Intensive Care Unit (ICU)

An intensive care unit is an area of a hospital in which critically ill people get highly specialized care, such as monitoring of vital functions and advanced life support. In some hospitals, the ICU may be called a critical care unit, an intensive treatment unit or an intensive therapy unit. These terms all mean essentially the same thing. 

Since the care provided in an intensive care unit is so specialized, there are a number of different types of ICUs. Some of the most common include:

• Coronary care or coronary/thoracic units (CCU or CTU), for patients who have had heart surgery or suffered a heart attack or other serious heart-related event.
• Surgical intensive care unit (SICU) for seriously ill patients who have had surgery
• Medical intensive care unit (MICU), for patients who have serious medical issues, such as liver, kidney or respiratory failure
• Long-term intensive care unit (LTAC ICU) for critically ill patients who require long-term care (for example, patients who are in a persistent vegetative state and need chronic ventilator support
• Pediatric intensive care unit (PICU) for critically ill children
• Neonatal intensive care unit, (NICU) for seriously ill and premature newborns

Some hospitals also house other specialized units, such as a burn, trauma or neurosurgery intensive care units, which deliver critical care to patients with life-threatening injuries. 

It’s worth noting, however, that not all hospitals in the U.S. have intensive care units, a deficiency highlighted by the SARS-COV-2 (COVID-19) pandemic of 2020-2022. According to data from KFF Health News, more than half of U.S. counties have no ICU beds at all, and a startling number have no hospital or emergency room. Additionally, the number of ICU beds per capita varies enormously, even within states, with the highest concentration being in wealthy urban areas. Rural and economically depressed urban areas are less likely to have either a hospital or a hospital with an ICU. 

The History of  ICU Care

The concept of the ICU dates back to the early 1950s, when the polio epidemic surged across the globe. The disease had been recognized since the late 1800s, and sporadic epidemics, mostly in the summer months, had claimed thousands of lives. Victims died of respiratory paralysis and bulbar palsy, which made it impossible for them to swallow their own secretions or to breathe effectively on their own. The only treatment available for these critically ill patients was an iron lung or a Cuirass ventilator, both of which used alternating air pressure to stimulate breathing. But there were far too few of these devices available, and they were woefully inadequate at saving lives. As a result, the mortality rate for polio patients with respiratory failure was close to 90%. 

Then, in 1952, the polio epidemic hit Copenhagen, Norway, and the city’s only infectious disease hospital was overwhelmed. The hospital had just one iron lung and six Cuirass ventilators, and there were hundreds of patients in respiratory failure needing care. Desperate for a solution, the chief physician at the hospital, Dr. Henry Cai Alexander Lassen, reached out to a colleague, Dr Bjorn Ibsen, an anesthesiologist. Specifically, Lassen wanted to explore the possibility of using positive-pressure ventilation to treat patients with respiratory paralysis due to polio. The technique had been used to support anesthetized patients in operating rooms for years, and Lassen hoped that Ibsen could provide some guidance on using it to save polio victims’ lives. 

Two days after the two doctors met, Ibsen performed a tracheostomy on a 12-year old girl suffering from polio-induced respiratory paralysis and bulbar palsy. After inserting the tracheostomy tube, he began manually inflating the girl’s lungs with a collapsible bag like those used during surgery. The girl’s condition immediately improved. 

Encouraged by the girl’s response,  Ibsen and Lassen devised a bold plan. They placed tracheostomies in the most seriously ill polio patients in the hospital at the time and recruited medical students to manually ventilate them around the clock — literally standing at the bedside, squeezing a bag delivering a mixture of oxygen and nitrogen to their failing lungs. According to one report, at the height of the epidemic, there were at least 250 medical students caring for over 70 patients at the same time. 

Somewhat astonishingly, the approach was successful. Despite the lack of sophisticated equipment and the dreadful amount of labor involved, the mortality rate for polio patients with respiratory paralysis in Copenhagen dropped from close to 100 percent to about 40 percent within the year. Encouraged, Ibsen proposed that all such patients be housed in a dedicated unit, each with their own nurse. This dedicated unit at Blegdam Hospital in Copenhagen opened in December 1953, becoming the prototype for the modern-day ICU. 

Since Ibsen first introduced the ICU concept, technological advancements, including mechanical ventilators, invasive monitoring techniques, and advanced life-support systems, contributed to the rapid evolution of ICU care. As of this writing, there are approximately 6,000 ICUs in the U.S. housing a total of about 68,000 beds. 

What Types of Patients Are Treated in the ICU?

Patients are admitted to the ICU with many different types of illnesses and injuries. According to the Society for Critical Care Medicine, the conditions most commonly seen in adults who require ICU care are:

• Respiratory illnesses such as pneumonia that require supplemental oxygen, a breathing tube and a breathing machine
• Acute myocardial infarction, also known as a heart attack
• Stroke due to bleeding or a blood clot in the brain
• Post-operative care following extensive surgery
• Post-operative care following a percutaneous cardiovascular procedure with a drug-eluting stent (a procedure to open a blocked artery in the heart)
• Septicemia or severe sepsis (an overwhelming blood infection)

Additionally, many people are admitted to the ICU for trauma related to an accident, such as a car crash, a fire, or a severe fall, or an intentionally inflicted injury such as a gunshot wound. Poisoning due to drug overdose; heart, respiratory and/or kidney failure; gastrointestinal bleeding; and complications of diabetes may also land a person in the ICU. 

