Short-term vs long-term prognosis in decisions to admit palliative care patients to intensive care
M. Escher1, M. Nendaz1, B. Ricou1, F. Scherer1, P. Hudelson1, S. Cullati1, T. Perneger1 (1Genève)
There are no definitive criteria for admission to intensive care (ICU). Current recommendations state that long-term prognosis should be considered along with patient need for life-sustaining therapies and potential to benefit from intensive care. We have shown that physicians accurately predict short-term survival for patients assessed for ICU and that survival prediction is associated with admission decisions. How physicians balance long-term against short-term prognosis is not known.
Assess the influence of long-term prognosis on the decision to admit or not a palliative care patient to intensive care.
All consecutive requests for ICU admission made for patients hospitalized in the division of general internal medicine of the Geneva University Hospitals were identified. The internal medicine (IM) physician and the intensive care (ICU) physician involved were contacted within 12 hours. They were asked to estimate the patient’s probability of survival if the patient was admitted to the ICU, and if the patient remained on the ward, in 5 ordered categories (<10%, 10-40%, 41-60%, 61-90%, >90%). Palliative care patients were defined as patients with an advanced disease compromising long-term prognosis, based on diagnoses in the medical record. The admission decision was recorded.
In total 201 patients were included, of whom 116 (57.7%) had an advanced disease. Patients with advanced diseases were as frequently admitted to the ICU (80/116, 69.0%) as those without (60/85, 70.6%). In multiple logistic regression, admission of the patient to the ICU was positively associated with a higher probability of survival in the ICU estimated by the ICU physician (odds ratio (OR) 2.0 per survival category, p=0.005) and by the IM physician (OR 2.1, p=0.003), negatively associated with a higher probability of survival on the ward (OR=0.28, p<0.001 for ICU physician, and OR=0.47, p=0.002 for IM physician), and was not associated with advanced disease (OR=1.04, p=0.93).
Admission to intensive care was strongly influenced by the physicians’ estimation of short term survival on the ward and in the ICU. The recommendation to take long-term prognosis into account when deciding on admission to the ICU is not routinely applied.
Funding: Swiss National Science Foundation, NRP 67 “End-of-life”