Managing expectations before the cancer intensive care unit.

Abstract

Sir: The last decade has seen major advances in both the surgical and medical approaches to cancer. This, combined with the advent of new medical technologies has markedly affected the oncologist's attitude towards cancer patients. Where once optimism was reserved for only a select few, now it is offered perhaps more often than it should be. This untempered enthusiasm can lead to unrealistic patient and family expectations and cause difficulties later on in the Intensive Care Unit (ICU). This imbalance of family and patient expectations versus medical reality can be most acutely felt when the issue of a Do Not Resuscitate (DNR) order is breached. The oncologist is justifiably buoyed by the recent advances in chemotherapy, radiation therapy, and more aggressive surgical approaches. However, the transference of that enthusiasm can often cause problems later on as the patient ultimately deteriorates to an ICU setting. The intensivist can face poorly managed family and patient expectations which can lead to a delay in obtaining a DNR order when the appropriate time has come. This can place the intensivist in the uncomfortable position of deciding whether to withhold costly medical interventions, at the end of life, which ultimately will not affect patient outcome. Managing patient and family expectations from the beginning, by guiding them through all of the possible stages of the disease process, makes logical sense both ethically, economically, and legally. A wellinformed family who knows the expected course of the disease process is far less likely to sue later for a perceived bad outcome. In some instances the ICU is the place where the family ultimately gains an acceptance of the patient's terminal condition. Unfortunately, the intensivist is often called upon to treat and manage a terminal condition aggressively with invasive monitors, ventilator therapy, and ionotropic drugs only to withdraw support abruptly once an acceptance of futility is reached. In this instance the ICU is unintentionally used to facilitate a DNR status, by demonstrating the medical futility of the situation through the show of intensive care measures. Intensivists are caught in the ethical, medical, and legal dilemma of whether to use inotropic drugs in such situations, while at the same time the nursing team becomes frustrated and confused as to the true status of the patient. The ICU is then transformed into a high-priced hospice, which can lead to disillusionment on the part of the entire ICU team. Managing patient and family expectations through early preparation and discussion of the entire possible disease course is recommended to avoid problems with DNR status when the patient ultimately ends up in the ICU. Well managed expectations will result in conservation of scarce ICU resources, improved physician-family relations, reduced stress on the ICU care team, and a more ethically and legally sound basis for removal of care in terminal situations.