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Review article: Biomedical intelligence

Vol. 147 No. 3132 (2017)

Oncological patients in the intensive care unit: prognosis, decision-making, therapies and end-of-life care

Cite this as:
Swiss Med Wkly. 2017;147:w14481


The effectiveness of intensive care unit (ICU) care for cancer patients remains controversial. Advances in antitumour and supportive care led to major improvements in outcomes of oncological patients in the ICU. Improved cancer therapies and supportive management of organ dysfunctions have contributed to improved survival rates. As a consequence, the number of cancer patients requiring ICU admission is rising. Frequently, cancer patients have a poor performance status and are vulnerable. It is a heterogeneous population, where the nature and curability of the neoplasm and the severity of critical illness cause a plethora of issues about ICU admissions. Therefore, oncological patients are often considered inappropriate for ICU admission. So far, no specific severity-of-illness scoring system can reliably predict the outcome of critically ill oncological patients and scoring systems or survival predictors are lacking. The major determinants of mortality and prognosis are the number of organ failures, need of mechanical ventilation (especially for acute respiratory distress syndrome), vasopressor support (>4 hours) and therapies that have preceded ICU admission. The underlying neoplasm seems to have a little impact on the outcome. The most frequent reasons leading a cancer patient to ICU are postoperative recovery, respiratory failure, infection and sepsis. To date, scientific reports suggest that acute organ dysfunction should be managed at its onset, preferably within 2 hours after the admission, whereas further aggressive ICU management should be reappraised after a few days of full support. Prognosis should be reassessed at frequent intervals with particular attention to the development of multiple organ dysfunctions. Discussing the code status is a sensitive matter and should be balanced between the patient’s wish and objective medical outcome assessment. The latter can only be achieved in a multidisciplinary team of intensivists, oncologists/haematologists and potentially palliative care experts, preferably by consensus. Transition from restorative to palliative care should be made when there is no benefit from further intensive treatment, there is no trend to recovery in the first days of intensive care and where symptom palliation would improve the quality of life. Patients’ autonomy and dignity should remain paramount in any decision-making.

Current data do not support any absolute criteria for triaging. Establishment of clear goals and approach to admit and treatment for oncological patients in the ICU are however urgently needed. This requires further prospective studies for independent validation in different medical settings and identifying prognostic tools that can aid with decision-making and patient selection for ICU. Cancer should not be seen as an exclusion criterion and priority should be given to assure the quality of life of oncological patients.


  1. Kostakou E, Rovina N, Kyriakopoulou M, Koulouris NG, Koutsoukou A. Critically ill cancer patient in intensive care unit: issues that arise. J Crit Care. 2014;29(5):817–22. doi:.
  2. Schapira DV, Studnicki J, Bradham DD, Wolff P, Jarrett A. Intensive care, survival, and expense of treating critically ill cancer patients. JAMA. 1993;269(6):783–6. doi:.
  3. Darmon M, Thiery G, Ciroldi M, de Miranda S, Galicier L, Raffoux E, et al. Intensive care in patients with newly diagnosed malignancies and a need for cancer chemotherapy. Crit Care Med. 2005;33(11):2488–93. doi:.
  4. Azoulay E, Soares M, Darmon M, Benoit D, Pastores S, Afessa B. Intensive care of the cancer patient: recent achievements and remaining challenges. Ann Intensive Care. 2011;1(1):5. doi:.
  5. Soares M, Salluh JIF, Torres VBL, Leal JVR, Spector N. Short- and long-term outcomes of critically ill patients with cancer and prolonged ICU length of stay. Chest. 2008;134(3):520–6. doi:.
  6. Hauser MJ, Tabak J, Baier H. Survival of patients with cancer in a medical critical care unit. Arch Intern Med. 1982;142(3):527–9. doi:.
  7. Larché J, Azoulay E, Fieux F, Mesnard L, Moreau D, Thiery G, et al. Improved survival of critically ill cancer patients with septic shock. Intensive Care Med. 2003;29(10):1688–95. doi:.
