ICU Experience & Transitions

The most common way ethical issues are addressed in the ICU setting is by utilizing ethical frameworks and principles in consultation with interdisciplinary teams. These teams maintain consistent discussions, also known as ethics consultations, to determine the next steps in difficult patient cases and share guidance in ethical decision-making within the context of the situation. Ethical consultations allow interdisciplinary teams to conduct a comprehensive evaluation of the patient’s condition, preferences, values, and conflicts or issues that have emerged during their care, often with the involvement of a bioethicist.  Examining these factors in further detail enables the team to make decisions that are in the patient’s best interest while respecting their autonomy. 

Although there are many clinical decisions that arise in the care of patients in the ICU, those that are most complex often pertain to patients receiving end-of-life care. Deaths in the ICU are frequently associated with medical orders that limit treatment or interventions, such as do-not-intubate (DNI) and do-not-resuscitate orders. However, physicians working in ICU settings do not always receive enough training regarding legal responsibilities and jurisprudential obligations in relation to end-of-life care, which makes ethical consultations with professionals such as ethicists even more of a valuable resource when addressing ethical dilemmas. An example of a common ethical dilemma in the ICU is when the patient is too ill to participate in decision-making and one family member wants to withdraw treatment, but other family members disagree. 

Ethics committees are another excellent resource for resolving ethical issues that arise in the ICU. Ethics committees are responsible for reviewing existing protocols and policies, facilitating training or continuing education regarding ethical issues, and establishing a forum for healthcare providers to share their concerns about ethical matters encountered in the workplace. The use of ethical consultations and the presence of ethics committees help to ensure that all issues are addressed effectively and in a timely manner. Further, these components ensure that healthcare professionals can confidently make informed decisions that will prioritize the welfare of the patients they serve. 

Sources

“Medical, ethical, and legal aspects of end-of-life dilemmas in the intensive care unit”. Cleveland Clinic Journal of Medicine. https://www.ccjm.org/content/88/9/516 

Like any medical intervention, admission to the ICU should be carefully considered by the patient and/or their family and their treating physicians. ICU care will not benefit everyone. For some patients, it is actually harmful in that it merely prolongs a certain death. It can also have a number of very serious, long-term adverse effects.

According to a 1999 article in BJM, the following factors should be weighed before making a decision to admit a patient to the ICU:

• Diagnosis (What is the underlying illness causing the patient’s symptoms?)
• Severity of illness 
• Age
• Coexisting disease (other medical conditions, such as diabetes, heart disease or cancer)
• Physiological reserve (how strong the patient is physically. Extremely frail patients tend to do poorly in the ICU)
• Prognosis ( the likelihood the patient will recover)
• Response to treatment to date 
• Recent cardiopulmonary arrest (The average survival to discharge rate for patients who have had an in-hospital cardiac arrest is only about 20 percent.)
• Anticipated quality of life 
• The patient’s wishes

Patients who are in the end stages of a life-limiting illness such as cancer, renal failure, or chronic obstructive pulmonary disease will typically not benefit from ICU care. In such cases, the aggressive interventions provided in the ICU may not improve the prognosis or quality of life and can potentially lead to unnecessary discomfort.

Age, in and of itself, should not preclude admission to the ICU for a potentially recoverable condition. However, advanced age is often associated with increased frailty, more coexisting conditions, and a lower incidence of long-term recovery. Physicians, families, and patients should weigh the likelihood that an ICU stay will measurably improve a very elderly person’s long-term outcome and quality of life. 

Sources

“Criteria for Admission”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC1115908/ 

“What Are the Chances a Hospitalized Patient Will Survive In-Hospital Arrest?” The Hospitalist. https://www.the-hospitalist.org/hospitalist/article/124220/what-are-chances-hospitalized-patient-will-survive-hospital-arrest

Unfortunately, yes. Researchers have identified many physical, emotional, and psychological effects of an ICU stay, some of which can last for many years. According to the Society of Critical Care Medicine the most common triad of symptoms is known as Post Intensive Care Syndrome or PICS.

