#310

The Oncology-ICU-Palliative Care Interface

  • Mamta Bhatnagar MD
  • Robert Arnold MD

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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, it is common for conflicts to 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 attitudes learned 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.
  • 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 represents 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 palliative care help?  By performing careful independent evaluations of the medical situation and exploring the points of view of the various specialty teams, the PC team 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 he or she should avoid taking sides between the different clinical teams but instead work to find a common story that they can agree on. PC consultants 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 consultant needs to remember that all the clinicians are doing their best to care for the patient.  Thus 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 teams 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.  Often reports of what one clinician said is from the family or another indirect source.  Consequently, these descriptions may be incomplete or filtered by the family’s hopes. In cases in which medical agreement cannot be reached, the PC team 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. 

Summary:  The goal of the PC consultant is to perform an independent evaluation in order to help the medical care team develop a unified medical narrative that is agreeable with all clinicians involved. As such, PC teams can be vital in conveying an accurate and understandable medical narrative to the families of critically ill cancer patients. By fostering an environment that allows regular clinician meetings to occur throughout a patient’s hospital stay, PC teams can better ensure that medical teams talk directly to each other about the patient’s prognosis and present a unified approach to the family and patient.

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

Conflicts of Interest: None