Life after critical illness: an overview

The Experiences of Family Members of Patients Discharged from Intensive Care Unit: A Systematic Review of Qualitative Studies

BACKGROUND

Improving the understanding of the post-discharge experiences of family members after their loved ones leave the Intensive Care Unit (ICU) is essential for developing effective follow-up strategies. These strategies are crucial for mitigating potential negative outcomes for both patients and their families. The aim of this study was to explore the lived experiences of family members after the discharge of their loved ones from the ICU.

METHODS

In September 2023, we conducted a systematic search of qualitative studies across the following databases: CINAHL, MEDLINE, Scopus and Web of Science. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was used to guide this review.

RESULTS

Eight articles met the inclusion criteria. Four themes were identified following evidence synthesis: (1) grappling with a weighty burden; (2) recognizing and confronting adversities along the way; (3) seeking support beyond one's own resources; and (4) addressing comprehensive care requirements.

CONCLUSIONS

Family members face significant psychological and physical challenges while caring for their loved ones recovering from an ICU stay. Adequate formal and informal help is imperative to provide support both during hospitalization and after discharge. A refined understanding of the distinct requirements and experiences of family members can serve as a strategic framework for informing educational interventions and follow-up programs during the transition from hospital settings to community-based care. This study was not registered.

Anxiety and depression in intensive care patients six months after admission to an intensive care unit: A cohort study

OBJECTIVES

To measure the prevalence of anxiety and depression in intensive care patients six months after admission to an intensive care unit and to investigate which variables are associated with anxiety and depression at six months.

RESEARCH METHODOLOGY

In this cohort study, patient-reported outcome measures were collected as soon as possible upon admission and at six months. Two logistic regression models were performed to examine variables associated with reporting anxiety and depression above ≥8 at six months.

SETTING

Patients were recruited from six intensive care units in two Norwegian hospitals between 2018 and 2020.

MAIN OUTCOME MEASURES

The Hospital Anxiety and Depression Scale.

RESULTS

A total of 145 patients was included in the study. The patients reported a prevalence of 18.6% (n = 27) and 12.4% (n = 18) of anxiety and depression, respectively. Higher baseline anxiety scores were associated with both higher odds of reporting anxiety and depression above ≥8. Younger age was associated with higher odds of reporting anxiety, and being female was associated with lower odds of reporting depression.

CONCLUSION

Several intensive care survivors reported having symptoms of anxiety and depression six months after admission to the intensive care unit. Younger age, and higher anxiety scores at baseline were variables associated with higher odds of reporting symptoms of either anxiety or depression, while being female was associated with a lower odds of reporting depression.

IMPLICATIONS FOR CLINICAL PRACTICE

Screening patients for anxiety and depression may help to identify vulnerable patients. Structured follow-ups with intensive care nurses in an outpatient setting may be useful to help patients to work through some of the experiences from the intensive care unit.

Patients' experiences of well-being when being cared for in the intensive care unit-An integrative review

OBJECTIVE

The aim of this integrative review was to identify facilitators and barriers to patients' well-being when being cared for in an ICU setting, from the perspective of the patients.

BACKGROUND

To become critically ill and hospitalised in an ICU is a stressful, chaotic event due to the life-threatening condition itself, as well as therapeutic treatments and the environment. A growing body of evidence has revealed that patients often suffer from physical, psychological and cognitive problems after an ICU stay. Several strategies, such as sedation and pain management, are used to reduce stress and increase well-being during ICU hospitalisation, but the ICU experience nevertheless affects the body and mind. DESIGN; METHODS: Since research exploring patients' sense of well-being in an ICU setting is limited, an integrative review approach was selected. Searches were performed in CINAHL, Medline, Psych Info, Eric and EMBASE. After reviewing 66 studies, 12 studies were included in the integrative review. Thematic analysis was used to analyse the studies. The PRISMA checklist for systematic reviews was used.

