This is probably going to draw out fire from gutonc but I detest the oncologists in my area for these types of patients. When your CM is so bad from chemo that you need ECMO to prolong life....you should probably be being enrolled into hospice, not cannulated for ECMO. So many of the sickest patients at the final stages of life, if you can even call it life, end up in the unit requiring massively laborious, expensive and often painful invasive procedures that in no way will affect there 30-60 day mortality. Most often I have found, these patients have never had a true sitdown and explanation of just how sick they are. Or they cant comprehend anymore because they are just too sick and they have a family member making decisions who has no idea how sick they are.
I am sure it has a lot to do with the individuals at my place but I have found the heme/onc skillset of our docs is great...for pts that need aggressive therapy and treatment to try and extend their lives in a meaningful way. IE if my otherwise healthy 65 y/o mother was diagnosed with lunc ca....I would want her aggressively treated and they would do great here.
Conversely if my decrepit 92 y/o grandmother with 3 prior MIs, 2 strokes, artificial hips and knees, an EF of 20 andhorrible functional status, was found to have colon ca with mets....theyd also be guiding her towards full code and chemo/rads/sx. The palliative care is very much lacking here. and more often then not, the old, sick cancer pts who are nearing the end of their lives are the pts that end up in MICU sick as death with no chance of meaningful recovery and yet thousands of dollars of labor and services pumped into them for them to suffer theire last few days. I think this is an area of medicine that really needs to be addressed.
the ECMO example is the epitomy of this. not a VAD candidate, not a tranplant candidate. failing maximal medical therapy. well, then its the end. ecmo is a bridge. and if there is nothing at the end of the bridge then the pt should not be offered it. I approach the vent the sameway to a degree. If your a gold stage 4 copd'r, still smoking, with an ef of 5-10%, horrible dyspnea at rest on 02 24/7 and virtually bipap dependent, and NOT a heart/lung transplant candidate, vad candidate, bypass candidate, "enter therapy X candidate here"...the vent will do nothing but keep you alive long enough for a family member to have to painfully terminally extubate you. I have found it is much easier on the family to make the decision to not initiate rather than to withdraw. they feel less resonsible for the inevitable death.
anyway, that last post really triggered my palliative care thoughts. sorry to derail the convo.