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

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

WASHINGTON--Many of the patients who will die of cancer this year
will receive care in the nation's intensive care units. Despite
heralded advances in drug research and medical technology, fewer
than one fourth of cancer patients admitted to an ICU survive
for 6 months, Mark S. Gelder, MD, said at the American Cancer
Society 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 the
patient. Today, as costs rise and societal and personal views
change, this attitude is under attack."

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

Simplistic standards like age won't do, Dr. Gelder said. "What's
your definition of age? Biological age or chronological age? Age
is not a single criterion. Severity of illness and comorbid conditions
are more important." In fact, he said, the best predictor
for survival is preadmission functional status. Eighty percent
of those who return to independent living get back to the same
level after their stay in the ICU.

Prognostic systems employing logistic regression modeling techniques
have been used to estimate the risk of death of patients in the
ICU, Dr. Gelder said. Systems such as APACHE, SAPS, and MPM attempt
to classify groups of patients based on the severity of illness
early in their ICU stay. "All three systems give an accurate
estimate of the number of patients expected to die in a group,
but not which individual patients will die," he said. "There's
nothing wrong with incorporating these systems into a patient's
evaluation, but the physician's assessment and prediction of outcomes
is as good or better than any scoring system."

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

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

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