Patients with malignant brain tumors admitted to an intensive care unit: intensive care or palliative approach?

Due to advanced modern technologies, some progress in recent years has been made in treatment of malignant brain tumors (MBT). However, the prognosis for many patients with malignant brain tumors remains poor. Patients with an expectedly poor prognosis require special attention and care as aggressive therapeutic approaches do not lead to full or partial restoration of function and current therapy is unable to prolong life. In this context, admission to an intensive care unit (ICU) is often inappropriate as the disease is in progress. This situation requires a palliative care specialist consultation along with a medical consilium to discuss the opportunities and goals of medical care and patients’ management in the ICU. The prognosis and realistic treatment goals understanding by relatives is crucial for decision-making, and hospice/palliative care unit/ care or home nursing may be a reasonable alternative to ICU admission. Although the benefits of this approach in terms of reducing ICU burden are obvious, the potential role of palliative care in neuro-oncology is underestimated. Early integration of palliative care into the healthcare system for patients with malignant brain tumors will not only ensure an ongoing clinical monitoring and improve the quality of life but also reduce the number of futile visits of an ambulance and unjustified ICU admissions.

1. Vvedenskaya E. S., Molkov A. М. Palliative care for patients with primary and metastatic brain tumors. Good Clinical Practice, 2025, no. 3, pp. 127–136. (In Russ.). https://doi.org/10.37489/2588-0519-2025-3-127-136. EDN: KDJWJZ.

2. Golanov A. V., Banov S. M., Vetlova E. R. et al. Metastatic brain tumor. Clinical features, diagnosis and treatment. Clinical review for general practice, 2023, vol. 4, no. 5, pp. 37–44. (In Russ.). (In Russ.). https://doi.org/10.47407/kr2023.4.5.00233.

3. Kalyango K., Dyachenko A. A., Bogdanov D. V. et al. Increment of the incidence of glioblastoma following decrease in the incidence of brain tumors in 2000-2020: a population based registry study. Burdenko Neurosurgery Issues, 2022, vol. 86, no. 5, pp. 28–36. (In Russ.). https://doi.org/10.17116/neiro20228605128.

4. The oncological care for the population of Russia in 2024. Edited by A. D. Kaprin, V. V. Starinsky, A. O. Shakhzadova. Moscow, P. A. Herzen Moscow Oncology Research Institute – branch of the National Medical Research Center of Radiology of the Ministry of Health of the Russian Federation, 2025. ill. P. 158 p. (In Russ.).

5. Federal Law “On the Citizens, Health Protection Fundamentals in the Russian Federation” dated November 21, 2011 N 323-FZ. URL: https://www.consultant.ru/document/cons_doc_LAW_121895/ (accessed: 10.01.26). (In Russ.).

6. Bakitas M., Lyons K. D., Hegel M. T. et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial // JAMA. – 2009. – Vol. 302, № 7. – P. 741–749. https://doi.org/10.1001/jama.2009.1198.

7. Barbaro M., Blinderman C. D., Iwamoto F. M. et al. Causes of death and end-of-life care in patients with intracranial high-grade gliomas: a retrospective observational study // Neurology. – 2022. – Vol. 98. – P. E260–E266. https://doi.org/10.1212/WNL.0000000000013057.

8. Bluck S., Mroz E. L., Baron-Lee J. Providers’ perspectives on palliative care in a neuromedicine-intensive care unit: end-of-life expertise and barriers to referral // J. Palliat. Med. – 2019. – Vol. 22. – P. 364–369. https://doi.org/10.1089/jpm.2018.0282.

9. Boersma I., Miyasaki J., Kutner J., Kluger B. Palliative care and neurology: time for a paradigm shift // Neurology. – 2014. – Vol. 83. – P. 561–567. https://doi.org/10.1212/WNL.0000000000000674.

10. Catalisano G., Ippolito M., Marino C. et al. Palliative care principles and anesthesiology clinical practice: current perspectives // J. Multidiscip. Health. – 2021. – Vol. 14. – P. 2719–2730. https://doi.org/10.2147/JMDH.S240563.

11. Chu D., Yen Y. F., Hu H. Y. et al. Factors associated with advance directives completion among patients with advance care planning communication in Taipei, Taiwan // PLoS ONE. – 2018. – Vol. 13. – e0197552. https://doi.org/10.1371/journal.pone.0197552.

12. Climans S. A., Mason W. P., Variath C. et al. Neuro-oncology clinicians’ attitudes and perspectives on medical assistance in dying // Can. J. Neurol. Sci. – 2021. – Vol. 48. – P. 772–778. https://doi.org/10.1017/cjn.2021.186.

13. Crawford G. B., Dzierzanowski T., Hauser K. et al. Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines // ESMO Open. – 2021. – Vol. 6, № 4. – 100225. https://doi.org/10.1016/j.esmoop.2021.100225.

14. Creutzfeldt C. J., Engelberg R. A., Healey L. et al. Palliative care needs in the Neuro-Icu // Crit. Care Med. – 2015. – Vol. 43. – P. 1677–1684. https://doi.org/10.1097/CCM.0000000000001018.