  8. Staudinger T, Stoiser B, Müllner M, Locker GJ, Laczika K, Knapp S, et al. Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit. Crit Care Med. 2000;28(5):1322–8. doi:.
  9. Shaw AT, Yeap BY, Solomon BJ, Riely GJ, Gainor J, Engelman JA, et al. Effect of crizotinib on overall survival in patients with advanced non-small-cell lung cancer harbouring ALK gene rearrangement: a retrospective analysis. Lancet Oncol. 2011;12(11):1004–12. doi:.
  10. Sznol M, Kluger HM, Callahan MK, Postow MA, Gordon RA, Segal NH, et al. Survival, response duration, and activity by BRAF mutation (MT) status of nivolumab (NIVO, anti-PD-1, BMS-936558, ONO-4538) and ipilimumab (IPI) concurrent therapy in advanced melanoma (MEL). J Cinical Oncol. 2014;32(18_suppl):LBA9003. Available at: doi:.
  11. Sieh W, Köbel M, Longacre TA, Bowtell DD, deFazio A, Goodman MT, et al. Hormone-receptor expression and ovarian cancer survival: an Ovarian Tumor Tissue Analysis consortium study. Lancet Oncol. 2013;14(9):853–62. doi:.
  12. Hickey M, Saunders CM, Stuckey BGA. Management of menopausal symptoms in patients with breast cancer: an evidence-based approach. Lancet Oncol. 2005;6(9):687–95. Available at: doi:.
  13. Woolf CJ, Mannion RJ. Neuropathic pain: aetiology, symptoms, mechanisms, and management. Lancet. 1999;353(9168):1959–64. doi:.
  14. Daud ML. Drug management of terminal symptoms in advanced cancer patients. Curr Opin Support Palliat Care. 2007;1(3):202–6. doi:.
  15. Pachman DR, Barton DL, Swetz KM, Loprinzi CL. Troublesome symptoms in cancer survivors: fatigue, insomnia, neuropathy, and pain. J Clin Oncol. 2012;30(30):3687–96. doi:.
  16. Nainis N, Paice JA, Ratner J, Wirth JH, Lai J, Shott S. Relieving symptoms in cancer: innovative use of art therapy. J Pain Symptom Manage. 2006;31(2):162–9. doi:.
  17. Lecuyer L, Chevret S, Thiery G, Darmon M, Schlemmer B, Azoulay E. The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med. 2007;35(3):808–14. doi:.
  18. Brenner H, Hakulinen T. Long-term cancer patient survival achieved by the end of the 20th century: most up-to-date estimates from the nationwide Finnish cancer registry. Br J Cancer. 2001;85(3):367–71. Available at: doi:.
  19. Verdecchia A, Francisci S, Brenner H, Gatta G, Micheli A, Mangone L, et al.; EUROCARE-4 Working Group. Recent cancer survival in Europe: a 2000-02 period analysis of EUROCARE-4 data. Lancet Oncol. 2007;8(9):784–96. doi:.
  20. Azoulay E, Mokart D, Pène F, Lambert J, Kouatchet A, Mayaux J, et al. Outcomes of critically ill patients with hematologic malignancies: prospective multicenter data from France and Belgium--a groupe de recherche respiratoire en réanimation onco-hématologique study. J Clin Oncol. 2013;31(22):2810–8. doi:.
  21. Maniate JM, Navaratnam S, Cheang M, Sharma S. Outcome of Lung Cancer Patients Admitted to the Intensive Care Unit. Clin Pulm Med. 2007;14(5):281–5. Available at: doi:.
  22. Hadjiliadis D, Steele MP, Govert JA, Davis RD, Palmer SM. Outcome of lung transplant patients admitted to the medical ICU. Chest. 2004;125(3):1040–5. doi:.
  23. Rubenfeld GD, Crawford SW. Withdrawing life support from mechanically ventilated recipients of bone marrow transplants: a case for evidence-based guidelines. Ann Intern Med. 1996;125(8):625–33. doi:.