RESULTS

The results are presented under one main theme, 'Well-being as a multidimensional experience-interwoven in barriers and facilitators' and six sub-themes representing barriers to and facilitators of well-being in an ICU. Barriers identified were physical stressors, emotional stressors, environmental disturbances and insecurity relating to time and space. Facilitators were meeting physical needs and activities that included dimensions of a caring and relational environment.

CONCLUSION

Our main findings were that experiences of well-being were multidimensional and included physical, emotional, relational and environmental aspects, and they were more often described through barriers than facilitators of well-being.

RELEVANCE FOR CLINICAL PRACTICE

This integrative review has shown that it is necessary to adopt an individual focus on patient well-being in an ICU setting since physical, emotional, relational and environmental stressors might impact each patient differently.

Experiences of surviving life-threatening illness: The meaning of recovery

BACKGROUND

Recovery from life-threatening illness may be experienced as more demanding and lasts longer than patients first expect. Many patients experience recovery after life-threatening illness, as filled with complex problems. These problems are primarily physical and psychological, although also social, and adversely affect daily life as well as perceived quality of life. Patients experience uncertainty about living with the legacy of a life-threatening illness and how it negatively limits their daily lives and experienced health.

AIM

The purpose is to illuminate experiences of the meaning of recovery from life-threatening disease.

ETHICAL APPROVAL

Approval for the study was obtained through a Regional Research Ethics Committee.

METHODS

This study was conducted as a qualitative narrative study. This means that written stories of human recovery beyond suffering from life-threatening disease were collected and analysed with a phenomenological hermeneutic method.

RESULTS

The findings reveal two major areas - intrapersonal meanings and relational meanings. Four themes were found in these areas, each of which was divided into subthemes as follows: obstacles, for example disappointment of life, alienation of self and opportunities/resources: for example balance, own knowledge, hope and gratitude; relational obstacles, for example a lack of care, stigmatisation and economic stress; and relational resources such as informal care and professional care.

STUDY LIMITATIONS

The informants were predominantly women that may be explained by the fact that females seem to be more often engaged in social media and willing to participate in these kinds of studies. Another limitation is that we only reached out to Swedish speaking Facebook groups when recruiting our informants.

CONCLUSIONS

In the narratives of their recovery process, surprisingly few focused on professional health care as a resource. Experiences from the study may be used to further develop care, especially to support patient self-care regarding intrapersonal and relational resources that promote patient recovery beyond suffering from life-threatening disease.

Acute respiratory distress syndrome: how do patients fare after the intensive care unit?

Patients with acute respiratory distress syndrome require ventilation strategies that have been shown to be important for reducing short-term mortality, such as protective ventilation and prone position ventilation. However, patients who survive have a prolonged stay in both the intensive care unit and the hospital, and they experience a reduction in overall satisfaction with life (independence, acceptance and positive outlook) as well as decreased mental health (including anxiety, depression and posttraumatic stress disorder symptoms), physical health (impaired physical state and activities of daily living; fatigue and muscle weakness), social health and the ability to participate in social activities (including relationships with friends and family, hobbies and social gatherings).

Impact of Critical Illness on Quality of Life after Intensive Care Unit Discharge

Objective

To assess the quality of life (QoL) following intensive care unit (ICU) discharge using 6 months’ prospective follow-up and to analyze the risk factors affecting quality-of-life post-discharge.

Design

A prospective observational cohort study. Conducted on adult patients, discharged from ICU after more than 7 days’ stay. Study duration is from January 2017 to October 2018. Patients <18 years, nonconsenting, preexisting neurological illness, and lost to follow-up were excluded. Follow-up was done at 1 and 6 months using the SF-36 questionnaire. The pre-ICU functional status, patient demographics, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACHE II) score, New York Health Evaluation (NYHA) classification, and details of ICU stay were collected.

