END-OF-LIFE DECISIONS IN CANCER CARE

The development of new treatment modalities for many types of cancer has resulted in increased patient survival. These same therapies, however, often result in serious complications to the patient. The decision to admit patients with cancer to the ICU is based on specific criteria including hemodynamic instability, respiratory compromise, and general prognosis. Prognostic scoring systems used for general ICU patients such as the Acute Physiology and Chronic Health Evaluation (APACHE) II and the Mortality Probability Model (MPM) II have been shown to underestimate hospital mortality in patients with cancer. 6, 8 Groeger and colleagues developed a multivariate logistic regression model to estimate the probability of hospital mortality in critically ill patients with cancer admitted to the ICU. 6 These models cannot predict with 100% certainty how any individual patient will fare but rather serve as tools to help physicians identify which types of patients may benefit from ICU care and which may not. Groeger et al reported an overall 41% mortality rate for patients with cancer admitted to the ICUs of four academic medical centers. 6 Thus, intensivists and oncologists are faced with many ethical and moral issues when patients with cancer become critically ill. In 1990, a group of physicians from the American College of Chest Physicians and the Society of Critical Care Medicine published Ethical and Moral Guidelines for the Intubation, Continuation, and Withdrawal of Intensive Care. 2 Among the issues addressed were ethical, medical, economic, and legal factors that influence the practice of critical care. This article focuses on each of these issues as it pertains to the treatment of critically ill patients with cancer. It ends with a discussion of issues that will become challenges in the future as cancer care becomes more sophisticated.