  24. Yeo CD, Kim JW, Kim SC, Kim YK, Kim KH, Kim HJ, et al. Prognostic factors in critically ill patients with hematologic malignancies admitted to the intensive care unit. J Crit Care. 2012;27(6):739.e1–6. doi:.
  25. Tamburro RF, Barfield RC, Shaffer ML, Rajasekaran S, Woodard P, Morrison RR, et al. Changes in outcomes (1996-2004) for pediatric oncology and hematopoietic stem cell transplant patients requiring invasive mechanical ventilation. Pediatr Crit Care Med. 2008;9(3):270–7. doi:.
  26. Butt W, Barker G, Walker C, Gillis J, Kilham H, Stevens M. Outcome of children with hematologic malignancy who are admitted to an intensive care unit. Crit Care Med. 1988;16(8):761–4. Available at: doi:.
  27. Benoit DD, Vandewoude KH, Decruyenaere JM, Hoste EA, Colardyn FA. Outcome and early prognostic indicators in patients with a hematologic malignancy admitted to the intensive care unit for a life-threatening complication. Crit Care Med. 2003;31(1):104–12. doi:.
  28. Levesque E, Saliba F, Ichaï P, Samuel D. Outcome of patients with cirrhosis requiring mechanical ventilation in ICU. J Hepatol. 2014;60(3):570–8. doi:.
  29. Pène F, Percheron S, Lemiale V, Viallon V, Claessens Y-E, Marqué S, et al. Temporal changes in management and outcome of septic shock in patients with malignancies in the intensive care unit. Crit Care Med. 2008;36(3):690–6. doi:.
  30. D Juneja D. Singh O, Javeri Y, Nasa P, Kumar P. Cancer patients with sepsis admitted to a specialized onco-medical ICU: Incidence, ICU course and outcome. Crit Care. 2011;15(suppl 3):S5–6. Available at:
  31. Azoulay E, Alberti C, Bornstain C, Leleu G, Moreau D, Recher C, et al. Improved survival in cancer patients requiring mechanical ventilatory support: impact of noninvasive mechanical ventilatory support. Crit Care Med. 2001;29(3):519–25. doi:.
  32. Pène F, Percheron S, Lemiale V, Viallon V, Claessens Y-E, Marqué S, et al. Temporal changes in management and outcome of septic shock in patients with malignancies in the intensive care unit. Crit Care Med. 2008;36(3):690–6. Available at: doi:.
  33. de Montmollin E, Tandjaoui-Lambiotte Y, Legrand M, Lambert J, Mokart D, Kouatchet A, et al. Outcomes in critically ill cancer patients with septic shock of pulmonary origin. Shock. 2013;39(3):250–4. doi:.
  34. Peres Bota D, Melot C, Lopes Ferreira F, Nguyen Ba V, Vincent JL. The Multiple Organ Dysfunction Score (MODS) versus the Sequential Organ Failure Assessment (SOFA) score in outcome prediction. Intensive Care Med. 2002;28(11):1619–24. doi:.
  35. Zimmerman JE, Knaus WA, Wagner DP, Sun X, Hakim RB, Nystrom PO. A comparison of risks and outcomes for patients with organ system failure: 1982-1990. Crit Care Med. 1996;24(10):1633–41. doi:.
  36. Azevedo LCP, Caruso P, Silva UVA, Torelly AP, Silva E, Rezende E, et al.; Brazilian Research in Intensive Care Network (BRICNet). Outcomes for patients with cancer admitted to the ICU requiring ventilatory support: results from a prospective multicenter study. Chest. 2014;146(2):257–66. doi:.
  37. Sihra L, Harris M, O’Reardon C. Using the improving palliative care in the intensive care unit (IPAL-ICU) project to promote palliative care consultation. J Pain Symptom Manage. 2011;42(5):672–5. doi:.