In children, the most common reason for ICU admission is respiratory illness, according to the SCCM. Additionally, over 50% of children who are treated in the PICU have complex chronic conditions, such as cerebral palsy, chromosomal abnormalities and congenital heart defects. Neonates, on the other hand, are mostly admitted to the NICU for low birth weight secondary to prematurity. The usual criteria for admission is birth weight under 1,500 grams (3.3 pounds) and/or severe prematurity requiring ventilator support. Full-term, normal birth weight infants may require intensive care when they inhale amniotic fluid containing meconium, a condition known as meconium aspiration syndrome. Neonatal sepsis and a deadly condition known as necrotizing enterocolitis also require ICU care. 

What Kind of Care Is Provided in the ICU? 

In the ICU setting, patients are cared for by a highly skilled team of caregivers led by an intensivist, a physician who is board-certified in critical care. Unlike other physician specialists, who typically focus on one body system (for example, the heart, the lungs, the kidneys, or the liver), these doctors are skilled at managing multiple comorbidities — medical conditions that occur in the same person at the same time. The intensivist calls on other specialists as the need arises and works with them to coordinate patient care. 

In addition to doctors, the ICU team typically consists of specially trained nurses who are experts in critical care, respiratory therapists, and one or more pharmacists. A physical and/or occupational therapist, a nutritionist,, a social worker and a chaplain are often part of the team as well, and are called in to consult depending on the patient’s needs. 

Once admitted to the ICU, patients typically undergo an array of highly invasive treatments and procedures. According to the Critical Care Innovations Group at the University of California, San Francisco, some of the most common of these are:

• Intubation and mechanical ventilation — a procedure in which the doctor inserts a tube into the patient’s windpipe, which is then attached to a machine that helps the person breathe, or breathes for them if they can’t breathe on their own.
• A central venous catheter —  similar to an intravenous catheter inserted into a small vein in the arm or hand,  a central venous catheter (also called a central line) is a much larger catheter that a doctor inserts into a large vein in the arm or the neck. This larger catheter lets the ICU staff administer large amounts of fluids, medications and/ or blood products to the patient quickly and safely. It also allows the staff to monitor the blood pressure in a large vein that is close to the heart, which makes it easier to titrate medications and fluids effectively.
• Vasopressors —  medicines that help stabilize a person’s blood pressure when they are in shock. Shock is a state in which a person’s blood pressure is too low to maintain blood flow to vital organs, such as the heart, lungs, kidneys and brain. Shock can result from a number of conditions, including infection, heart failure, blood loss, and trauma. 
• Continuous renal replacement therapy, (CRRT or continuous dialysis) —  a procedure in which the patient is attached to a machine that continuously removes excess fluid and toxins from their blood. CRRT is used to treat acute kidney failure, which is a common development in patients who are seriously ill. 

Unfortunately, the highly invasive nature of ICU care can lead to a host of complications, which can both exacerbate the patient’s underlying condition and create new problems that didn’t exist before. Some of the most common and most serious of these complications are infections, including ventilator-associated pneumonia and blood infections, which often arise from a central venous catheter. Urinary tract infections are also common due to the use of indwelling urinary catheters to measure urine output. These infections typically start in the bladder, but they can spread to the kidneys, where they can cause serious complications, sepsis, and even death. ICU patients who undergo surgery may also develop surgical site infections, especially if the surgery involves the repair of a traumatic injury. 

Nor are infections the only serious complications ICU patients encounter. Acute kidney injury occurs in up to 50 percent of patients, which can progress to acute kidney failure necessitating CRRT. Elderly patients who have heart or liver failure or preexisting kidney disease are at greatest risk, as are patients who receive drugs known to damage the kidneys, such as certain antibiotics, NSAIDS and contrast dyes. Infections, sepsis, shock and the need for ventilator support are also associated with a higher risk of kidney damage in the ICU. According to a report published in the journal Chest in 2018, about 5- 10% of patients who develop acute kidney injury will progress to acute kidney failure, and between 30 and 70% of those patients will die. 

ICU patients may also develop stress ulcers that result in severe gastrointestinal bleeding, and venous thromboembolism or VTE. A life-threatening complication, VTE occurs when a blood clot forms in a vein in the leg, groin or arm (this is known as a deep-vein thrombosis or DVT) and travels to the lung, causing a deadly pulmonary embolism. Today, most ICUs use a variety of methods to try to prevent VTE, including compression stockings, intermittent pneumatic compression devices and  “blood thinning” agents such as heparin. 

Ventilated patients are also at risk of pulmonary barotrauma —  lung damage caused by excessive pressure within the lungs. This may occur due to high-pressure mechanical ventilation or by ventilator settings that are changed too rapidly. In either case, the small air sacs in the lungs that are responsible for gas exchange rupture, causing air to enter the chest cavity and restrict breathing. This is a medical emergency that typically requires the insertion of a chest tube. 

Lastly, but by no means less importantly, medical and nursing errors are common in the ICU due in large part to the complexity of care. According to one study from 2008, the vast majority of these (78%) are medication errors. However, errors involving other aspects of patient care, such as fluid management, maintenance of blood pressure, and communication between caregivers are common as well. Not all of these result in adverse patient outcomes, but many of them do.

Obviously, being cared for in the ICU is fraught with risk, though there is no doubt that — in the right circumstances — ICU care can save lives. Accurate data about the number of patients who are discharged from the ICU alive is difficult to come by, since outcomes vary widely depending on the hospital and the characteristics of patients it serves. But according to an article published in the journal Critical Care in 2013, mortality for all ICU patients has been falling for the last several decades, and now stands at about 12 percent. (Although a more recent analysis places the number at about 22 percent.) It would be foolish, however, to assume that this number applies to all patients admitted to the ICU. Age, illness severity, and diagnosis are important factors that greatly influence a person’s chance of surviving an ICU stay. Still, the numbers suggest that the vast majority of patients who enter the ICU will be discharged alive. 