Results

One hundred patients (M = 60, F = 40) with ICU stay (13.64 ± 3.75 days), days of mechanical ventilation (7.93 ± 3.89 days), admission APACHE II (18.88 ± 4.34) and SOFA (7.73 ± 1.54) scores. Comparison showed physical component summary (PCS) score and mental component summary (MCS) score at pre-ICU were 55.12 and 55.09 which decreased to 39.59 and 35.49 (p < 0.05) at 1 month post-discharge and 47.93 and 37.46 at 6 months. Age, APACHE II, and SOFA scores are the significant factors affecting PCS and MCS. Length of ICU stay and duration of mechanical ventilation did not affect significantly at 6 months. When compared with general population PCS and MCS showed significant deterioration at 1 and 6 months.

Conclusion

Post-ICU discharge patients have significant functional impairment and compromised health-related QoL (HRQoL). Age and severity of illness significantly affects health quality parameters and decline is below the normal data of general population.

How to cite this article

Rai R, Singh R, Azim A, et al. Impact of Critical Illness on Quality of Life after Intensive Care Unit Discharge. Indian J Crit Care Med 2020;24(5):299–306.

An audit of completion of diaries for rehabilitation in an intensive care unit

Intensive care unit (ICU) diaries are increasingly being used in UK hospitals as a therapeutic means to address the psychological effects of an ICU stay on patients. The National Institute for Health and Care Excellence recommends that services are developed to meet the psychological needs of patients following critical illness. This article discusses ICU diaries as a service to meet these needs. There is a greater demand for evidence-based research to support the positive effects of the diaries. Equally, there is a need to highlight the negative impact they may have on patients who would not wish to have a diary because of the traumatic experience of critical illness. To gain an insight into the use of patient diaries, an audit was conducted at one ICU, which found compliance with completing them was poor. This article gives an overview of the available literature. Recommendations are made to improve the use of ICU diaries for clinical practice in the future.

Long-term outcome after the acute respiratory distress syndrome: different from general critical illness?

Purpose of review

To review the current research data on long-term outcome and health-related quality of life in survivors of the acute respiratory distress syndrome (ARDS) and to compare these findings with those from non-ARDS patients surviving critical illness.

Recent findings

Between 6 months and 2 years after discharge from ICU, survivors of ARDS present with substantial impairments of the levels of body function (muscle strength, walking capacity and/or physical activity (physical SF-36 score). In contrast to non-ARDS patients from surgical ICUs, a standardized intensified physical therapy during early course of illness in ARDS patients could not show an improvement of long-term physical function performance. Furthermore, a substantial part of further ARDS patients suffer from depression (26–33%), anxiety (38–44%) or posttraumatic stress disorder (22–24%). In general, the level of functional autonomy and daily life activities was reduced, and in one study, 6 months after ICU-discharge this level was significantly lower in ARDS patients compared with non-ARDS patients. In a recent study, 44% of ARDS survivors were jobless 1 year after critical illness, whereas half of previously employed patients returned to work within 4 months after hospital discharge. General health-related quality of life was significantly reduced compared with a matched population in all studies.

Summary

Surviving ARDS is associated with a long-term substantial reduction in health-related quality of life and such a reduction does not differ from findings in patients surviving other critical illness. In further research, a special attention should be paid to prevention measures of the ‘post intensive care syndrome’ as well as to patient important domains, which might better explain the patient's and families’ demands.

Health-related quality of life after general surgical intensive care

BACKGROUND

Impaired mental and physical health are common complications after intensive care that could influence the patient's health-related quality of life (HRQoL). Earlier research has mainly focused on HRQoL in mixed surgical and medical ICU populations. This study aimed to describe and analyze factors associated with HROoL after discharge from a general surgical ICU.

METHODS

A prospective cohort study was conducted in a general surgical ICU in Sweden between 2005 and 2012. Adult patients (≥18 years) with an ICU length of stay ≥96 hours were included. HRQoL was measured at 3, 6, and 12 months after discharge from the ICU using a questionnaire (SF-36). A linear mixed model was used to analyze changes over time and Wilcoxon Signed Rank Tests were used to compare the 12-months results to an age and gender matched reference population in Sweden. Linear regression analyses were performed to explore the impact on HRQoL from background variables.

