Indicators of Clinical Trajectory in Patients With Cancer Who Receive Cardiopulmonary Resuscitation

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Sanjay ChawlaCritical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York

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Cristina GutierrezDivision of Anesthesia and Critical Care, Department of Critical Care, The University of Texas MD Anderson Cancer Center, Houston, Texas

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Prabalini RajendramCritical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio

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Kenneth SeierDepartment of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York

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Kay See TanDepartment of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York

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Kara StoudtCritical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York

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Marian Von-MaszewskiDivision of Anesthesia and Critical Care, Department of Critical Care, The University of Texas MD Anderson Cancer Center, Houston, Texas

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Jorge L. Morales-EstrellaPulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic Health System, Cleveland, Ohio

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Natalie T. KosteleckyCritical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York

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Louis P. VoigtCritical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York

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Background: Patients with cancer who require cardiopulmonary resuscitation (CPR) historically have had low survival to hospital discharge; however, overall CPR outcomes and cancer survival have improved. Identifying patients with cancer who are unlikely to survive CPR could guide and improve end-of-life discussions prior to cardiac arrest. Methods: Demographics, clinical variables, and outcomes including immediate and hospital survival for patients with cancer aged ≥18 years who required in-hospital CPR from 2012 to 2015 were collected. Indicators capturing the overall declining clinical and oncologic trajectory (ie, no further therapeutic options for cancer, recommendation for hospice, or recommendation for do not resuscitate) prior to CPR were determined a priori and manually identified. Results: Of 854 patients with cancer who underwent CPR, the median age was 63 years and 43.6% were female; solid cancers accounted for 60.6% of diagnoses. A recursive partitioning model selected having any indicator of declining trajectory as the most predictive factor in hospital outcome. Of our study group, 249 (29%) patients were found to have at least one indicator identified prior to CPR and only 5 survived to discharge. Patients with an indicator were more likely to die in the hospital and none were alive at 6 months after discharge. These patients were younger (median age, 59 vs 64 years; P≤.001), had a higher incidence of metastatic disease (83.0% vs 62.9%; P<.001), and were more likely to undergo CPR in the ICU (55.8% vs 36.5%; P<.001) compared with those without an indicator. Of patients without an indicator, 145 (25%) were discharged alive and half received some form of cancer intervention after CPR. Conclusions: Providers can use easily identifiable indicators to ascertain which patients with cancer are at risk for death despite CPR and are unlikely to survive to discharge. These findings can guide discussions regarding utility of resuscitation and the lack of further cancer interventions even if CPR is successful.

Submitted April 18, 2022; final revision received August 24, 2022; accepted for publication August 24, 2022.

Author contributions: Study concept and/or design: Chawla, Gutierrez, Rajendram, Seier, Kostelecky, Voigt. Provision of study materials or patients: Chawla, Gutierrez, Von-Maszewski, Rajendram, Morales-Estrella, Voigt. Collection and/or assembly of data: Chawla, Gutierrez, Rajendram, Seier, Tan, Stoudt, Von-Maszewski, Morales-Estrella, Kostelecky. Data analysis and/or interpretation: All authors. Writing and final approval of manuscript: Chawla, Gutierrez, Rajendram, Tan, Von-Maszewski, Morales-Estrella. Integrity and accuracy of data: Chawla, Seier, Tan.

Disclosures: The authors have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: Research reported in this publication was supported in part by the Core Grant under award number P30 CA008748, and by the Department of Anesthesiology and Critical Care Medicine at Memorial Sloan Kettering Cancer Center.

Correspondence: Sanjay Chawla, MD, Critical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C-1179, New York, NY 10065. Email: chawlas@mskcc.org

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