Sadly, however, the truth is that being discharged from the ICU doesn’t mean that a person is “out of the woods”. According to an analysis of over 40,000 patients who were discharged from the ICU over a seven year period in Wales, about one in five patients died within one year. About half of these patients died before leaving the hospital, and most deaths occurred within three months. The risk of dying was highest in people who had spent the most time in the hospital, those who were elderly, and those who suffered from multiple disease processes. Patients who lived in low-income communities or communities without a local hospital had a greater chance of dying as well.  

In conclusion, the ICU is a vital component of the U.S. healthcare system, specifically designed to care for patients with life-threatening illnesses and complications The conditions treated in these units vary widely, encompassing severe trauma, respiratory distress, cardiac crises, and post-operative complications, among others. While the survival rates fluctuate depending on the condition, severity, and individual patient factors, the ICU’s primary goal remains providing specialized, intensive care to enhance patients’ chances of recovery. The evolution of the ICU is a remarkable testament to the advancements in medical technology, along with the growing understanding of patient care needs and high-quality healthcare standards.

Sources

“What to Know About Drug Eluting Stents”. WebMD. https://www.webmd.com/heart-disease/what-to-know-about-drug-eluting-stents 

“Sepsis”. MedlinePlus. https://medlineplus.gov/sepsis.html 

“Meconium Aspiration Syndrome (MAS)”. Nemour’s Kids Health. https://kidshealth.org/en/parents/meconium.html 

“Necrotizing Enterocolitis”. Children’s Hospital Los Angeles. https://www.chla.org/necrotizing-enterocolitis 

“Central Venous Catheter”. American Thoracic Society. https://www.thoracic.org/patients/patient-resources/resources/central-venous-catheter.pdf 

“Common Complications in the Critically Ill Patient”. Elsevier. https://maryland.ccproject.com/wp-content/uploads/sites/3/2013/12/To-KB-Surg-Clin-North-Am-2012-Common-complications-in-the-critically-ill-patient.pdf 

“Nosocomial infections in the intensive care unit: Incidence, risk factors, outcome and associated pathogens in a public tertiary teaching hospital of Eastern India”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC4296405/ 

“Ventilator-associated Pneumonia Basics”. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/ventilator-associated-pneumonia/about/?CDC_AAref_Val=https://www.cdc.gov/hai/vap/vap.html 

“Acute kidney injury in the ICU: from injury to recovery: reports from the 5th Paris International Conference”. Annals of Intensive Care. https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-017-0260-y 

“Acute Kidney Failure”. Healthline. https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-017-0260-y 

“Continuous Renal Replacement Therapy”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC6435902/ 

“VTE Risk Assessments”. World Thrombosis Day. https://www.worldthrombosisday.org/know-thrombosis/for-heath-professionals/vte-risk-assessments/#:~:text=Venous%20thromboembolism%20(VTE)%20is%20a,as%20pulmonary%20embolism%2C%20PE). 

“Stress ulcers in the intensive care unit: Diagnosis, management, and prevention”. UpToDate. https://www.uptodate.com/contents/stress-ulcers-in-the-intensive-care-unit-diagnosis-management-and-prevention 

“DVT Prevention: Intermittent Pneumatic Compression Devices”. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/dvt-prevention-intermittent-pneumatic-compression-devices 

“Pulmonary barotrauma: What to know”. Medical News Today. https://www.medicalnewstoday.com/articles/pulmonary-barotrauma 

“Chest Tube Insertion”. MedlinePlus. https://medlineplus.gov/ency/article/002947.htm 

“Medication errors in critical care: risk factors, prevention and disclosure”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC2670906/ 

“The five most common errors in the ICU”. Today’s Hospitalist. https://todayshospitalist.com/errors-icu/ 

“Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC4057290/ 

“Determinants of long-term outcome in ICU survivors: results from the FROG-ICU study”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC5774139/ 

“High risk of death in the year after ICU discharge; more hospital days linked to higher mortality”. Medical XPress. https://medicalxpress.com/news/2018-11-high-death-year-icu-discharge.html 

“Medical Aspects of the Persistent Vegetative State”. The New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJM199405263302107 

“Millions Of Older Americans Live In Counties With No ICU Beds As Pandemic Intensifies”. KFF. https://kffhealthnews.org/news/as-coronavirus-spreads-widely-millions-of-older-americans-live-in-counties-with-no-icu-beds/ 

“Cuirass Ventilator”. Science Direct. https://www.sciencedirect.com/topics/nursing-and-health-professions/cuirass-ventilator 

“Intensive care medicine is 60 years old: the history and future of the intensive care unit”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC4952830/ 

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  

There are many questions that family members can ask the intensive care unit (ICU) team. These questions will help the family stay informed about their loved one’s condition and provide insight that may support essential decisions surrounding their care. Additionally, knowing who to direct your questions can ensure you receive a timely answer. The following questions can be very helpful when interacting with the physician, or intensivist, responsible for a loved one’s care. 

• What is the current condition of my loved one? What is wrong?
• How is their pain being managed? 
• Are any operations or procedures needed? What are the potential complications? 
• What treatments are being administered? Why? 
• What are the goals of my loved one’s treatment plan? 
• How long is the expected duration of the ICU stay? 
• Is my loved one expected to recover? If they cannot recover, what should be done? 
• What should we do if we don’t have power of attorney or a living will? 

Family members can take an active role in their loved one’s care by asking for information about their condition, treatment plan, prognosis, and other details. Maintaining effective communication with the ICU team ensures that family members are able to make an informed decision regarding interventions and treatments if needed. General questions about visiting a loved one, adhering to ICU policies or hospital etiquette, or information about certain types of procedures can be directed to nurses. These questions may include:

• Are there any guidelines or restrictions for visiting the ICU? 
• When are visiting hours? Is anyone allowed to stay overnight? 
• What do the other members of the ICU team do? How do they help my loved one?
• How do we arrange for religious clergy to visit?
• Will you call at night if anything changes regarding my loved one’s condition? 
• Is it okay if we stay in the room when a procedure is conducted? 
• What resources or support services are available? 