RESULTS

Of 447 patients eligible for the study, 276 patients (62%) answered SF-36 at least once at 3, 6 or 12 months after ICU care and were included in the study. HRQoL improved over time but was still significantly lower at 12 months compared to the reference population. Female gender, age <75 years, living single, and ICU-stay of more than 14 days were associated with lower HRQoL.

CONCLUSION

General surgical ICU patients reports low HRQoL 1 year after ICU stay. The impaired HRQoL could be a long-lasting problem with major consequences for the individual, family, and society.

Picking up the pieces: Qualitative evaluation of follow-up consultations post intensive care admission

OBJECTIVES

On an intensive care unit at a university hospital in Denmark patients are offered a nurse-led consultation three months post intensive care unit admission, to help them cope with Post Intensive Care Syndrome and identify opportunities for further intervention. The aim of the study was: 1) To describe former intensive care patients' experiences of the consultation, specifically regarding content and setting. 2) To explore the benefits of the consultation in regard to the individual patients' symptoms of Post Intensive Care Syndrome.

METHODS

Focused ethnography was chosen as methodology combining observations and interviews. Ten patients participated in a two-part qualitative study: 1) an observational study of the current follow-up consultation; 2) a semi-structured interview based upon observations and statements arising during the initial consultation. The data was analysed using a hermeneutic-phenomenological approach.

FINDINGS

Content and setting of the consultation were of upmost importance. Revisiting the unit and experiencing the setting in person played a huge role in coping with Post Intensive Care Syndrome. Involving relatives was essential as they were an important part of the patient's rehabilitation.

CONCLUSIONS

Participating in the consultation and revisiting the unit proved important. It helped patients understand their symptoms and make sense of what had happened during their stay in intensive care unit.

Changes in biopsychosocial outcomes for a mixed cohort of ICU survivors

Background

Prolonged inflammation and infection associated with being critically ill and the ensuing physical inactivity has proven negative effects on the recovery of physical function, psychological health and reintegration into society for intensive care unit (ICU) survivors. Limited evidence is available on changes in biopsychosocial outcomes for South Africans recovering from an episode of critical illness.

Objectives

To determine changes in biopsychosocial outcomes for a mixed cohort of ICU survivors in hospital and at 1 month and 6 months after discharge.

Method

A prospective, observational, longitudinal study was conducted. Severity of illness, mechanical ventilation (MV) duration and ICU and hospital length of stay (LOS) were recorded. Physical function in ICU test-scored (PFIT-s) was performed at discharge from ICU and hospital. At 1 month and 6 months, peripheral muscle strength, exercise endurance, health-related quality of life (HRQOL), depression status and return to work were assessed. Descriptive and inferential statistics were used.

Results

Participants (n = 24) had a median age of 51.5 years, majority were male (n = 19; 79%) and most were employed before admission (n = 20; 83%). At 6 months, 11 participants (n = 11) were part of the final sample. Median PFIT-s changed significantly (0.3 points; p = 0.02) between ICU and hospital discharge. Peripheral muscle strength improved significantly for upper and lower limbs over 6 months (p = 0.00–0.03) but change in median 6-minute walk test distance (65m) was not significantly different. Significant improvements occurred in mean Medical Outcomes Short Form-36 (SF-36) physical health component scores (8.8 ± 7.6; p = 0.00). Mean SF-36 mental health component scores had a strong negative relationship with MV duration (r = −0.7; p = 0.01), LOS (r = −0.56; p = 0.04) and Patient Health Questionnaire 9 scores (r = −0.72; p = 0.01). Six participants (55%) returned to employment.

Conclusion

Clinically important improvements in biopsychosocial outcomes related to physical function and social factors were observed. Limitations in mental aspects of HRQOL were present at 6 months and some reported mild depressive symptoms.

Clinical implications

Intensive care unit survivors with a history of prolonged MV duration and hospital LOS who exhibit limitations in mental HRQOL, and signs of depressive symptoms should be referred to a psychologist for evaluation.

