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* From the Division of Pulmonary, Critical Care and Sleep Medicine, Georgetown University Hospital, Washington, DC.
Correspondence to: Cristina A. Reichner, MD, Division of Pulmonary, Critical Care and Sleep Medicine, Georgetown University Hospital, 4N Main Hospital, 3800 Reservoir Rd NW, Washington, DC 20007; e-mail: reichnerc{at}aol.com
Abstract
Objectives: To determine the outcome of lung cancer patients admitted to the medical ICU (MICU), to examine their code status at MICU admission and prior to death, and to determine which subspecialty physician was responsible for the change in code status.
Design: Retrospective chart review study.
Setting: A 19-bed MICU in a tertiary-care university hospital.
Patients: Consecutive patients with a diagnosis of lung cancer admitted to the MICU from July 2002 to June 2004.
Measurements and main results: Forty-seven patients with a diagnosis of lung cancer accounted for 53 MICU admissions. Mean (± SD) age at MICU admission was 65 ± 10 years. Sixty-six percent were male. Eighty-three percent had non-small cell lung cancer (NSCLC); 64% of these were stage IV NSCLC. The most common organ system implicated on MICU admission was pulmonary, with 38% of patients presenting with pneumonia. Overall MICU mortality was 43%, and in-hospital mortality was 60%. Patients who required mechanical ventilation or had more advanced lung cancer stage had the worst prognosis, with mortality rates of 74% and 68%, respectively. Seventy-four percent of patients were "full code" at MICU admission. Subsequently, the code status was changed to "do not resuscitate" in 49% of these cases. The pulmonary/critical care physician was involved in this change 96% of the time and was the sole physician in 65% of cases.
Conclusions: This study confirms that patients with lung cancer admitted to the MICU have a high mortality. Despite this, the majority of patients are full code on MICU admission. Pulmonary/critical care physicians play an important role in the end-of-life decision making of lung cancer patients admitted to the MICU, perhaps because of their availability in the MICU and also because of their sense of responsibility in maintaining and withdrawing life support.
Key Words: critical care • end of life • lung cancer • outcome
Lung cancer is the leading cause of cancer deaths in both men and women in the United States. Despite advances in therapy, 5-year survival for all patients with lung cancer is < 15%.1 Regardless of this poor prognosis, patients with lung cancer are often admitted to the medical ICU (MICU). Many of these patients do not have a clear understanding of their significant risk of death and have not expressed their preferences for end-of-life care. We examined MICU and hospital mortality for patients admitted to the MICU with a diagnosis of lung cancer. In addition, we reviewed the code status of lung cancer patients on arrival to the MICU and prior to death. We also studied which subspecialty physician was responsible for the discussion prompting a change in code status.
Methods and Materials
After obtaining institutional board review approval, a retrospective review of the medical records of all patients with a pathologically proven diagnosis of lung cancer admitted to the Georgetown University Hospital MICU from July 2002 to June 2004 was performed. Georgetown University Hospital is a tertiary-care teaching hospital located in Washington, DC. The MICU is a 19-bed intensive care "closed" unit managed by full-time faculty members of the Division of Pulmonary, Critical Care, and Sleep Medicine. At the time of this study, there was an in-house faculty intensivist on call 16 h/d on weekdays. Medical oncologists also conducted daily rounds on oncology patients in the MICU.
Data collected included demographics (age, gender, race), histologic type and stage of lung cancer, time since diagnosis, and treatment received, if any. The sepsis-related (or sequential) organ failure assessment (SOFA)2 score was calculated on admission to the MICU. Other MICU data included need, timing, and duration of mechanical ventilation or noninvasive positive pressure ventilation, presence or absence of neutropenia, and code status on admission to the MICU. Mortality for the hospital admission was also determined.
Statistical software (version 12.0; SPSS; Chicago, IL) was used for statistical analysis. Continuous variables were analyzed using Student t test, and discrete variables were analyzed with 
2 test. A p value < 0.05 was used for statistical significance.