While it is not always possible due to circumstances, preparing questions ahead of time can empower families of patients in the ICU to be effective advocates for their loved ones and provide valuable input to the ICU team. 

Sources 

“ICU Patient Questions to Ask”. ICU Answers. https://www.icuanswers.com/icu-patient-questions.html 

“Intensive Care Units”. The Austrailian and New Zealand Intensive Care Foundation. https://intensivecarefoundation.org.au/patients-families/intensive-care-units 

A variety of support services for families of ICU patients are available including hospital-based services, ICU support groups, and community organizations. Since families typically experience high levels of stress and difficult emotions when a loved one is admitted into the ICU, having access to resources can help them cope as they navigate the uncertainty of the situation. Hospitals often have patient advocates, social workers, or family support specialists on their ICU team to provide additional guidance, emotional support, and general education regarding important decisions that may need to be made. 

ICU support groups can be a helpful resource for patients and their families. These groups provide a space for family members to express their concerns and fears or talk about their experience with other individuals who have a loved one in the ICU. Sometimes group members might share advice or support, but other times, they might simply listen to each other and share their empathy. This helps families of ICU patients to feel less isolated or alone since these shared interactions provide validation of their emotions and concerns. 

In most cases, organizations in the local community also have resources available. Some may provide counseling, educational material, financial support, or transportation to help reduce some of the burden that families may experience while a loved one is in the ICU. Nonprofit organizations and charities are often a great source for additional support and guidance. If you are uncertain about organizations available in your community, a hospital social worker can usually locate and provide additional information about potential options.

Sources

“ICU Patient and Family Resources”. Atlantic Health System. https://ahs.atlantichealth.org/conditions-treatments/intensive-care/icu-resources.html 

“Support Groups”. Mayo Clinic. https://connect.mayoclinic.org/groups/ 

Many intensive care units (ICUs) have implemented policies that allow and support family participation in the care of loved ones, although the guidelines may vary. The involvement of family members is an important component of patient-centered care, and many ICUs recognize the benefits that participation can offer to both patients and their families. Studies have found that families appreciate being able to participate in the care of their loved ones, and likewise, their participation contributes to the patient’s healing and a reduction in readmission rates. 

Family participation in ICU care can help patients feel less stressed and increase feelings of safety due to having someone familiar take care of them and advocate for their preferences. Participation in the patient’s care in the ICU may also reduce family members’ feelings of helplessness and build confidence in their ability to manage essential care activities when their loved one is discharged to the home.

Carfe activities that family members may be allowed to participate in include:

• Bed bathing 
• Hair care
• Toileting 
• Applying body lotion
• Cleaning nose 
• Mouth care
• Tracheal suctioning 
• Mobilization 
• Assisting with feeding 
• Repositioning 
• Massage 
• Aspirating secretions from mouth 

Family participation in essential care can also help foster a greater sense of partnership between the family and the ICU team. It ensures that the patient can receive the most appropriate care possible while also supporting the psychological and emotional needs of the visiting family. Finally, it can provide a greater sense of comfort to the patient since they know that they are actively being monitored and cared for by a trusted loved one who is aware of their needs, preferences, and values. 

Sources

“Engaging Family Members in Care of Hospitalized Loved Ones Enhances Healing, Reduces Readmission Rates, New Study Finds”. Intermountain Health. https://news.intermountainhealth.org/engaging-family-members-in-care-of-hospitalized-loved-ones-enhances-healing-reduces-readmission-rates-new-study-finds/ 

“Family participation in essential care activities: Needs, perceptions, preferences, and capacities of intensive care unit patients, relatives, and healthcare providers—An integrative review”. Science Direct. https://www.sciencedirect.com/science/article/pii/S1036731422000297 

When a patient’s condition deteriorates and ICU admission is considered, the healthcare provider facilitates a transparent conversation with the patient and their family to set expectations and ensure that the patient’s values, preferences, and treatment goals are taken into account. This discussion includes a review of the patient’s condition and reasons for potential admission, an explanation of the prognosis, and an exploration of available treatment options. 

An explanation of potential risks and benefits associated with treatment is provided along with details regarding the required level of care and monitoring necessary based on the patient’s condition. Throughout this discussion, the patient and their family are encouraged to ask questions or share their concerns. The patient is ultimately responsible for deciding whether they want to continue with the ICU admission or if they would prefer alternative treatment options. However, if the patient is incapacitated due to their condition, the designated healthcare proxy or next of kin is responsible for making the admission decision on their behalf. Any decisions made should be in alignment with the patient’s wishes and preferences, if previously indicated. 

Healthcare providers aim to create a patient-centered and collaborative experience that emphasizes the values and wishes of the patient and their family. Achieving a partnership with patients and their families helps to ensure that decisions respect patient autonomy and remain in the best interest of the patient at all times. Ultimately, engaging patients and their families in ICU admission decisions is one way to establish a therapeutic relationship and uphold patient-centered care, increasing the likelihood of a better outcome for everyone involved. 

Sources

“When a Loved One Is in the Intensive Care Unit”. VeryWell Health. https://www.verywellhealth.com/what-to-expect-when-your-loved-one-is-in-the-icu-4147672 

“4 Questions To Ask if Your Loved One Is in the ICU”. Cleveland Clinic. https://health.clevelandclinic.org/4-questions-to-ask-if-your-loved-one-is-in-the-icu 

Visiting loved ones in the ICU can be a difficult and emotional experience, but it’s valuable for patients to have support from family and friends. Just be mindful of the loved one’s energy and tiredness levels and adjust your visits accordingly. Before scheduling a visit, it is important to know the particular ICU’s rules, as they are in place to ensure that the patient’s stay is safe and comfortable.