  38. Parikh S, Shah R, Kapoor P. Portal vein thrombosis. Am J Med. 2010;123(2):111–9. doi:.
  39. Ciesla DJ, Moore EE, Johnson JL, Burch JM, Cothren CC, Sauaia A. A 12-year prospective study of postinjury multiple organ failure: has anything changed? Arch Surg. 2005;140(5):432–8, discussion 438–40. doi:.
  40. Ferreira AMP, Sakr Y. Organ dysfunction: general approach, epidemiology, and organ failure scores. Semin Respir Crit Care Med. 2011;32(5):543–51. doi:.
  41. de Montmollin E, Annane D. Year in review 2010: Critical Care--Multiple organ dysfunction and sepsis. Crit Care. 2011;15(6):236. Available at: doi:.
  42. Sprung CL, Danis M, Iapichino G, Artigas A, Kesecioglu J, Moreno R, et al. Triage of intensive care patients: identifying agreement and controversy. Intensive Care Med. 2013;39(11):1916–24. doi:.
  43. Orsini J, Butala A, Ahmad N, Llosa A, Prajapati R, Fishkin E. Factors influencing triage decisions in patients referred for ICU admission. J Clin Med Res. 2013;5(5):343–9. Available at:
  44. Guidelines for intensive care unit admission, discharge, and triage. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med. 1999;27(3):633–8. Available at: doi:.
  45. Ferreira FL, Bota DP, Bross A, Mélot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA. 2001;286(14):1754–8. Available at: doi:.
  46. Ho KM. Combining sequential organ failure assessment (SOFA) score with acute physiology and chronic health evaluation (APACHE) II score to predict hospital mortality of critically ill patients. Anaesth Intensive Care. 2007;35(4):515–21.
  47. Kopterides P, Liberopoulos P, Ilias I, Anthi A, Pragkastis D, Tsangaris I, et al. General prognostic scores in outcome prediction for cancer patients admitted to the intensive care unit. Am J Crit Care. 2011;20(1):56–66. doi:.
  48. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. Prognosis in acute organ-system failure. Ann Surg. 1985;202(6):685–93. doi:.
  49. Namendys-Silva SA, Texcocano-Becerra J, Herrera-Gómez A. Prognostic factors in critically ill patients with solid tumours admitted to an oncological intensive care unit. Anaesth Intensive Care. 2010;38(2):317–24.
  50. Azoulay E, Pochard F, Chevret S, Vinsonneau C, Garrouste M, Cohen Y, et al.; PROTOCETIC Group. Compliance with triage to intensive care recommendations. Crit Care Med. 2001;29(11):2132–6. doi:.
  51. Vandijck DM, Benoit DD, Depuydt PO, Offner FC, Blot SI, Van Tilborgh AK, et al. Impact of recent intravenous chemotherapy on outcome in severe sepsis and septic shock patients with hematological malignancies. Intensive Care Med. 2008;34(5):847–55. doi:.
  52. Bird G, Gruber P, Farquhar-Smith P, Forrest R, Saini R. Outcomes and prognostic factors in patients with haematological malignancies in a specialist cancer intensive care unit. Intensive Care Med. 2010;36:S157. Available at:
  53. Rhee CK, Kang JY, Kim YH, Kim JW, Yoon HK, Kim SC, et al. Risk factors for acute respiratory distress syndrome during neutropenia recovery in patients with hematologic malignancies. Crit Care. 2009;13(6):R173. doi:.
  54. Gilbert CR, Lerner A, Baram M, Awsare BK. Utility of flexible bronchoscopy in the evaluation of pulmonary infiltrates in the hematopoietic stem cell transplant population -- a single center fourteen year experience. Arch Bronconeumol. 2013;49(5):189–95.
  55. Champigneulle B, Merceron S, Lemiale V, Geri G, Mokart D, Bruneel F, et al. What is the outcome of cancer patients admitted to the ICU after cardiac arrest? Results from a multicenter study. Resuscitation. 2015;92:38–44. doi:.
