prior to admission (83.8%, n = 57). Similarly, only 4.0% (n = 2) of patients with hematologic malignancies had advance care planning discussions with their oncologists prior to their terminal ICU admission. 27.5% (n = 33) of all patients had an inpatient palliative care consult. The inpatient pulmonary/critical care team had a high rate of inpatient code status transitions, with 85.6% (n = 97) of FULL CODE admissions transitioning to DNR/DNI. Conclusions: These findings reflect contemporary practice at a major academic cancer center. Despite most patients having regular contact with their outpatient oncologists, the intensity of health care utilization noted highlights a need to optimize recognition of patients at high risk of death and to engage patients in advance care planning discussions to avoid terminal ICU admissions.