In general, only two visitors are allowed per ICU visit, though the number of visitors per day varies depending on the hospital. Sometimes the visitors will be limited to immediate family members and significant others, and often children under 12 or even 16 years of age are not allowed, though exceptions may be made for family. There are often more limited visiting hours than other units, sometimes with limits on how long each visit can be. 

Preparing to visit the ICU

Visitors to the ICU should not be sick or have any symptoms associated with an illness or infection, such as a cold, the flu, or gastrointestinal issues. Many ICUs require visitors to wear masks at all times while in the unit, some require gowns and gloves, and all follow strict hand hygiene protocols. To ensure that ICU patients receive the best care possible, visitors should not stay too long and allow room for medical staff to do their work. To this end, large gifts like balloons or flowers are often barred. It’s also helpful to check with a nurse about bringing in and/or using cell phones and electronics before entering the patient’s room. The same is true when it comes to bringing or sharing food or beverages, even water. 

Bringing small gifts or cards, and, for immediate family members, their medical history and any advance directives, is often welcome.

As hours and protocols vary, ICU visitors should contact the hospital ahead of time to confirm times and any other rules. With some small adjustments, visitors can be a source of comfort and support for their loved ones while they stay in the ICU.

Sources

“Intensive Care Unit (ICU) Guidelines”. UMass Memorial Health. https://myhealth.umassmemorial.org/RelatedItems/3,83280 

“Visiting Guidelines”. Allina Health. https://www.allinahealth.org/mercy-hospital/services/intensive-care-unit/visiting-guidelines 

“The Intensive Care Unit (ICU) Visitors’ Guide”. Memorial Sloan Kettering Cancer Center. https://www.mskcc.org/cancer-care/patient-education/intensive-care-unit-icu-visitors-guide 

It can be highly nerve-racking when a loved one is admitted to the Intensive Care Unit. However, it is not an indication that the patient will die. Many people recover after admission to the ICU and can transition to a regular hospital unit or home.

When a loved one goes into the ICU, typically it is because they require more advanced care, such as additional monitoring or treatments that are not available in a regular hospital room. The ICU team of health professionals will closely assess the patient’s condition and provide additional support to help them recover and stabilize.

According to the Society of Critical Care Medicine, the mortality rate for ICU patients varies widely, from 10% to 29% for adult patients. It’s essential to remember that the prognosis hugely depends on factors such as the reason for admission, any underlying health conditions or comorbidities and age. Each patient’s situation is unique, and these statistics do not necessarily predict individual outcomes. It is always best to speak directly with the healthcare team for the most accurate information regarding your loved one’s condition and prognosis.

Sources

“When a Loved One Is in the Intensive Care Unit”. VeryWell Health. https://www.verywellhealth.com/what-to-expect-when-your-loved-one-is-in-the-icu-4147672 

“Critical Care Statistics”. Society of Critical Care Medicine. https://www.sccm.org/communications/critical-care-statistics

Any stay in the ICU is stressful and anxiety-inducing, and this is especially true when the patient is not going to get better. Whether spiritual or religious before entering the ICU, connecting with spiritual support in this unfamiliar scenario can provide comfort and reassurance both for the patient and their decision-makers or caregivers. If you do not have a resource already identified, ask the staff to contact the hospital chaplain who can offer spiritual support for patients of any religion, or none at all. 

A hospital chaplain can help facilitate religious rituals you may want to incorporate into your end-of-life care, join or lead you and your loved ones in prayer, and advocate for your spiritual or religious needs with your medical team. If you prefer to have someone from a different religion or a specific church, temple, or synagogue visit, the chaplain can connect you with local resources or likely make the arrangements you would like. Also, as valuable as the spiritual support of a chaplain is, don’t be shy about making religious needs known to your doctor or other members of your medical team. Any healthcare professional should have high sensitivity to the situation and be amenable to supporting your specific spiritual desires during end-of-life care.

Sources

“Study shows enhanced spiritual care improves well-being of ICU surrogate decision-makers”. Newswise. https://www.newswise.com/articles/study-shows-enhanced-spiritual-care-improves-well-being-of-icu-surrogate-decision-makers 

“What is a hospital chaplain?” Advent Health University. https://www.ahu.edu/blog/what-is-a-hospital-chaplain 

Navigating the end-of-life process in any scenario can feel overwhelming and emotionally taxing — this can feel even more true when you or your loved one is in the unfamiliar surroundings of the ICU. There are several resources and organizations that offer guidance, support and information, both for the person nearing end of life, and their family, friends and caregivers. 

In-hospital resources:

• Hospital Social Workers — Many hospitals have social workers who specialize in end-of-life care and can provide emotional support, help with decision-making and connect families with resources.
• Hospital Chaplaincy Services — Most hospitals have chaplains or spiritual care providers who offer support and spiritual guidance to patients and families during times of crisis and loss. However, you or your loved one needn’t be religious in order to seek a chaplain’s support.
• Palliative Care Teams — Increasingly, ICUs are offering palliative care; such a care team specializes in providing relief from the symptoms and stress of serious illness. They work alongside the primary medical team to address physical, emotional and spiritual needs of patients and families.
  • CaringInfo (part of the National Hospice and Palliative Care Organization) has a robust collection of online resources related to serious illness and care.