  56. Aldawood AS. Prognosis and resuscitation status of critically ill patients with lung cancer admitted to the intensive care unit. Anaesth Intensive Care. 2010;38(5):920–3.
  57. Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J, et al.; University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175–83. doi:.
  58. Laky B, Janda M, Kondalsamy-Chennakesavan S, Cleghorn G, Obermair A. Pretreatment malnutrition and quality of life - association with prolonged length of hospital stay among patients with gynecological cancer: a cohort study. BMC Cancer. 2010;10(1):232. doi:.
  59. Greer JA, Jackson VA, Meier DE, Temel JS. Early integration of palliative care services with standard oncology care for patients with advanced cancer. CA Cancer J Clin. 2013;63(5):349–63. doi:.
  60. Nelson JE, Azoulay E, Curtis JR, Mosenthal AC, Mulkerin CM, Puntillo K, et al. Palliative care in the ICU. J Palliat Med. 2012;15(2):168–74. doi:.
  61. Hua M, Wunsch H. Integrating palliative care in the ICU. Curr Opin Crit Care. 2014;20(6):673–80. doi:.
  62. Luce JM. End-of-life decision making in the intensive care unit. Am J Respir Crit Care Med. 2010;182(1):6–11. doi:.
  63. Khandelwal N, Kross EK, Engelberg RA, Coe NB, Long AC, Curtis JR. Estimating the effect of palliative care interventions and advance care planning on ICU utilization: a systematic review. Crit Care Med. 2015;43(5):1102–11. Available at: doi:.
  64. Aslakson RA, Curtis JR, Nelson JE. The changing role of palliative care in the ICU. Crit Care Med. 2014;42(11):2418–28. Available at: doi:.
  65. Campion EW, Kelley AS, Morrison RS. Palliative Care for the Seriously Ill. N Engl J Med [Internet]. 2015;373(8):747–55. Available from:
  66. Yang Ying, Chen Huizhu Z, Xiaoping G. A survey of family members of cancer patients in ICU toward limitation of accompanies and nursing strategy of them.
  67. Campbell ML, Weissman DE, Nelson JE. Palliative care consultation in the ICU #253. J Palliat Med. 2012;15(6):715–6. doi:.
  68. Delgado-Guay MO, Parsons HA, Li Z, Palmer LJ, Bruera E. Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team. Cancer. 2009;115(2):437–45. doi:.
  69. Saft HL, Richman PS, Berman AR, Mularski RA, Kvale PA, Ray DE, et al. Impact of critical care medicine training programs’ palliative care education and bedside tools on ICU use at the end of life. J Grad Med Educ. 2014;6(1):44–9. Available at: doi:.
  70. Hu K, Feng D. Barriers in palliative care in China. Lancet. 2016;387(10025):1272. Available at: doi:.
  71. Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, Fan L, Li J, Chavarri-Guerra Y, et al. Challenges to effective cancer control in China, India, and Russia. Lancet Oncol. 2014;15(5):489–538. doi:.
  72. Depuydt OE, Daeze C, Benoit D, Praet M, Vermassen E, Decruyenaere M. Diagnostic potential of open lung biopsy in mechanically ventilated patients with diffuse pulmonary infiltrates of unclear aetiology. Anaesth Intensive Care. 2013;41(5):610–7. Available at:
  73. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–42. doi:.
  74. Ho KM, Knuiman M, Finn J, Webb SA. Estimating long-term survival of critically ill patients: the PREDICT model. PLoS One. 2008;3(9):e3226. doi:.
  75. Soares M, Carvalho MS, Salluh JI, Ferreira CG, Luiz RR, Rocco JR, et al. Effect of age on survival of critically ill patients with cancer. Crit Care Med. 2006;34(3):715–21. doi:.
  76. Orsini J, Butala A, Salomon S, Studer S, Gadhia S, Shamian B, et al. Prognostic factors associated with adverse outcome among critically ill elderly patients admitted to the intensive care unit. Geriatr Gerontol Int. 2015;15(7):889–94. doi:.