Elsevier

General Hospital Psychiatry

Volume 47, July 2017, Pages 68-74
General Hospital Psychiatry

Acute psychological trauma in the critically ill: Patient and family perspectives

https://doi.org/10.1016/j.genhosppsych.2017.04.009Get rights and content

Abstract

Objective

Post-intensive care syndrome (PICS), which encompasses profound psychological morbidity, affects many survivors of critical illness. We hypothesize that acute psychological stress during the intensive care unit (ICU) confinement likely contributes to PICS. In order to develop strategies that mitigate PICS associated psychological morbidity, it is paramount to first characterize acute ICU psychological stress and begin to understand its causative and protective factors.

Methods

A structured interview study was administered to adult critical illness survivors who received ≥ 48 h of mechanical ventilation in medical and surgical ICUs of a tertiary care center, and their families.

Results

Fifty patients and 44 family members were interviewed following ICU discharge. Patients reported a high level of psychological distress. The families' perception of patient's stress level correlated with the patient's self-estimated stress level both in daily life (rho = 0.59; p < 0.0001) and in ICU (rho = 0.45; p = 0.002). 70% of patients experienced fear of death, 38% had additional other fears, 48% had hallucinations. Concerns included inability to communicate (34%), environmental factors (30%), procedures and restraints (24%), and being intubated (12%). Emotional support of family/friend/staff/clergy (86%), and physical therapy/walking (14%) were perceived to be important mitigating factors. Clinicians' actions that were perceived to be very constructive included reassurance (54%), explanations (32%) and physical touch (8%).

Conclusions

Fear, hallucinations, and the inability to communicate, are identified as central contributors to psychological stress during an ICU stay; the presence of family, and physician's attention are categorized as important mitigating factors. Patients and families identified several practical recommendations which may help assuage the psychological burden of the ICU stay.

Introduction

Millions of people are admitted to intensive care units (ICU) in the United States every year [1] and a substantial majority survive [2]. However, survival often does not equate with the resolution of a patient's struggles. Following discharge, many suffer from persistent impairment in the domains of physical, cognitive, and psychological functioning [3] collectively known as post intensive care syndrome (PICS) [4].

Effective inpatient strategies to prevent or minimize the development of PICS likely include pharmacologic treatment of pain and agitation, judicious use of sedatives and antipsychotics, early mobilization, and reorientation [5]. There is insufficient understanding of the etiology and potential interventions to specifically target the persistent psychological manifestations of PICS. Identified risk factors for post-ICU psychological sequelae include underlying psychopathology, receiving benzodiazepines, presence of in-ICU psychologic distress symptoms, and having memories of frightening/delusional ICU experiences, as well as having no factual recall of the ICU stay and only memories of delusions [6], [7], [8], [9], [10]. A single center trial of intra-ICU psychological intervention demonstrated lower rates of post ICU psychological morbidity among surviving trauma patients and the use of daily diaries during hospitalization has been to be beneficial [11], [12]. Following discharge, data suggest that cognitive behavioral therapy is superior to pharmacological management of anxiety, depression, and post-traumatic stress disorder (PTSD) [13], [14].

We and others have identified components of a patients' ICU experience and the behavior of clinicians that contribute to patients' acute psychological distress and subsequent morbidity [15], [16], [17]. Strategies for patient's self-actualization and positive support from the ICU personnel and family may alleviate the psychological cost of critical illness [18]. Despite these clinical observations of contributors to ICU stress and the link between acute stress during the ICU stay and subsequent morbidity, a more rich understanding of this problem is mandatory.

We believe that improved comprehension of the psychological impact of an ICU stay is necessary in order to change behaviors that contribute to acute psychological distress and its sequelae. In this study we aimed to 1) evaluate the burden of psychological trauma perceived by mechanically ventilated patients in the ICU and their families and 2) identify the factors felt to exacerbate or mitigate that trauma in order to begin to inform our understanding of this phenomenon. We chose to study patients who were mechanically ventilated (MV)  48 h in order to target those likely to experience a longer ICU confinement with greater medical interventions and potentially greater risk of PICS.

Section snippets

Methods

We conducted a prospective observational study in medical and surgical ICUs at the Mayo Clinic in Rochester, MN. Critically ill patients and their families were queried about psychological distress following an ICU stay and the perceived exacerbating or mitigating factors. The study was approved by the Mayo Clinic institutional review board. Written informed consent was obtained from each enrolled patient. Oral consent was obtained from participating family members.

Results

During a period between August 2015 and May 2016 we identified and screened 87 subjects meeting pre-defined enrollment criteria. Thirty seven patients were excluded as per study design; 50 patients and 44 family members were interviewed (Fig. 1). Six families were not interviewed: four families were not available for interview, one family refused to participate and one patient did not have a family. Median duration of interview was 12 (7–19) min for patients, and 20 (10–35) min for families.

Discussion

We performed this observational study to characterize acute ICU psychological stress in survivors of critical illness requiring MV for > 48 h. 52% of our study patents assessed shortly following ICU transfer were identified by IPAT scores as high risk for the development of PTSD. Our study demonstrated that stress, hallucinations, inability to communicate, presence of family, and physician's attention are perceived by patient's to impact their psychological state in the ICU. Patients and their

Abbreviations

    ICU

    Intensive care unit

    PICS

    post intensive care syndrome

    PTSD

    post-traumatic stress disorder

    MV

    mechanical ventilation

    EMR

    Electronic Medical Records

    IPAT

    intensive care psychological assessment tool

Authors' contributions

VD and MAD contributed to data collection, statistical analyses, and manuscript preparation; MMJ contributed to manuscript preparation, OG and LVK contributed to the study design and manuscript preparation.

Acknowledgements

Not applicable.

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