放弃生命支持治疗后 ICU 出院癌症患者的结局。

Outcomes of Cancer Patients Discharged From ICU After a Decision to Forgo Life-Sustaining Therapies.

机构信息

Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil.

Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

出版信息

Crit Care Med. 2019 Jun;47(6):e454-e460. doi: 10.1097/CCM.0000000000003729.

DOI:10.1097/CCM.0000000000003729

PMID:30889028

Abstract

OBJECTIVES

Many cancer patients are admitted to an ICU and decisions to forgo life-sustaining therapies are frequent during ICU stay. A significant proportion of these patients are subsequently discharged from ICU, but their outcomes are unknown.

DESIGN

Retrospective.

SETTING

ICU of oncological hospital.

PATIENTS

Adult cancer patients admitted to ICU, then with a decision to forgo life-sustaining therapies and that were discharged from ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Hospital mortality, long-term survival, recommencement of cancer treatment, and ICU readmission were recorded. Hospital mortality predictors were evaluated. The propensity score method was used to test the hypothesis that decision to forgo life-sustaining therapies was independently associated with hospital mortality. Among the 16,998 patients that were admitted to ICU, in 1,369 patients (8.1%) a decision to forgo life-sustaining therapies was made during ICU stay. Among the latter group, 507 were discharged from ICU and were examined in this study. The hospital mortality of this group was 80.1% and was independently predicted according to the occurrence of delirium or acute kidney injury during their ICU stay. Six-month and 12-month survival rates were 3.6% and 0.6%. Sixty-four patients (12.6%) resumed cancer treatment and had a longer survival (p < 0.01). Fifty-two patients (10.3%) were readmitted to ICU and had a longer survival (p < 0.01). The decision to forgo life-sustaining therapies was associated with higher hospital mortality (80.0% vs 26.3%, respectively; p < 0.01) and lower rates of survival (p < 0.01).

CONCLUSIONS

Approximately 20% of cancer patients discharged from our ICU after a decision to forgo life-sustaining therapies were discharged from hospital. Delirium and acute kidney injury during ICU stay were predictors of hospital mortality. The decision to forgo life-sustaining therapies was independently associated with hospital mortality. Patients readmitted to the ICU and those that resumed cancer treatment had longer survival. Knowledge of these outcomes is important for providing proper therapeutic planning and counseling for patients and their relatives.

摘要

目的

许多癌症患者被收入 ICU，并且在 ICU 住院期间经常做出放弃生命维持治疗的决定。这些患者中有相当一部分随后从 ICU 出院，但他们的结局尚不清楚。

设计

回顾性研究。

地点

肿瘤医院的 ICU。

患者

收入 ICU 的成年癌症患者，然后做出放弃生命维持治疗的决定，并从 ICU 出院。

干预措施

无。

测量和主要结果

记录了住院死亡率、长期生存率、癌症治疗的重新开始以及 ICU 再入院。评估了住院死亡率的预测因素。使用倾向评分法检验了放弃生命维持治疗的决定与住院死亡率独立相关的假设。在 16998 例收入 ICU 的患者中，有 1369 例（8.1%）在 ICU 住院期间做出了放弃生命维持治疗的决定。在后一组中，有 507 例从 ICU 出院，并在本研究中进行了检查。该组的住院死亡率为 80.1%，并根据其 ICU 期间发生的谵妄或急性肾损伤进行了独立预测。6 个月和 12 个月的生存率分别为 3.6%和 0.6%。64 例（12.6%）患者重新开始癌症治疗，生存率更高（p<0.01）。52 例（10.3%）患者再次被收入 ICU，生存率更高（p<0.01）。放弃生命维持治疗的决定与更高的住院死亡率（分别为 80.0%和 26.3%；p<0.01）和更低的生存率相关（p<0.01）。

结论

在做出放弃生命维持治疗的决定后，约有 20%的癌症患者从我们的 ICU 出院后出院。ICU 期间的谵妄和急性肾损伤是住院死亡率的预测因素。放弃生命维持治疗的决定与住院死亡率独立相关。再次入住 ICU 和重新开始癌症治疗的患者生存率更高。了解这些结果对于为患者及其家属提供适当的治疗计划和咨询非常重要。