Patients who suffer from PICS may have one or all of the following issues:

• ICU acquired weakness: ICU acquired weakness is profound, debilitating muscle weakness that happens during an ICU stay. It occurs in about 30 percent of people who were on mechanical ventilators; half of people who had sepsis; and up to half of all patients who were in the ICU for at least one week. Patients with this condition may take more than a year to recover. During that time, they may be unable to perform even simple activities of daily living, such as bathing, grooming or dressing themselves. 
• Cognitive dysfunction: After discharge from the ICU, 30 to 80 percent of people have difficulty remembering, concentrating, solving problems, organizing their lives or completing complex tasks. Some of these people improve within the first year after discharge. In the interim, they may be unable to return to work or complete activities they once did easily, such as preparing a grocery list or balancing a checkbook. Some people never recover full cognitive function.
• Mental health problems: A significant percentage of patients who are discharged from intensive care suffer serious mental health problems, including depression and posttraumatic stress. Their symptoms can range from insomnia, nightmares, flashbacks and unwanted memories, to feeling hypervigilant, or constantly on edge. They may also be terrified of visiting a doctor and avoid anything that reminds them of their ICU stay. 

Sadly, these physical, cognitive and mental health issues may lead to other major stressors, such as lost wages, loss of employment, and serious financial hardship. Some people are forced to declare bankruptcy or find alternative housing because they can’t pay their bills. Social isolation, loss of identity, anxiety and depression are also common, says the Society for Critical Care Medicine. And, of course, all of the issues affect family dynamics and relationships as well. 

Sources 

“Improving Post-ICU Stay Outcomes: How SCCM’s Discovery Grant Helped Establish an NIH-Funded Study”. Society of Critical Care Medicine. https://www.sccm.org/blog/improving-post-icu-stay-outcomes-how-sccm%E2%80%99s-discovery-grant-helped-establish-an-nih-funded-study 

ICU syndrome or ICU psychosis,is a form of delirium, or acute brain failure, that occurs in patients who are hospitalized in an ICU or similar setting. Patients who develop ICU syndrome may have symptoms such as anxiety, paranoia, agitation and aggression. They may also see and hear things that aren’t there (auditory and visual hallucinations) and exhibit fluctuating levels of consciousness.

Although not a universal phenomenon, ICU psychosis is, unfortunately, quite common. Current estimates state that up to 80% of critically ill patients housed in the ICU will develop this form of delirium, although the exact reason for the reaction is unclear. Some researchers theorize that  sleep deprivation, overstimulation, under-treated physical pain and disruption of normal day-night rhythm may be some causative factors. Loss of control or the sudden and complete change of surroundings may contribute to the problem as well. 

With that being said, there is little empirical research to support these conclusions, and some experts theorize that the underlying mechanisms for delirium in the ICU are physiologic rather than environmental. According to a paper published in JAMA  Internal Medicine, organic causes of ICU syndrome may include metabolic abnormalities, electrolyte disturbances, hypoxia (low blood oxygen) infections, and neurologic problems such as stroke. Patients with certain pre-existing conditions, such as dementia and HIV/AIDS, the elderly, and those with multiple comorbidities are also at greater risk. Lastly, many drugs used in the ICU setting, including sedatives, antihistamines, antibiotics, steroids, opiates,  benzodiazepines and metoclopramide, are associated with delirium, especially in people who are critically ill. 

Regardless of the cause or causes of ICU delirium, its cost to the healthcare system and patients and their loved ones is clear. According to an article published in the Journal of Emergencies, Trauma and Shock delirium in ICU patients is associated with longer duration of mechanical ventilation, longer hospitalizations, higher rates of self-extubation (accidental dislodging of an endotracheal tube), and increased mortality. It can also be a horrific experience for ICU patients, who often suffer long-term cognitive and psychological effects, including PTSD and mild to moderate dementia. 

