Background:  Cancer patients may be admitted to an intensive care unit (ICU) at any point in the disease trajectory (1).  When these patients have an advanced malignancy, and/or when their disease has progressed despite standard anti-cancer treatments, conflicts may arise between oncologists and the critical care team regarding appropriate management. This Fast Fact discusses an approach to conflict management for cancer patients in the ICU. 

Same patient-different opinions:  Every specialty has a unique culture based on the type of diseases it treats and the acquired attitudes from peers and teachers during training years. Having a general awareness of these cultural tendencies among various specialty groups could better enable Palliative Care (PC) clinicians to manage inter-specialty conflicts. 

Oncologists … 

• See a wide range of patients, some who are cured and others who die.  
• Are trained to examine all potential anti-cancer treatments to extend life. 
• There has been a rapid growth in effective, non-cytotoxic cancer therapies (e.g., Car T Cell therapy, immunotherapy) for advanced cancer. 
• May view ICU care as nothing more than a “bump in the road,” noting that the prognosis of cancer patients in the ICU is similar to non-cancer patients.  This point of view may be especially apparent in patients who have recently undergone a bone marrow transplant but have not yet shown signs of bone marrow recovery – reengraftment (1,5).   
• Often have long-term outpatient relationships with patients creating strong emotional connections. 

Intensivists … 

• Are likely to see many cancer patients near the time of death when ICU care may represent a ‘last-ditch’ effort to sustain life.  
• Often have brief relationships with patients/families during a time of crisis. 
• Like many non-oncology specialties, they may have a more negative view of the potential benefits of anti-cancer treatments than oncologists. 
• May worry about prolonging suffering through ICU interventions when death appears imminent (1). 

How can PC specialists help?  By performing careful independent evaluations of the medical situation and exploring the points of view of the various specialty teams, the PC interdisciplinary team (IDT) members can serve as mediators who assist in creating a shared message for the family (2).  

• Neutral Caring:  An important trait of a PC consultant is the mindset of neutral caring. Neutral in that they should avoid preconceived notions or “taking sides” between the different clinical teams but instead work to find a common story that they can agree on. The PC IDT should be aware of their own potential biases or conflicts of interest, which could influence the direction of the patient’s care.  For example, PC teams may be more likely to assume that a focus on comfort with a shortened hospital stay is preferred (3). Caring because the PC IDT needs to remember that all the clinicians are doing their best to care for the patient.  Even if the PC clinician is sure that their view is “right”, they need to respectfully negotiate with other clinicians who also may be sure their view is correct. 
• Pre-meeting of clinicians:  Regardless of who initiates the consult, PC IDTs should reach out to both the oncologist and the intensivist to understand their points of view regarding disease, treatment options and prognosis.  In many such circumstances, attending-to-attending level conversations are necessary. Given that prognosis is often uncertain, it may help to reach agreement on the best, worst, and most likely prognosis (4).  This may identify areas of agreement among the specialist teams involved and clarify what medical data are needed to better forecast prognosis.  

Managing Conflict: Multi-disciplinary goals of care meetings are often the most effective and efficient way to bring all specialty care teams together along with the patient and/or family and negotiate the best way forward (see Fast Facts #16, 65, 183-184, 222-227).  If there is disagreement between specialty teams, it is critical that such attending clinicians talk directly before meeting with the family.  See Fast Fact #368 about the Pre-meeting Huddle.  Often reports of what one clinician said is from an indirect source. Consequently, these descriptions may be incomplete or filtered by other’s hopes or biases. In cases in which medical agreement cannot be reached, the PC IDT can assist by presenting the differing opinions to the family as part of a cohesive medical reality on which the family can base their decisions or pursue a time-limited trial (see Fast Fact #401).   

Summary:  The goal of the PC consultant is to perform an independent evaluation to help the medical care team develop a unified medical narrative that is agreeable with all clinicians involved. As such, PC IDTs can be vital in conveying an accurate and understandable medical narrative to the families of critically ill cancer patients. 

References: 

1. Youngner SJ, Allen M, Montenegro H, Hreha J, Lazarus H. Resolving problems at the intensive care unit/oncology unit interface. Perspect Biol Med. 1988;31(2):299-308. doi:10.1353/pbm.1988.0060.
2. Meier DE, Beresford L. Consultation etiquette challenges palliative care to be on its best behavior. J Palliat Med. 2007;10:7-11.
3. Barnard D, Towers A, Boston P, Lambrinidou Y. Crossing Over: Narratives of Palliative Care. Oxford University Press; 2000.
4. Campbell T, Elise C, Jackson V a, et al. Discussing Prognosis: Balancing Hope and Realism. Cancer J. 2010;16(5):461-466.
5. Staudinger T, Stoiser B, Müllner M, et al. Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit. Crit Care Med. 2000;28(5):1322-1328.

Authors Affiliation: University of Pittsburgh Medical Center 
Version History: First electronically published in January 2016; reviewed and updated in April 2024. 
Conflicts of Interest: None