What Can Psychologists Do in Intensive Care?
As awareness has grown of the great distress intensive care patients may suffer, units have begun recruiting psychologists to their teams. Intensive care unit psychologists aim to assess and reduce distress for patients, families and staff, to improve outcomes. This paper summarises research on the psychological impact of critical illness, highlights the growth of critical care health psychology as a speciality, and discusses potential roles of psychologists and the evidence base for psychological interventions in critical care departments.
It is now widely recognised that the experience of critical illness, with admission to an intensive care unit (ICU), has a powerful psychological impact on people. A body of evidence about the prevalence of acute stress and frightening psychological experiences in the ICU and adverse psychological outcomes post-ICU has grown. Consequently, the necessity of psychological assessment and support of patients has gained acceptance. Since families of critically ill patients and ICU staff can also become stressed or traumatised, they may also require psychological input. With the gradual dissemination of these research findings among clinicians, critical care departments have started to employ psychologists as key colleagues in the multidisciplinary team.
Psychological Impact of Critical Care
The psychological impact of a critical care admission can be severe. It is known that patients may experience extreme stress (Samuelson 2007; Wade et al. 2012) and altered states of consciousness (Ely et al. 2001). Subsequently there is a high prevalence of psychological morbidity, including post-traumatic stress disorder (PTSD), depression and anxiety among survivors (Wade et al. 2013). Studies have found that more than half of critical care patients suffered symptoms of a psychological disorder after their admission. Cognitive deficits in memory, attention and executive function, affecting activities of daily living, are also common (Pandharipande et al. 2013).
Patients are exposed to multiple stressors in the ICU, including illness, pain, sleep deprivation, thirst, hunger, dyspnoea, unnatural noise and light, nakedness and lack of dignity, inability to communicate, isolation, fear of dying and witnessing other people suffering and dying. They may also have strong emotional or behavioural reactions in response, including anxiety, panic, low mood, anger or agitation. Interventions, such as mechanical ventilation (MV) or invasive monitoring for cardiovascular support, may be difficult for patients to tolerate. Furthermore, the onset of delirium, including frightening symptoms such as hallucinations and paranoid delusions, is common in intensive care. Flashbacks, nightmares and traumatic memories of hallucinations and delusions may form part of post-ICU PTSD, while delirium is associated with later cognitive impairment.
There is also evidence that the critical care experience is traumatic for families, with relatives frequently suffering from PTSD (33% in one study) once their family member has left the ICU (Davidson et al. 2012). Critical care staff have been shown to suffer from high rates of stress, burnout and PTSD in a number of large studies (Moss et al. 2016).
Need for Psychological Assessment and Support
A landmark document on the organisation of critical care services in the UK (Department of Health 2000) recognised that the ICU environment was “extremely distressing” for relatives and patients, who needed support from staff. However, psychological support was “difficult and time-consuming”, and senior staff and appropriate materials were needed to deliver it. A National Institute for Health and Care Excellence (NICE) guideline (Tan et al. 2009) stated that patients should be assessed during their critical care stay for acute symptoms such as anxiety, depression, panic episodes, nightmares, delusions, hallucinations, intrusive memories, flashback episodes and underlying psychological disorders, to determine their risk of future psychological morbidity. Furthermore, psychological support should be provided to aid rehabilitation and recovery in critical care units, on general wards, and in the community. However, it is not known to what extent psychological assessment and support are really carried out in ICUs.
Research suggests that acute stress in the ICU may be one of the strongest patient risk factors for poor psychological and cognitive outcomes after intensive care (Wade et al. 2012; Davydow et al. 2013). Therefore it is important to detect and minimise acute tress where possible. It is known that healthcare staff who have not been trained in mental health may find it difficult to recognise that a patient is suffering from acute stress, hallucinations or delusions. However, tools to detect distress in the ICU are now available. The Confusion Assessment Method for the ICU (CAM-ICU) can be used by staff to detect delirium in critical care patients (icudelirium. org/delirium/monitoring.html). An intensive care psychological assessment tool (IPAT) has recently been validated and may be used by trained critical care staff to detect acute stress and indicate the risk of future psychological morbidity (uclh.nhs.uk/OurServices/Consultants/Documents/Dorothy%20Wade%20profile%20documents/IPATTool.pdf).
Families of critical care patients also frequently need support to deal with anxiety and fatigue, to comfort them when they learn that a loved one is dying, or after a death. Conflict may arise between family members who have different views on a patient’s care, or between families and staff, particularly around withdrawal of support or non-resuscitation orders.
Staff in critical care have much higher than average rates of stress and burnout than other hospital staff (Moss et al. 2016). This may be related to the responsibility of maintaining lives through sophisticated technological interventions; difficult emotions created by caring for patients who are dying or who die, and a culture in which staff may be perfectionist, driving themselves to provide high standards of care, without utilising appropriate self-care strategies. Conflict between patients’ families who are upset, angry or grieving, and staff who are not trained to deal with these emotions, can also escalate. Excessive stress can lead to staff going on long-term sick leave or eventually leaving the service. The United States critical care societies’ collaborative has recently issued a call to action on burnout syndrome (Moss et al. 2016).
Dorothy Wade, PhD writing
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