Code status was defined as "do not resuscitate" (DNR), "full code," or "limited code." The charts were reviewed to determine if the code status changed during the MICU stay and which subspecialty physician (pulmonary/critical care vs oncology) was responsible for the discussion prompting the change in code status. The time to the actual change in code status was also noted. Available outpatient oncology and pulmonary charts were reviewed to determine if a prior code discussion had taken place.
Results
During a 2-year period, 47 patients with a diagnosis of lung cancer accounted for 53 admissions to the MICU. The demographics are shown in Table 1 . Thirty-nine patients had a diagnosis of non-small cell lung cancer (NSCLC). Twenty-five of these patients (64%) had stage IV NSCLC, 8 patients (21%) had stage III NSCLC, 2 patients (5%) had stage II NSCLC, and 4 patients (10%) had stage I NSCLC. For the seven patients with small cell lung cancer (SCLC), 6 patients (86%) had extensive stage and 1 patient (14%) had limited stage. One patient had simultaneous NSCLC stage IIIA and limited-stage SCLC. Lung cancer was diagnosed in five of the patients during this hospitalization. Eighty-seven percent of patients had received some form of treatment (ie, chemotherapy, radiation, and/or surgical resection) prior to MICU admission.
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Overall MICU mortality was 43%. The in-hospital mortality was 60%. Five patients were terminally extubated and died receiving comfort care. Mortality was 74% if the patient required mechanical ventilation, 68% if the patient had stage IV NSCLC, and 86% if the patient had stage IV NSCLC and required mechanical ventilation. Predictors of mortality included NSCLC stage IV, higher SOFA score, and need for mechanical ventilation (Table 3 ). Length of time since diagnosis did not influence MICU and hospital mortality (p = 0.77 and p = 0.74, respectively). Patients who had received prior oncologic therapy did not have a survival benefit (MICU mortality, p = 0.51; hospital mortality, p = 0.83).
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On admission to the MICU, 26% of all lung cancer patients had DNR orders. Sixty-four percent of the patients with stage IV NSCLC were full code. The code status was subsequently changed to DNR in 23 patients (49%), and the mean time to change in code status was 7 ± 7 days. The pulmonary/critical care physician was solely responsible for the change in code status in 65% of the cases and participated in 96% of the code status discussions. A medical oncology physician was solely responsible for one change (4%) and, in an additional 20% of cases, participated in the process with the pulmonary/critical care physician. For two patients (9%), an ethics consult was obtained to address the code status.
Of the 35 patients who were full code on admission to the MICU, oncology outpatient charts were available for 20 of these patients and pulmonary outpatient charts were available for 18 patients. There was no record of code discussion documented in any of these outpatient charts.
Discussion
Lung cancer is the third most common malignancy for both men and women but carries the highest mortality.1 Lung cancer is the third most common solid tumor in critically ill patients3 and accounts for 16% of all malignancies in cancer admissions to the ICU.4 Previous studies56 have shown that lung cancer patients have a high mortality when admitted to the MICU. In a study by Boussat et al,5 MICU mortality was 66% and in-hospital mortality was 75%. Karnofsky performance status score < 70 and acute pulmonary disease were predictors of mortality. Mechanical ventilation in lung cancer patients also portends a higher mortality.6789
Our study confirms that lung cancer patients have a significant mortality of 43% when admitted to the MICU and an in-hospital mortality of 60%. The need for mechanical ventilation, a higher SOFA score, and more advanced lung cancer stage are predictors of mortality. There was only a 12% 30-day survival for patients with stage IV NSCLC who were admitted to the MICU, but we were not able to determine any predictors of survival, probably because of our small numbers. The only subset of patients we identified with a 100% MICU mortality was extensive-stage SCLC patients who required mechanical ventilation, but our number (n = 5) was too small to draw any firm conclusions.
