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RESOLVING PROBLEMS AT THE INTENSIVE CARE UNIT/ONCOLOGY UNIT INTERFACE STUARTJ. YOUNGNER, MARTHA ALLEN, HUGO MONTENEGRO, JILL HREHA, and HILLARD LAZARUS* While the rapid development of medical science and technology has given us the ability to check and reverse life-threatening illness, it has also raised the specter of overtreatment—that is, prolongation of the dying process at the cost of unnecessary suffering and loss of dignity. Decisions to limit life-sustaining treatment have received considerable attention, especially with respect to the proper roles for patients, families , and health professionals in the decision-making process [1-5]. These issues sometimes result in acrimonious interactions between two modern, highly technical, and acute clinical services, the hematology -oncology unit (HOU) and the medical intensive care unit (MICU). Although HOUs are less common in hospitals than MICUs, their numbers are growing as sophisticated technology is increasingly applied to the treatment of cancer patients. This paper will examine the different historical development and clinical perspectives of each of these two highly specialized units in the university setting. These dynamics set the stage for mutual misperceptions, misunderstandings, and communication breakdowns—all of which have adverse consequences for patients, families, and health professionals. Although others have addressed the issues of decision making and the physician-patient relationship with respect to cancer [6-8], we will focus on the interactions between the personnel of the two units. By sharing our own experience and attempts to improve the interaction between the MICU and HOU at University The authors thank Barbara Juknialis of the Center for the Critically 111 at University Hospitals for her editorial assistance in the preparation of this manuscript. They also thank Drs. David AgIe, Nathan Berger, and Oscar Ratnoff for their constructive criticism. ?Authors are from the R. Livingston Ireland Cancer Center, Center for the Critically 111, and the Departments of Medicine, Psychiatry, and Nursing, University Hospitals of Cleveland and Case Western Reserve University School of Medicine. Address: Ireland Cancer Center, University Hospitals, 2074 Abington Road, Cleveland, Ohio 44106.© 1988 by The University of Chicago. All rights reserved. 0031-5982/88/3102-0560$01.00 Perspectives in Biology andMedicine, 31, 2 · Winter 1988 \ 299 Hospitals of Cleveland, we hope to assist other hospitals in which similar situations exist. The Case ofMrs. A A 48-year-old white, married woman was admitted to the HOU in March 1983 with a relapse of acute myelomonocytic leukemia, which had been diagnosed 7 months earlier. Her three previous admissions for induction and intensive consolidation chemotherapy had been complicated by prolonged neutropenia and fevers treated with broadspectrum antibacterial and antifungal agents. The patient was an extremely dependent and fearful person, with a problematic and unstable family situation. During each previous hospitalization , her husband had left her. Her mother and sister, who were overinvolved in her life, constantly manipulated the patient and staff concerning the marital relationship and the patient's adaptation to her illness; they were often more concerned with their own needs than with those of the patient. The patient had developed a close and dependent relationship with the staff on the HOU during her lengthy hospital stays; they provided the reliable and consistent family support she lacked. During this admission for acute leukemia in first relapse, she was treated with intensive chemotherapy. The first 2 weeks of her hospital course were relatively uneventful, except for the persistent pancytopenia that appeared after chemotherapy. In the third week, however, she developed fever and shortness of breath. Severe hypoxia, tachypnea, and pulmonary infiltrates developed coincident with early recovery of peripheral neutrophil count. The HOU personnel discussed with the patient and family the transfer to the MICU for more intensive support, including the possibility of mechanical ventilation. When her condition worsened over the next few days, she was indeed transferred to the MICU. The patient was frightened about her deteriorating medical situation and about leaving the familiar and supportive HOU environment. The HOU staff shared with the patient and her family their conviction that she could survive this lifethreatening crisis. The patient and her family were given a description of the MICU environment and procedures likely to be instituted shortly after arrival. They were cautioned that family visits would be more restricted...


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