15. Diamond E. L. Panageas K. S., Dallara A. et al. Frequency and predictors of acute hospitalization before death in patients with glioblastoma // J Pain Symptom Manage. – 2017. – Vol. 53, № 2. – P. 257–264. http://dx.doi.org/10.1016/j.jpainsymman.2016.09.008.

16. Dumble K., Driessen A., Borgstrom E. et al. How much information is ‘reasonable’? A qualitative interview study of the prescribing practices of palliative care professionals // Palliat. Med. – 2022. – Vol. 36. – P. 1242–1251. https://doi.org/10.1177/02692163221103471.

17. Fabbro M., Thomaso M., Darlix A. et al. Integrated early palliative care for patients with newly diagnosed glioblastoma: The GLIOSUPPORT feasibility study // Neuro-Oncology Advances. – 2025. – Vol. 7, Is. 1. – vdaf064. https://doi.org/10.1093/noajnl/vdaf064.

18. Ferrell B. R., Twaddle M. L., Melnick A. et al. National Consensus Project Clinical Practice Guidelines for Quality Palliative Care Guidelines, 4th Edition // J. Palliat. Med. – 2018. – Vol. 21. – P. 1684–1689. https://doi.org/10.1089/jpm.2018.0431.

19. Friedenberg A. S., Levy M. M., Ross S. et al. Barriers to end-of-life care in the intensive care unit: perceptions vary by level of training, discipline, and institution // J. Palliat. Med. – 2012. – Vol. 15. – P. 404–411. https://doi.org/10.1089/jpm.2011.0261.

20. Frisella S., Bonosi L., Ippolito M. et al. Palliative care and end-of-life issues in patients with brain cancer admitted to ICU // Medicina (Kaunas). – 2023. – Vol. 59, № 2. – P. 288. https://doi.org/10.3390/medicina59020288.

21. Frontera J. A., Curtis J. R., Nelson J. E. et al. Integrating palliative care into the care of neurocritically ill patients // Crit. Care Med. – 2015. – Vol. 43. – P. 1964–1977. https://doi.org/10.1097/CCM.0000000000001131.

22. Getie A., Edmealem A., Kitaw T. A. Сomparative impact of integrated palliative care vs. standard care on the quality of life in cancer patients: a global systematic review and meta-analysis of randomized controlled trials // PLoS One. – 2025. – Vol. 20, № 4. – P. e0321586. https://doi.org/10.1371/journal.pone.0321586.

23. Giammalva G. R., Iacopino D. G., Azzarello G. et al. End-of-life care in high-grade glioma patients. The palliative and supportive perspective // Brain Sci. – 2018. – Vol. 8, № 7. – P. 125. https://doi.org/10.3390/brainsci8070125.

24. Harrison R. A., Ou A., Naqvi S. M. A. A. et al. Aggressiveness of care at end of life in patients with high-grade glioma // Cancer Med. – 2021. – Vol. 10. – P. 8387–8394. https://doi.org/10.1002/cam4.4344.

25. Ippolito M., Giarratano A., Cortegiani A. Healthcare-associated central nervous system infections // Curr. Opin. Anaesthesiol. – 2022. – Vol. 35. – P. 549–554. https://doi.org/10.1097/ACO.0000000000001167.

26. Kang J. H., Price M., Dalton T. et al. Palliative care use for critically ill patients with brain metastases // J. Pain Symptom Manag. – 2021. – Vol. 62, № 5. – P. 927–935. https://doi.org/10.1016/j.jpainsymman.2021.05.003.

27. Karnik S., Kanekar A. Ethical issues surrounding end-of-life care: a narrative review // Healthcare. – 2016. – Vol. 4. – P. 24. https://doi.org/10.3390/health-care4020024.

28. Koekkoek J. A., Dirven L., Reijneveld J. C. et al. End of life care in high-grade glioma patients in three European countries: a comparative study // J Neurooncol. – 2014. – Vol. 120, № 2. – P. 303–310. https://doi.org/10.1007/s11060-014-1548-5.

29. Kotzé C., Roos J. L. Ageism, human rights and ethical aspects of end-of-life care for older people with serious mental illness // Front. Psychiatry. – 2022. – Vol. 13. – 906873. https://doi.org/10.3389/fpsyt.2022.906873.

30. Libert Y., Langhendries C., Choucroun L. et al. Interventions aiming to improve advance care planning uptake in oncology: a scoping review of recent randomized controlled trials // Curr Opin Oncol. – 2024. – Vol. 36, № 4. – P. 233–247. https://doi.org/10.1097/CCO.0000000000001045.

31. Morris M., Mroz E. L., Popescu C. et al. Palliative care services in the neuroicu: opportunities and persisting barriers // Am. J. Hosp. Palliat. Med. – 2021. – Vol. 38. – P. 1342–1347. https://doi.org/10.1177/1049909120987215.

32. Morrison E. E., Furlong B. Health Care Ethics. 3rd ed. Jones & Bartlett Learning; Sudbury, MA, USA, 2014.

33. Neville T. H., Wiley J. F., Holmboe E. S. et al. Differences between attendings’ and fellows’ perceptions of futile treatment in the intensive care unit at one academic health center: implications for training // Acad. Med. – 2015. – Vol. 90. – P. 324–330. https://doi.org/10.1097/ACM.0000000000000617.

