Heroic measures when treating patients with hematologic malignancies - the economic cost of survival

The survival of patients with hematologic malignancies who require admission to the intensive care unit (I.C.U.) is poor. The potential for cure in this group of patients necessitates aggressive treatment that can result in life-threatening complications. A medical, ethical and financial dilemma arises when aggressive therapy and intensive support is balanced with actual survival, meaningful survival and the financial burden to society and the patient's family. We collected complete financial information on 64 leukemia and lymphoma patients admitted for the first time to the intensive care unit (I.C.U.) at the H. Lee Moffitt Cancer Center and Research Institute between 7/1/88 and 6/30/90. The charges were calculated from actual itemized statements and included all inpatient and out-patient charges. Survival was addressed by individually evaluating candidate variables with parametric and non-parametric analysis. Survival after I.C.U. admission and hospital discharge were studied as dependent variables in a stepwise multiple regression analysis. The nadir of the platelet count and albumin level prior to and during the I.C.U. admission significantly affected survival. During the I.C.U. admission, the BUN, serum creatinine and the need for mechanical ventilation significantly affected survival. Seventy-eight percent of patients survived less than five months and spent less than two and one half months at home. Fifty percent of patients expired during the I.C.U. admission. Only 3.2% of patients who had received two or more chemotherapeutic regimens had survived more than one year. The cost per year of life gained for the entire group of patients was $189,339. The results of this study show that the majority of leukemia and lymphoma patients who are admitted to the I.C.U. expire prior to discharge or spend a minimal amount of time at home prior to expiring. This study suggests that the cost of meaningful survival must be borne in mind by physicians and should encourage them to discuss treatment options, potential outcomes, risks and benefits so that a reasonable strategy can be planned by the physician, patient and family prior to treatment.