Outcomes of ICU patients with and without perceptions of excessive care: a comparison between cancer and non-cancer patients

Dominique D Benoit,Erwin J O Kompanje,Andreas Hvarfner,Alexander Wilmer,Victoria Metaxa,Pieter Depuydt,Anne-Pascale Meert,An K L Reyners,Ruth Piers,Esther N Van Der Zee,Michael Darmon,Emma Uyttersprot,Jacques Devriendt,Elie Azoulay,Jan G Zijlstra,François Vincent,Katerina Rusinova,Dimitrios Lathyris,Djamel Mokart

doi:10.1186/s13613-021-00895-5

Abstract

BackgroundWhether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer.MethodsThis study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer.ResultsOf the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p < 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60–1.72 and HR 0.87, 95% CI 0.49–1.54) and TLDs (HR 0.81, 95% CI 0.33–1.99 and HR 0.70, 95% CI 0.27–1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58–3.15 and 1.66, 95% CI 1.28–2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups.ConclusionsThe absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.

Highlights

Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown
We found no evidence for a difference in the combination of clinicians who provided concordant Perception of excessive care (PEC) across subgroups (p = 0.51)
In patients with concordant PECs, we found no statistical evidence for a difference in time from admission until death between cancer patients and patients without cancer

Summary

Introduction

Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. Recent data show that 5–6.5% of patients with solid cancer and up to 10% of patients with a hematological malignancy are admitted to ICU during the course of their disease [1,2,3,4] This results in an ICU bed occupancy by cancer patients of 15–20% [5,6,7]. According to hematologists and oncologists, ICU clinicians are often too pessimistic regarding short-term and longterm prognosis of cancer patients, while hematologists and oncologists are often too optimistic according to the ICU clinicians [8] This may result in overt conflicts or in more subtle chronic conflicts such as animosity, distrust or communication gaps, neither of which benefit the patients and their families

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