Beyond the hospital: 

• Support Groups — Support groups for families of ICU patients, or individuals navigating end-of-life in the ICU, provide a safe space to share experiences, receive support and learn to move through grief. You can ask a hospital social worker for information about local, in-person groups or connect with online communities, such as at ICUSteps or the online ICU Support Group from the Mayo Clinic.
• Online Resources — In addition to support groups, there are many online resources and even a hotline that can provide information and support for individuals and families managing end-of-life in the ICU.
  • ICUSteps has a fantastic and thorough End of Life In ICU Guide (also available as a PDF).
  • The Conversation Project has an excellent Guide for Talking With a Health Care Team, in addition to several other end-of-life guides.
  • You can receive a free booklet, Understanding Your ICU Stay: Information for Patients and Families, from the Society of Critical Care Medicine.

You are not alone during this challenging time, and it can be helpful to know that there are many resources and forms of support available — both inside and outside of the hospital — to help you and your loved ones through this particular end-of-life journey.

Sources

“Patient Communicator App”. Society of Critical Care Medicine. https://www.sccm.org/clinical-resources/patient-and-family 

CaringInfo. https://www.caringinfo.org/ 

“Your Guide for Talking with a Health Care Team”. The Conversation Project. https://theconversationproject.org/wp-content/uploads/2020/12/HealthCareTeamGuide.pdf 

“End of Life in Intensive Care”. ICU Steps. https://icusteps.org/information/information-sheets/end-of-life 

“ICU Support Group”. Mayo Clinic. https://connect.mayoclinic.org/group/intensive-care-icu/ 

“The ICUsteps online community at HealthUnlocked”. ICU Steps. https://icusteps.org/support/online-community 

When a patient dies in the Intensive Care Unit, it can have a significant impact on the emotional and mental well-being of their surviving family members. Deaths in the ICU are often sudden and can result in feelings of disbelief, shock, guilt, or other expressions of grief after receiving notification of the death. Research studies have shown that patient deaths in the ICU are frequently associated with higher levels of posttraumatic stress, depression, and anxiety. 

Sometimes the environment of the ICU can be overwhelming for loved ones who are present. Being surrounded by unfamiliar medical equipment and hearing the frequent tones of alerts or other audible notifications can increase stress while viewing the decline of a loved one who has been admitted for care. It can also be upsetting to witness a loved one’s health decline in a setting that is unfamiliar to them, especially if that individual’s preference would be to die in the privacy of their own home. The setting of the ICU often has the potential to contribute to the trauma associated with the loss. 

Although ICU teams aim to be as accommodating as possible, it may be challenging for loved ones to say goodbye in a manner that is authentic to their cultural or religious traditions. ICUs typically have to adhere to specific regulations and restrictions, so issues such as limited hours for visitation or restrictions on who can be in the same room as the patient can disrupt efforts to maintain traditions or specific rituals. When individuals are unable to honor a loved one per cultural or religious traditions, it can make them feel guilty or limit their ability to fully process their grief.

Overall, the emotional toll of a loved one dying in the ICU can have a long-lasting and detrimental effect on mental health. It is not uncommon for individuals to experience intrusive thoughts, nightmares, or difficulty sleeping after the loss of a loved one in the ICU. Individuals who are experiencing disruption to their daily life following such a loss are encouraged to contact a healthcare provider or mental health professional for further evaluation and additional support.

Sources 

“Factors influencing post-ICU psychological distress in family members of critically ill patients: a linear mixed-effects model”. BMC. https://bpsmedicine.biomedcentral.com/articles/10.1186/s13030-021-00206-1 

“ICU bereaved surrogates’ comorbid psychological-distress states and their associations with prolonged grief disorder”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC8996508/ 

The procedure for handling unclaimed bodies at the hospital often varies depending on the hospital policy and the jurisdiction, but most unclaimed bodies are eventually cremated. While burial is also an option, direct cremation is cost-effective and conserves space. The United States does not have a standardized process or system for managing unclaimed bodies, but the general expectation is that the hospital will make a reasonable effort to identify the body of the person who died and contact their next of kin. The length of time dedicated to this search can vary based on state guidelines and may range from a week to a month. 

If the body is not identified and matched to the next of kin or a claimant, what happens to the body next can vary. Some states, such as Florida and Oregon, allow for unclaimed bodies to be sent to medical schools where they will be used to educate students or further progress in important medical research. When the schools are finished using the bodies for these purposes, they are typically cremated. In the event that the body has been cremated and remains unclaimed, the cremation ashes will be disposed of. 

In Washington D.C., and states such as Virginia, unclaimed bodies may be transferred to a funeral home that will handle the upcoming direct cremations. Some funeral homes may choose to conduct their own investigation to try to identify the bodies prior to cremation. Once cremated, the remains are typically provided to the state, which may keep them for up to several years. However, if the cremains are not identified, they are typically scattered in a common grave with other cremains.

Throughout this process, every effort is made to ensure that unclaimed bodies are treated with respect. Hospitals, state departments, law enforcement, and funeral homes all have specific regulations and protocols that emphasize the importance of maintaining the dignity of those that they serve. Ample actions are taken to try to identify unclaimed bodies in a timely manner, but for those who remain unclaimed, professionals strive to handle them in a manner that demonstrates genuine compassion and respect in the absence of a family member or loved one. 

Sources

“This is What Happens to Unclaimed Bodies in America”. TalkDeath. https://talkdeath.com/this-is-what-happens-to-unclaimed-bodies-in-america/ 

“The 2024 Florida Statutes (including 2025 Special Session C)”. Florida Legislature. http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400-0499/0406/Sections/0406.50.html 

“What Happens to an Unclaimed Body?”. Direct Cremate. https://www.directcremate.com/what-happens-to-an-unclaimed-body/ 

The amount of time you may spend with a loved one who has died in the ICU is typically left to the discretion of the hospital and can vary based on their internal policies. Many hospitals have policies that allow families to spend some time with their loved ones after death as a way of processing their loss. However, the amount of time is usually somewhat short since the hospital needs to transfer the loved one’s body to the morgue or mortuary. This usually occurs within one to two hours after death.