Intensive care survivors’ experiences of recovery after hospital discharge: A qualitative interview study

To suffer from a critical illness or injury requiring treatment in an Intensive Care Unit (ICU) is a traumatic experience that may affect patients and their relatives for a long time. This study aimed to explore intensive care survivors’ experiences of recovery after hospital discharge, from the patient perspective. A qualitative interview study with 12 interviews was conducted and analyzed using inductive content analysis. Four categories emerged from the data: Bodily changes, Emotional experiences, A prolonged struggle and Gratitude. The findings indicate that the life situation of intensive care survivors is changed, that recovery takes time and that the feeling of gratitude for having survived is strong.

Intensive care survivor-reported symptoms: a longitudinal study of survivors' symptoms

BACKGROUND

There is growing interest in potential long-term outcomes following intensive care, but few researchers have studied the prevalence of multiple symptoms or the association between pain and other symptoms.

AIMS

To investigate the prevalence of anxiety, depression, fatigue, sleep disturbance and post-traumatic stress symptoms (PTSS) among intensive care survivors 3 months and 1 year after being discharged from an intensive care unit (ICU) and to determine whether pain is associated with higher prevalence of these symptoms 3 months and 1 year after ICU stay.

STUDY DESIGN

Exploratory, longitudinal cohort of intensive care survivors from two mixed ICUs in a tertiary referral hospital in Norway.

METHODS

Intensive care survivors completed surveys at 3 months (n = 118) and 1 year (n = 89) after ICU discharge. Clinical Trials: NCT02279212.

RESULTS

Prevalence rates of intensive care survivors' symptoms were pain 58 (49·2%), anxiety/depression 24/118 (20·8%), fatigue 18/118(15·3%), PTSS 15 (12·8%) and sleep disturbance 58/118 (49·2%) at 3 months after ICU discharge (n = 118). Prevalence rates at 1 year (n = 89) changed only slightly to pain 34 (38·2%), anxiety/depression 17 (20·0%), fatigue 12 (13·8%), PTSS 13 (15·1%) and sleep disturbance 40/89 (46·5%). Associations were strong between pain and presence of sleep disturbance, anxiety/depression, PTSS and fatigue.

CONCLUSIONS

Intensive care survivors have multiple symptoms and the prevalence rates of these symptoms remained almost unchanged from 3 months to 1 year after ICU discharge. The presence of pain was associated with high odds for the presence of sleep disturbance, anxiety/depression, PTSS and fatigue, compared to a no-pain group. ICU survivors may benefit from targeted interventions designed to alleviate the symptom burden.

RELEVANCE TO CLINICAL PRACTICE

Knowledge about ICU survivor's prevalence and risk for having multiple symptoms may help health care professionals to give better care, if needed, to the ICU survivors.

PReventing early unplanned hOspital readmission aFter critical ILlnEss (PROFILE): protocol and analysis framework for a mixed methods study

INTRODUCTION

Survivors of critical illness experience multidimensional disabilities that reduce quality of life, and 25-30% require unplanned hospital readmission within 3 months following index hospitalisation. We aim to understand factors associated with unplanned readmission; develop a risk model to identify intensive care unit (ICU) survivors at highest readmission risk; understand the modifiable and non-modifiable readmission drivers; and develop a risk assessment tool for identifying patients and areas for early intervention.

METHODS AND ANALYSIS

We will use mixed methods with concurrent data collection. Quantitative data will comprise linked healthcare records for adult Scottish residents requiring ICU admission (1 January 2000-31 December 2013) who survived to hospital discharge. The outcome will be unplanned emergency readmission within 90 days of index hospital discharge. Exposures will include pre-ICU demographic data, comorbidities and health status, and critical illness variables representing illness severity. Regression analyses will be used to identify factors associated with increased readmission risk, and to develop and validate a risk prediction model. Qualitative data will comprise recorded/transcribed interviews with up to 60 patients and carers recently experiencing unplanned readmissions in three health board regions. A deductive and inductive thematic analysis will be used to identify factors contributing to readmissions and how they may interact. Through iterative triangulation of quantitative and qualitative data, we will develop a construct/taxonomy that captures reasons and drivers for unplanned readmission. We will validate and further refine this in focus groups with patients/carers who experienced readmissions in six Scottish health board regions, and in consultation with an independent expert group. A tool will be developed to screen for ICU survivors at risk of readmission and inform anticipatory interventions.

