Time-Limited Trials of Intensive Care for Critically Ill Patients With Cancer: How Long Is Long Enough?

Abstract

Importance: Time-limited trials of intensive care are commonly used in patients perceived to have a poor prognosis. The optimal duration of such trials is unknown. Factors such as a cancer diagnosis are associated with clinician pessimism and may affect the decision to limit care independent of a patient's severity of illness.

Objective: To identify the optimal duration of intensive care for short-term mortality in critically ill patients with cancer.

Design, setting, and participants: Decision analysis using a state-transition microsimulation model was performed to simulate the hospital course of patients with poor-prognosis primary tumors, metastatic disease, or hematologic malignant neoplasms admitted to medical and surgical intensive care units. Transition probabilities were derived from 920 participants stratified by sequential organ failure assessment (SOFA) scores to identify severity of illness. The model was validated in 3 independent cohorts with 349, 158, and 117 participants from quaternary care academic hospitals. Monte Carlo microsimulation was performed, followed by probabilistic sensitivity analysis. Outcomes were assessed in the overall cohort and in solid tumors alone.

Interventions: Time-unlimited vs time-limited trials of intensive care.

Main outcomes and measures: 30-day all-cause mortality and mean survival duration.

Results: The SOFA scores at ICU admission were significantly associated with mortality. A 3-, 8-, or 15-day trial of intensive care resulted in decreased mean 30-day survival vs aggressive care in all but the sickest patients (SOFA score, 5-9: 48.4% [95% CI, 48.0%-48.8%], 60.6% [95% CI, 60.2%-61.1%], and 66.8% [95% CI, 66.4%-67.2%], respectively, vs 74.6% [95% CI, 74.3%-75.0%] with time-unlimited aggressive care; SOFA score, 10-14: 36.2% [95% CI, 35.8%-36.6%], 44.1% [95% CI, 43.6%-44.5%], and 46.1% [95% CI, 45.6%-46.5%], respectively, vs 48.4% [95% CI, 48.0%-48.8%] with aggressive care; SOFA score, ≥ 15: 5.8% [95% CI, 5.6%-6.0%], 8.1% [95% CI, 7.9%-8.3%], and 8.3% [95% CI, 8.1%-8.6%], respectively, vs 8.8% [95% CI, 8.5%-9.0%] with aggressive care). However, the clinical magnitude of these differences was variable. Trial durations of 8 days in the sickest patients offered mean survival duration that was no more than 1 day different from time-unlimited care, whereas trial durations of 10 to 12 days were required in healthier patients. For the subset of patients with solid tumors, trial durations of 1 to 4 days offered mean survival that was not statistically significantly different from time-unlimited care.

Conclusions and relevance: Trials of ICU care lasting 1 to 4 days may be sufficient in patients with poor-prognosis solid tumors, whereas patients with hematologic malignant neoplasms or less severe illness seem to benefit from longer trials of intensive care.

Figure

Comparison of Optimal Intensive Care Trial Duration for Each Sequential Organ Failure Assessment (SOFA) Score for the Outcome of Mean Survival Duration The healthiest quartile is not depicted. Trial durations that led to no more than a 1-day difference in mean survival compared with aggressive care, and no more than a 3-day difference in mean survival, were calculated.