Remarkably, 74% of the patients with lung cancer were full code on MICU admission, including 68% of patients with stage IV NSCLC. This is quite different from a previous study10 that showed that 60% of seriously ill hospitalized stage III and IV NSCLC patients wanted comfort-focused care. The code status was then changed in 49% of patients, a higher percentage than described in a previous study4 in which 37% of critically ill cancer patients received DNR orders during their ICU stay. An increased incidence of withholding and withdrawal of life support had been noted previously.11
Lung cancer patients who require MICU admission represent a small subgroup of lung cancer patients in whom there is a sudden life-threatening event that leads to the MICU admission. Many lung cancer patients with advanced disease are not aware of the poor prognosis or imminent risks of their disease.3 A study by Lamont and Christakis12 showed that physicians provide cancer patients a frank survival estimate 37% of the time, and provide no estimate, consciously overestimate, or consciously underestimate the rest of the time. Cancer patients have been shown to base their treatment preferences on their beliefs about their prognosis, which they tend to overestimate.13 It may be difficult for physicians to predict the outcome of individual patients because illness severity scores lack accuracy.14 Additionally in the MICU, it is sometimes challenging to distinguish the degree of impairment attributable to a reversible process such as pneumonia vs the progression of the lung cancer itself.6
It is not uncommon that seriously ill patients have not discussed their preferences for cardiopulmonary resuscitation.15 It is also possible that although DNR status was recommended to them, they might have decided to pursue further care because of unrealistic expectations and not wanting to die.16 Our patient population at a tertiary referral center may have a selection bias, as some patients come for second opinions and therefore are seeking more aggressive state-of-the-art treatment. This high proportion of lung cancer patients who are full code might therefore not apply to other hospital settings such as community hospitals.
Our study also shows that pulmonary/critical care physicians are instrumental in discussions that lead to a change in code status. Possible explanations for this involvement include physician availability in the MICU, expertise in critical care outcomes, sense of responsibility in maintaining and withdrawing life support,17 and also the timing of the discussion that is now occurring in a circumstance in which the patients are more ill. Patient preferences may change over time.14 Unfortunately, end-of-life discussions with lung cancer patients in the MICU are often difficult. Frequently, the code discussion has to be hastened because of impending respiratory or circulatory failure. There is less time, compared to repeated outpatient encounters, to establish a rapport with the patient and family. Ideally, a physician who has been caring for the patient throughout his or her illness should be most involved at the end of life. In addition, ill patients may be unable to make their own decisions, and the end-of-life decision-making process may now be in the hands of the surrogate.
Lung cancer patients, especially those with stage IV NSCLC and extensive-stage SCLC, have significant mortality when admitted to the MICU. Despite this, most are full code on admission. Although individual outcome may be difficult to predict, the need for mechanical ventilation, higher SOFA score, and more advanced lung cancer stage should be considered in the end-of-life decision-making process. This information will inform clinicians in their discussions regarding prognosis and identify patients who will most likely benefit from critical care. Based on our study and that of others,3 end-of-life discussion should be an important aspect in the care of patients with lung cancer and should, if possible, occur early in the course of management (American College of Chest Physicians recommendation grade C).
Footnotes
Abbreviations: DNR = do not resuscitate; MICU = medical ICU; NSCLC = non-small cell lung cancer; SCLC = small cell lung cancer; SOFA = sepsis-related (or sequential) organ failure assessment
This work was performed at Georgetown University Hospital.
Drs. Reichner, Thompson, O’Brien, Kuru, and Anderson have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Received for publication November 11, 2005. Accepted for publication February 28, 2006.
References
This article has been cited by other articles:
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  M. Soares, M. Darmon, J. I. F. Salluh, C. G. Ferreira, G. Thiery, B. Schlemmer, N. Spector, and E. Azoulay Prognosis of Lung Cancer Patients With Life-Threatening Complications Chest, March 1, 2007; 131(3): 840 - 846. [Abstract] [Full Text] [PDF]
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