ETHICS AND DISSEMINATION

Data linkage has approval but does not require ethical approval. The qualitative study has ethical approval. Dissemination with key healthcare stakeholders and policymakers is planned.

TRIAL REGISTRATION NUMBER

UKCRN18023.

Health-Related Quality of Life and Associated Factors in Intensive Care Unit Survivors 6 Months After Discharge

BACKGROUND

Intensive care unit survivors often have diminished health-related quality of life.

OBJECTIVES

To describe health-related quality of life of former intensive care patients and identify associated factors 6 months after hospital discharge.

METHODS

Six months after discharge, 193 patients from an intensive care unit completed the Short Form-36 Health Survey; measures of sleep; Intensive Care Experience Questionnaire; Depression, Anxiety and Stress Scales; and Posttraumatic Stress Disorder Checklist. Norm-based scores were calculated for the Short Form-36. Bivariate associations with Short Form-36 scores were tested by using the Pearson correlation. Multiple linear regression was used to identify independent associations with health-related quality of life.

RESULTS

All scores on the Short Form-36 (physical component summary, 41.8; mental component summary, 48.2) were less than population norms. Bivariate associations with health-related quality of life (P < .05) were scores on the Acute Physiology and Chronic Health Evaluation II, hospital length of stay, awareness of surroundings and frightening experiences, depression, anxiety, stress, posttraumatic symptoms, and sleep quality at 2 and 6 months. In linear regression, scores on the Acute Physiology and Chronic Health Evaluation II, hospital length of stay, and sleep quality at 6 months were independently associated with Short Form-36 physical summary scores (P < .001); depression and stress were independently associated with mental summary scores (P < .001).

CONCLUSION

Sleep, depression, and stress are potential targets for interventions to improve health-related quality of life and improve recovery.

Critical illness trajectory for patients, families and nurses - a literature review

BACKGROUND

In the 21st century, we are starting to discover and understand the longer term sequelae of critical illness from both patient's and family members' perspectives. The consequential effects on physical and psychological function and the social landscape are being slowing realized. We are beginning to understand the long-term legacy of critical care, with survivorship possibly the greatest challenge within the critical care setting.

AIM

To draw together research that has appraised the experience of surviving critical illness from the holistic, triadic perspectives of survivor, relative and critical care nurse. In doing so, knowledge of the complexities of the critical care trajectory is enhanced.

SEARCH STRATEGY

Using Medline; Assia; CINAHL Plus; SCOPUS; Web of knowledge searches from 2000 to 2015 were conducted utilizing the terms 'critical care'; 'intensive care', ITU; patient*; relative*; family member*; experience*; nurse*, and trajectory. Relevant exclusion criteria were applied to provide a generalist adult critical care perspective.

RESULTS

Following a process of constant comparative analysis of the literature and thematic synthesis, seven themes were highlighted. Facing mortality, critical junctures, physiological sequelae, psychological sequelae, family presence, beyond meeting the needs of family members and technology versus humanity were all emergent themes.

CONCLUSION

As humans, we do not live an isolated life; we are interdependent upon each other. This inclusive review of literature has highlighted the lacunae and areas of dissonance both in the literature and in clinical practice in relation to the critical care trajectory as experienced by survivors of critical illness and their families.

RELEVANCE TO CLINICAL PRACTICE

Critical care nurses can and should play a role in preparing and supporting patients and families beyond the critical care unit. In turn, Registered Nurses needed to be supported to fulfil this important role in enabling the process of moving patients and their families from surviving to thriving (survivorship).