Fortunately, there is mounting evidence that ICU syndrome can be prevented entirely or its detrimental effects lessened with appropriate care. Apart from correcting metabolic abnormalities, monitoring fluid and electrolyte status, and withdrawing medications that may exacerbate the condition, it has been suggested that modifying environmental noise can significantly lessen a patient’s distress. Suggestions include discontinuing the use of monitors and other equipment as soon as possible, avoiding telephone use near the patient’s bed, adjusting alarm volumes and providing the patient with earplugs. Regularly reminding the patient of where they are and why (e.g., you had an operation; you’re in the hospital;), ensuring that pain is adequately treated, and minimizing interventions during nighttime hours have also been shown to be effective strategies at preventing ICU delirium.

Sources

“The intensive care unit syndrome: causes, treatment, and prevention”. National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/3881234/ 

“Delirium in the intensive care unit”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC2391269/ 

“Intensive Care Unit Syndrome”. JAMA. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/522898 

“After the ICU: What Does It Mean to Be ‘Okay’?” The Atlantic. https://www.theatlantic.com/health/archive/2013/11/after-the-icu-what-does-it-mean-to-be-okay/281609/ 

When a patient no longer requires the highest degree of monitoring or highly specialized types of treatments, they may be transferred out of the ICU to another hospital unit or be discharged home with their family. Often, patients are transitioned to a step-down unit, also known as an Intermediate Care Unit or (IMCU) or Progressive Care Unit (PCU). In a step-down unit, the patient’s heart, circulatory and respiratory system will continue to be monitored. However there is typically not the one-to-one nurse-patient ratio often found in the ICU. From the step-down unit, a patient may be transferred to a regular hospital unit, a rehabilitation center, nursing facility or home. Whatever the situation, a case manager will work closely with the patient and their medical team to determine the best course for a safe and medically appropriate transition. 

In the case that an ICU patient is able to be discharged home, the medical team will provide clear instructions regarding how to take care of the patient after leaving the unit, such as guidance on medications that need for follow-up appointments. Some patients may require home visits from nurses or from physical and/or occupational therapists. 

The ICU team also often provides guidance on any necessary lifestyle changes, including diet modifications or increasing physical activity levels, that may aid the patient’s recovery and ensure they remain healthy after leaving the ICU. In order for a successful transition out of the ICU, it is important that medical instructions are carefully followed and any questions or concerns are promptly addressed with the care team. 

Sources

“The ICU”. UCSF. https://anesthesia.ucsf.edu/patient-care/icu 

Critical care and emergency medicine are two distinct but complementary branches of medical care that provide life-saving interventions to patients with injuries or conditions that require immediate care. However, although both deal with urgent medical situations, they differ in their scope and approach to treatment. Both specialties are crucial in providing life-saving interventions when immediate care is needed and frequently partner to achieve the best possible patient outcome.

Emergency medicine typically focuses on initial stabilization and acute care of patients in medical emergencies, emphasizing making immediate decisions and taking action quickly to prevent death or further injury. Emergency medicine physicians are skilled in making assessments, diagnoses, and treatments for conditions such as cardiac emergencies, trauma, respiratory distress, and other situations that may be life-threatening. Additionally, they are frequently responsible for determining whether a patient needs to be hospitalized or receive other specialized care. 

In contrast, critical care medicine focuses on providing care to patients who require more intensive monitoring and specialized treatment in a critical care unit (CCU) or an intensive care unit (ICU). Critical care physicians, also called intensivists, are skilled in the management of life-threatening conditions and complex chronic medical conditions. They frequently use intensive interventions such as mechanical ventilation, life support, and hemodynamic monitoring. Additionally, they are usually part of a multidisciplinary care team that provides comprehensive patient care for an extended period. Conditions typically requiring critical care include kidney failure, sepsis, shock, or respiratory failure. 

Sources

“Emergency medicine”. University of Michigan Medical School. https://medschool.umich.edu/departments/emergency-medicine/education 

“Critical Care”. MedlinePlus. https://medlineplus.gov/criticalcare.html 

The ICU medical team is composed of many different healthcare professionals who work together to provide specialized care to patients who are critically ill. The team is typically led by a physician known as an intensivist and also includes nurses, psychologists, dieticians, and social workers or chaplains. It can also include a variety of ancillary professionals including occupational therapists, speech therapists, and physiotherapists. 