34. Pace A., Dirven L., Koekkoek J. A. F. et al. European association of neuro-oncology palliative care task force. European Association for Neuro-Oncology (EANO) guidelines for palliative care in adults with glioma // Lancet Oncol. – 2017. – Vol. 18, № 6. – e330–e340. https://doi.org/10.1016/S1470-2045(17)30345-5.

35. Paladino J., Bernacki R., Neville B. A. et al. Evaluating an intervention to improve communication between oncology clinicians and patients with life-limiting cancer: a cluster randomized clinical trial of the serious illness care program // JAMA Oncol. – 2019. – Vol. 5. – P. 801–809. https://doi.org/10.1001/jamaoncol.2019.0292.

36. Pottash M., McCamey D., Groninger H. et al. Palliative care consultation and effect on length of stay in a tertiary-level neurological intensive care unit // Palliat. Med. Rep. – 2020. – Vol. 1. – P. 161–165. https://doi.org/10.1089/pmr.2020.0051.

37. Price M., Ballard C., Benedetti J. et al. CBTRUS statistical report: primary brain and other central nervous system tumors diagnosed in the united states in 2017–2021 // Neuro-Oncology. – 2024. – Vol. 26, Is. 6. – P. vi1–vi85. https://doi.org/10.1093/neuonc/noae145.

38. Rivoirard R., Vallard A., Boutet C. et al. A retrospective survey of the last 3 months of life in patients carrying glioblastoma: clinical treatments and profiles // Mol Clin Oncol. – 2018. – Vol. 8, № 1. – P. 115–120. https://doi.org/10.3892/mco.2017.1479.

39. Scanlon A., Murphy M. Medical Futility in the care of non-competent terminally ill patient: nursing perspectives and responsibilities // Aust. Crit. Care. – 2014. – Vol. 27. – P. 99–102. https://doi.org/10.1016/j.aucc.2012.10.003.

40. Sizoo E. M., Braam L., Postma T. J. et al. Symptoms and problems in the end-of-life phase of high-grade glioma patients // Neuro Oncol. – 2010. – Vol. 12, № 11. – P. 1162–1166. https://doi.org/10.1093/neuonc/nop045.

41. Song K., Amatya B., Voutier C. et al. Advance care planning in patients with primary malignant brain tumors: a systematic review // Front Oncol. – 2016. – Vol. 6. – P. 223. https://doi.org/10.3389/fonc.2016.00223.

42. Tan A. C., Ashley D. M., Lopez G. Y. et al. Management of glioblastoma: state of the art and future directions // CA Cancer J Clin. – 2020. – Vol. 70, № 4. – P. 299–312. https://doi.org/10.3322/caac.21613.

43. Tang S. T. When death is imminent: where terminally ill patients with cancer prefer to die and why // Cancer Nurs. – 2003. – Vol. 26, № 3. – P. 245–251. https://doi.org/10.1097/00002820-200306000-00012.

44. Thier K., Calabek B., Tinchon A. et al. The Last 10 days of patients with glioblastoma: assessment of clinical signs and symptoms as well as treatment // Am. J. Hosp. Palliat. Med. – 2016. – Vol. 33. – P. 985–988. https://doi.org/10.1177/1049909115609295.

45. Thorns A. Ethical and legal issues in end-of-life care // Clin. Med. J. R. Coll. Physicians Lond. – 2010. – Vol. 10. – P. 282–285. https://doi.org/10.7861/clin-medicine.10-3-282.

46. Tran L. N., Back A. L., Creutzfeldt C. J. Palliative care consultations in the neuro-ICU: a qualitative study // Neurocrit. Care. – 2016. – Vol. 25. – P. 266–272. https://doi.org/10.1007/s12028-016-0283-5.

47. Walbert T. Palliative care, end-of-life care, and advance care planning in neuro-oncology // Continuum Lifelong Learn. Neurol. – 2017. – Vol. 23. – P. 1709–1726. https://doi.org/10.1212/CON.0000000000000538.

48. Walsh L. E., Polacek L. C., Panageas K. et al. Coping with glioblastoma: prognostic communication and prognostic understanding among patients with recurrent glioblastoma, caregivers, and oncologists // J. Neurooncol. – 2022. – Vol. 158. – P. 69–79. https://doi.org/10.1007/s11060-022-04010-x.

49. Wegier P., Varenbut J., Bernstein M. et al. No thanks, i don’t want to see snakes again: a qualitative study of pain management versus preservation of cognition in palliative care patients // BMC Palliat. Care. – 2020. – Vol. 19. – P. 182. https://doi.org/10.1186/s12904-020-00683-1.

50. Yan H., Kukora S. K., Arslanian-Engoren C. et al. Aiding end-of-life medical decision-making: a cardinal issue perspective // Palliat. Support. Care. – 2020. – Vol. 18. – P. 1–3. https://doi.org/10.1017/S1478951519000981.