It’s crucial to understand that hospitals often require additional bed space due to the high volume of patients. This is why they prioritize transferring your loved one to the morgue or mortuary. Some hospitals may be more flexible, allowing families extended time with their loved ones based on cultural or religious grounds. Generally, both ICU and hospital staff are highly respectful and considerate of requests for privacy after the death of a loved one, and they are willing to accommodate reasonable requests to the greatest extent possible. 

Sources

“End of Life in Intensive Care”. ICUSteps. https://icusteps.org/information/information-sheets/end-of-life 

When patients are identified as potential organ donors, the intensive care unit (ICU) staff follows designated protocols and works closely with the families of these patients while demonstrating an overarching sense of compassion and respect. Many of the organs that are appropriate for donation come from patients who were in the ICU. Since the circumstances surrounding organ donation in the ICU can be a sensitive topic for families, the ICU team knows that they need to provide emotional support and respect when navigating related discussions. 

When the ICU team initially identifies a patient who fits the criteria for organ donation, they will contact an organ procurement organization or OPO. The OPO is responsible for evaluating the patient’s medical history and determining if they are appropriate for organ donation. Since the OPO has to evaluate the appropriateness of each organ donor, the ICU team needs to contact the OPO before any discussions are shared with the patient’s family. This prevents the possibility of asking a family about organ donation and moving forward with the process only to later determine that the patient isn’t a suitable donor. 

If the OPO determines that the patient is a suitable donor, the ICU team will begin to introduce the topic of organ donation to the family and discuss it further. Providing accurate information and education about organ donation can be crucial in order to get written permission for donation from the family. The ICU team will discuss the potential benefits of organ donation, its potential to save lives, and also answer common questions about the implications of donation, such as concerns surrounding conducting an open casket funeral after the donation process is complete. During this period, the team’s focus is to ensure that the family understands the donation process and the significance of making a decision. 

Throughout this process, the ICU team will provide emotional support to the family and respect their wishes. If the family agrees to the organ donation, the team will collaborate with the OPO to ensure that procedures, logistics, and other aspects of the process are taken care of. If the family has any cultural or religious beliefs in relation to organ donation, the ICU team will also ensure that these beliefs and values are respected and maintained to the fullest extent. 

Sources

“Deceased donor organ donation”. Nursing 2020 Critical Care. https://journals.lww.com/nursingcriticalcare/fulltext/2018/07000/deceased_donor_organ_donation__the_critical_care.5.aspx 

“Views on organ donation: donor families”. Health Talk. https://healthtalk.org/experiences/organ-donation/views-organ-donation-donor-families/ 

Intensive care unit (ICU) staff provide families with information, guidance, and emotional support when deciding post-mortem examinations or autopsies. Doctors may suggest an autopsy or post-mortem examination in an ICU to gain further medical insight or determine the cause of death. Sometimes, the information gained through autopsy findings can provide family members with peace of mind regarding the death of their loved one, especially if they have doubts or concerns about the medical care they received or the severity of the disease or injury that resulted in death. 

However, autopsies are frequently a sensitive topic for family and loved ones. Members of the ICU care team provide education about the purpose and potential benefits of autopsies or post-mortem examinations. This information is often also shared with the patient before death since an autopsy can contribute valuable information to medical research and education by allowing others to gain insight into a disease or condition. By explaining the purpose of autopsies to families and patients, the ICU staff empowers them to make informed decisions.

The ICU staff also provides emotional support as families navigate the decision-making process associated with autopsies or post-mortem examinations. They aim to create a non-judgmental, compassionate environment for those considering whether to proceed with an autopsy. They also recognize that these decisions often directly follow the loss of a loved one, so they may connect family members with support groups and resources or facilitate open discussions regarding concerns and expectations about the autopsy process. 

Similarly, ICU staff provide families with information if they decide they want to move forward with an autopsy. ICU care teams are experienced in coordinating with medical examiners, pathology departments, funeral homes, and many other professionals who can help facilitate the process or make logistics easier to handle. Since documentation can sometimes become complicated and overwhelming, they also spend considerable time guiding how to navigate the legal aspects associated with an autopsy. Through consistent education, coordination and emotional support, ICU staff support patients and their families through challenging decisions while upholding the importance of respecting their preferences.

Sources

“Autopsy”. MedicineNet. https://www.medicinenet.com/autopsy/article.htm 

“Autopsy and critical care”. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC5606467/ 

Policies regarding advance care planning and end-of-life directives often vary among intensive care units in different healthcare institutions. Many patients with life-limiting illnesses or injuries do not have any documented advance directives while receiving care in the ICU, which can prompt conversations surrounding end-of-life preferences. However, in circumstances where an advance directive is not already in place, and the patient is already incapacitated due to injuries or life-limiting illnesses, the ICU team typically must contact the patient’s next-of-kin to make decisions regarding the patient’s care.

In an ideal situation in which the patient is not already incapacitated, the process of advance care planning would involve a discussion between the patient, their family, and the attending healthcare provider. This conversation would encompass preferences regarding interventions, life-sustaining treatments, and resuscitation, as well as any necessary documents that need to be included in the patient’s chart. These efforts ensure that the patient’s autonomy and capacity for decision-making are respected and upheld when decisions must be made regarding their care. Even so, studies have shown that physicians and nurses in the ICU sometimes struggle to facilitate end-of-life discussions with patients, which can suggest that this is not entirely appropriate within the scope of services provided in the ICU.