Intensivists oversee the care of the patients in the ICU and are responsible for making some of the most important decisions that define their care. Intensivists usually have advanced training in a specialty such as internal medicine, pediatrics, surgery, or anesthesiology. A nurse practitioner may also be present and will work closely with the intensivist, along with assisting on important tasks such as interpreting medical tests, performing certain types of procedures, or gathering more information about the patient’s medical history. Most ICU teams have specialized nurses with expertise in critical care. They are knowledgeable about providing complex treatments, monitoring vital signs, administering medications, and coordinating the communication that occurs among patients, families, and healthcare professionals. Additionally, they have an important role in keeping patients comfortable and ensuring that they remain stabilized. 

Other members of the ICU team have very specific responsibilities based on the needs of the patients who will receive their care. Physical therapists and occupational therapists provide support to patients who need rehabilitation services to regain their mobility or strength. If a respiratory therapist is part of the team, they are responsible for the management and monitoring of respiratory function. Dietitians focus on helping patients to regain control of their nutrition and may suggest changes to their diet or the use of a feeding tube. 

Psychologists are usually included if they need to assess the patient’s psychological status or decision-making capacity. However, they may also be present to offer counseling, provide interventions, or help families cope with stress and grief. Social workers in the ICU often spend time addressing the psychological, emotional, and practical needs of patients and their loved ones. They might provide resources, counseling, or aid in the decision-making process. Similarly, chaplains are present to provide spiritual support and may connect patients or their families with a clergy member of their faith for additional guidance. Chaplains are typically involved in end-of-life care settings, but may also be present by request from the patient or their loved ones. 

Sources

“Teamwork in the Intensive Care Unit”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC6662208/ 

“Intensive Care Staff”. The Australian & New Zealand Intensive Care Foundation. https://intensivecarefoundation.org.au/about-intensive-care-units/intensive-care-staff 

The ICU can be an overwhelming place for patients and their loved ones. In the vast majority of cases, ICU patients are attached to numerous machines that monitor heart rate and blood pressure, administer intravenous fluids and medications, and, very often, perform vital functions such as breathing or supporting the kidneys. These machines can be noisy, and it’s not uncommon for alarms to be going off. These alarms are rarely a sign that something is wrong;  most machines have settings that activate an alarm to let staff know that a task, such as adding medication or changing an IV bag, needs to be done. Nonetheless, they can be disconcerting to patients and visitors alike. 

Additionally, most patients in the ICU have many tubes in place These might include:

• a breathing tube through their mouth or nose; 
• a nasogastric tube that goes through the nose into the stomach 
• a tube in the bladder to drain and measure urine output
•  tube in the rectum
• a central line in the arm of neck

Patients who have sustained a head injury may also have a catheter protruding from the skull that’s attached to a machine that measures intracranial pressure. This type of catheter may also be used to drain excess fluid that has built up around the brain. In some cases of head and/or neck injuries, the patient’s head may be immobilized in a device known as a Halo brace. The device is held in place by screws that are temporarily inserted into the skull and may or may not be attached to a pulley that exerts traction on the spine. 

Depending on why the patient is in the ICU, they may also appear swollen or bruised, or have multiple dressings in place. If the person sustained traumatic injuries such as broken bones, they may also have one or more casts, or pins and other hardware in their extremities. 

Although most patients in the ICU are receiving sedatives and pain medicine, they can still hear and perceive some of what is going on. Thus, family and loved ones are generally encouraged to speak to and touch the patient, even if they appear unconscious and are unable to respond. 

Obviously, seeing a loved one in an ICU setting can be very traumatic. The sights, sounds and sometimes frantic pace of activity may overwhelm some visitors, so it’s important to prepare yourself and your family before you arrive. Most ICUs limit visiting hours to short periods throughout the day. But even if the hours are fairly liberal, it’s a wise idea to keep visits short.

Sources

“Intracranial Pressure (ICP) Monitors”. MedScape. https://emedicine.medscape.com/article/1983045-overview#a3?form=fpf 

“Halo Vest”. London Health Sciences Centre. https://www.lhsc.on.ca/critical-care-trauma-centre/critical-care-trauma-centre-295