From the Division of Pulmonary and Critical Care Medicine (Dr Cooke), Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, Michigan Center for Integrative Research in Critical Care, University of Michigan; Center for Healthcare Organization and Implementation Research (Dr Wiener), Edith Nourse Rogers Memorial VA Hospital; The Pulmonary Center, Boston University School of Medicine (Dr Wiener), Boston, MA; Health Services Research and Development (Dr Slatore) and Section of Pulmonary and Critical Care Medicine, Portland VA Medical Center; and Division of Pulmonary and Critical Care Medicine, Department of Medicine (Dr Slatore), Oregon Health and Science University.
CORRESPONDENCE TO: Colin R. Cooke, MD, FCCP, University of Michigan, Center for Healthcare Outcomes and Policy, 2800 Plymouth Rd, Bldg 16, Rm 127W, Ann Arbor, MI 48109; e-mail: firstname.lastname@example.org
FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
FUNDING/SUPPORT: This work was supported, in part, by grants from the Agency for Healthcare Research and Quality [K08HS020672 to Dr Cooke], the National Cancer Institute [K07 CA138772 to Dr Wiener], and Health Services Research & Development of the Department of Veterans Affairs [CDP 11-227 to Dr Slatore]. Drs Wiener and Slatore are also supported by resources from the US Department of Veterans Affairs.
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We greatly appreciate the comments from Dr Soares and colleagues, who are right to be concerned that our results will not inform the decision to admit a patient with lung cancer to the ICU.1 Our study does not provide clinicians with information or tools to help inform the decision-making process for ICU admission.1 Instead, it describes temporal changes in, and predictors of, the aggressiveness of care delivered to elderly patients with lung cancer as reflected by use of the ICU. We identified greater ICU use among patients with lung cancer who were younger, as well as those with nondistant disease. These findings suggest that providers are reserving the ICU for patients with the greatest ability to benefit, but more research is required to understand how these decisions are made. Our results do not supplant clinicians’ need to provide prognostic information and elicit preferences for aggressive care when deciding whether to admit a patient to the ICU.
We wholeheartedly agree that the decision to admit a patient to the ICU is complex and dependent on multiple factors. Balancing an individual’s need for critical care and his or her desire for aggressive care with the available resources is one of the greatest challenges facing intensivists. As intensivists have come to recognize that more care does not necessarily represent better care, integrating objective prognostic data into the decision-making process becomes increasingly important. When intensivists do not engage patients with lung cancer and their families about the likely outcomes of ICU admission, they may be providing unnecessary, or worse, unwanted care.2-4
Role of sponsors: The sponsors had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript. The views expressed here are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or the National Institutes of Health.
Other contributions: The work was performed at Oregon Health & Science University and University of Michigan.
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