Rehabilitating the critically ill: a cultural shift in intensive care unit care.

As we move from not simply saving but to fully recovering the lives of our patients, the devastating consequences that a critical illness reaps for some patients and families becomes apparent (1). In a move to bring together the view points of various stakeholders, the Society of Critical Care Medicine held a 2-day conference, the report of which is published in this issue of Critical Care Medicine (2). Principally drawn from North America, the experts examined the evidence on long-term consequences and, importantly, what can be performed to improve this for both patient and their families. Rightly, they point out the need to raise the awareness of the considerable challenges through education and the needs to address the barriers to best practice and to identify the research gaps that must be filled to help develop the best care. This is an important milestone in critical care thinking that emphasizes our responsibility to research and explore all aspects of a patient’s care so that what we do within and after the intensive care unit (ICU) can bring their well-being back to the best that is possible. This requires a cultural shift in ICU care that is not only focused on the immediacy of the clinical problem but also expands to accommodate the wider implications of recovery and the family. Essential to this is the realization that what we do within the ICU matters in the long-term. Twenty-five years ago, when I first started researching and exploring ways to improve the recovery of my patients, the level of interest for longer-term issues was muted. Some referees from major grant funders even considered it “not of relevance to intensive care;” however, fortunately across Europe, interested groups of doctors, nurses, and physiotherapists were recognizing the later problems and through collaborative research projects have allowed many lessons to be learned. Our collective experience shows that to best recover lives there needs to be a cultural change in ICU care, with a distinct early active and selective decision-making process with a therapeutic strategy starting within the ICU addressing physical and psychological needs that continues as patients move through the hospital and to home. It is selective to allow for the many particularly short-stay patients to foster normal recovery and coping but to support those usually longer-stay patients who need that support. This is summarized in U.K. guidelines suggesting that a clinical risk assessment and screening process should be maintained during an ICU stay and should be formalized on leaving the ICU to plan for the immediately apparent (e.g., weakness) and start screening for later developments (e.g., acute anxiety state) (3). Rehabilitation starts within the ICU not only because ICU-acquired weakness and the harmful consequence of excessive bed rest and immobility are now recognized (4). New ways of sedating, ventilating, and mobilizing patients are all important, but some of the key lessons learned are that psychological stress of both the patient and the family are confounders to later recovery (5), which may be ameliorated by taking preventive measures within the ICU. The outstanding North American research on acute brain dysfunction and later cognitive impairment (6, 7) has emphasized the considerable neurologic burden experienced. However, an acute consequence is that the disturbance of memory combined with abnormal perceptual and delusional experiences is a powerful precipitant of posttraumatic stress disorder, a major confounder of recovery. Fortunately, the realization that a patient and family diary collated during the ICU stay could be used therapeutically afterward to significantly reduce the development of posttraumatic stress disorder offers some hope for this devastating complication (8). The greatest practical implication is that in an event as catastrophic as a major critical illness, one must manage the patient and the family at all stages within and after the ICU to get optimal recovery. The patient and the family have different perspectives on the illness but are equally traumatized. In this report, I disagree with the idea that there is some unique “postintensive care syndrome. ” This is a mistake they may come to regret. I can understand there is a need to promote an awareness of the many varied problems patients have after the ICU and some particularly long-stay patients may share them. However, it is not a distinct pathologic syndrome and I fear the adoption of a single term will lump together diverse problems that need specific research and diagnostic and therapeutic focus. I do not recall the useless term “ICU syndrome” ever promoting a research and therapeutic culture that advanced our care! Rehabilitation is part of routine ICU care and patients and families must be engaged to appreciate that this is “treatment” as important as any other. In the end, we are the mere guardians of the patient and we must foster and not damage the social support framework to which our patient will return. Richard D. Griffiths, MD, FRCP, FFICM Intensive Care Research Group Department of Musculoskeletal Biology II Institute of Ageing and Chronic Disease University of Liverpool Liverpool, UK