Although ICUs have policies in place to address advance care planning and end-of-life directives, it is essential to recognize that these components should be addressed proactively before an ICU admission is ever required. Since the purpose of intensive care is typically to provide life-saving interventions, it is not the most appropriate setting for discussing how aggressive patient care should be. Additionally, it can be challenging to effectively develop these plans due to the severity of the patient’s condition. Therefore, it is best to ensure that all preferences regarding end-of-life care are established well in advance of these decisions needing to be made in an emergency. 

Sources

“Intervention and efficacy of advance care planning for patients in intensive care units and their families: a scoping review protocol”. Nursing Open. https://pmc.ncbi.nlm.nih.gov/articles/PMC7877163/

“Advance directives in the trauma intensive care unit: Do they really matter?” International Journal of Critical Illness & Injury Science. https://pmc.ncbi.nlm.nih.gov/articles/PMC3249846/

Intensive care unit (ICU) teams typically implement a multidisciplinary approach to address all of the needs of the patient and their family, including those that are spiritual and emotional. Spiritual care providers or chaplains have an important role in offering spiritual support to patients and families. They may provide prayers, conduct spiritual assessments, facilitate discussions, or perform rites and rituals if requested by the patient or their family. 

A common misconception is that spiritual care providers are representative of specific faith traditions. However, most spiritual care providers are interfaith or interspiritual, meaning that they provide guidance and support regardless of affiliation or religious belief. Some clinicians in the ICU also have received basic training to assess spiritual and religious distress, enabling them to refer patients to chaplains and spiritual care providers in a timely manner.

If the patient or family is in emotional distress, a counselor or social worker on the team may help them navigate the often overwhelming emotions associated with terminal illness or end-of-life decisions. These members of the team create space for patients and families to share their concerns and express their feelings in a judgment-free environment. They can also provide resources and general advice on healthy coping strategies. 

Some ICUs offer support groups or group therapy to help patients and their families connect with other individuals who are experiencing similar challenges. ICU team professionals dedicate themselves to ensuring support and guidance are available at every level and in a variety of settings. Ultimately, the ICU has many components that emphasize spiritual and emotional needs are an integral part of holistic care. 

Sources

“Challenges and Enablers of Spiritual Care for Family Members of Patients in the Intensive Care Unit”. Sage Journals. https://journals.sagepub.com/doi/abs/10.1177/1542305019890120 

“What to Expect in the Trauma ICU”. Scrubbing In. https://www.bswhealth.com/blog/expect-trauma-icu 

The options for end-of-life care in the ICU are numerous and should be tailored to the unique needs of each patient. In general, end-of-life care in this setting is aimed at providing comfort, reducing suffering, and ensuring dignity and respect during the dying process.

One common form of end-of-life care in the ICU is palliative care, a multidisciplinary approach aimed at alleviating symptoms and improving the quality of life for patients facing severe illness. Palliative care generally entails pain management for the ICU patient along with emotional support for the patient and their family members. It can occur along with intensive, curative medical treatments, though, and isn’t restricted only to end-of-life. 

Hospice care is another option, typically reserved for patients who have a life expectancy of six months or less. Provided by a team of healthcare professionals, hospice care prioritizes comfort and quality of life over curative treatment, along with emotional and spiritual support for the patient and family. Few hospitals offer inpatient hospice in the ICU. However, a dying patient may be transferred to a dedicated inpatient hospice unit if one is available. In some cases, the patient may even be discharged from the ICU directly to home hospice, although the logistics of this can be challenging. If the patient is extremely unstable,  it may not be possible to transfer them out of the ICU.

Comfort care, another alternative, focuses solely on quality of life and symptom relief, potentially including the withdrawal of life-sustaining treatments. It is similar to palliative care yet does not incorporate any curative treatments. The terms “palliative,” “hospice,” and “comfort” care are often used interchangeably, and if a doctor or member of your loved one’s medical team uses one of these terms, it’s important to clarify precisely what they mean.

Finally, shared decision-making involves patients, families, and healthcare providers working together to make decisions about end-of-life care that align with the patient’s values and preferences. Note that these care options can and often do overlap. 

Each of these options presents its own set of benefits and considerations, and the best choice will depend on the patient’s condition, prognosis, and personal wishes.

Dying in the ICU

It’s not unusual for a patient to die in the ICU, and there are a few common circumstances under which this may occur.

One common scenario is after the decision is made to limit life-sustaining treatment, such as when the patient or their family elects to decline or withdraw aggressive interventions. This could be due to the understanding that the interventions are no longer beneficial or in line with the patient’s wishes.

Another such circumstance is death following an unsuccessful resuscitation attempt, or a “Code Blue.” This usually happens when a patient’s heart stops (cardiac arrest) or they stop breathing, and despite the best efforts of the medical team, they cannot be revived.

Death may also occur as a natural progression of a severe illness that has become untreatable or unmanageable. This is often the case with advanced stages of diseases like cancer, heart disease, liver disease, or neurodegenerative disorders. In some of these cases, a patient may die even when on life support. 

Lastly, some deaths in the ICU occur unexpectedly due to sudden health complications, such as a severe infection, a sudden heart attack, or a massive stroke. These situations can occur even in patients who were initially admitted to the ICU for less critical conditions.

Sources

“Primary palliative care recommendations for critical care clinicians”. Journal of Intensive Care. https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-022-00612-9 

“What Are Palliative Care and Hospice Care?”. National Institute on Aging. https://www.nia.nih.gov/health/hospice-and-palliative-care/what-are-palliative-care-and-hospice-care 

“What is Comfort Care?” Caring Info. https://www.caringinfo.org/types-of-care/comfort-care/#different-from-palliative 

“Types of Care”. Caring Info. https://www.caringinfo.org/types-of-care/ 

“Patient participation in shared decision-making in palliative care – an integrative review”. National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/34028923/