#45 Re-imagining Intensive Care
This book review first appeared online in The DO on August 1, 2022
The DO Book Club, Aug. 2022: Every Deep Drawn Breath
When Wes Ely, MD, started as a resident headed for a career in critical care medicine, he encountered one of his first intensive care unit (ICU) patients who survived her near-death experience, but was never the same person again. She could barely move, and her cognitive abilities were greatly diminished.
This was his first encounter with a person suffering from Post-Intensive Care Syndrome (PICS), and Dr. Ely realized something might be wrong with the way critical patients were being managed. Although the patient was alive, her treatment had caused lasting physical, cognitive and emotional harm.
Could it be those approaches that seem so logical when it comes to saving a life, caused unintentional difficulties for patients down the road? As he listened to patients tell him of their disordered dreams and delusions during intubation and sedation in the ICU, he wondered, how much sedation did ICU patients really need?
Along with his colleagues, Dr. Ely designed a study to show that early mobilization made a tremendous difference in reducing delirium and disability in ICU patients. Delirium is defined as a temporary mental state characterized by confusion, anxiety, incoherent speech and hallucinations.
‘Remarkable results’
Dr. Ely identified an innovative program in Odense, Denmark that got remarkable results by getting critically ill patients out of bed, less sedated and off their ventilators so that they could communicate more effectively with the medical staff and their own family members. He helped set the wheels in motion to employ similar techniques at his own hospital and various other locations in the United States.
How could researchers convince physicians and nurses who had treated critically ill patients in this way that seemed most humane and beneficial, be persuaded that they were actually doing harm? Dr. Ely writes, “As physicians, we generally think we are most likely to harm our patients with an errant scalpel, a central line placement gone awry, or a medication error, but sometimes we cause more harm by blindly accepting usual practice as best practice. Familiarity can breed complacency.” (pp. 131)
Dr. Ely collaborated with Kelly McCutcheon Adams, a trauma ICU social worker and a director at the Institute for Healthcare Improvement. The team helped formulate the ABCDEF (A2F) Bundle: an interprofessional, evidence-based safety bundle of care principles to help reduce length of stay, mortality, bounce-backs and the duration of ICU delirium and coma. Data was collected at multiple centers located throughout the U.S. and the world over 10 years.
Data from the study published in the New England Journal of Medicine in 2018 showed that antipsychotic drugs did not lessen delirium in critically ill patients. “… The best reduction of delirium in the ICU is from the six steps of the A2F Bundle: control pain, lessen sedation, wake people up, manage delirium, mobilize early, and involve family. Follow the science and find the humanity. The bundle had helped me to see the person in the patient, the human inside the hospital gown.” (pp. 175)
Developing relationships
Dr. Ely employs the narratives of several patients whom he has cared for over the years to personalize the experience of critical care and transplant patients. As he grows as a clinician, he becomes more comfortable with establishing relationships, recognizing the humanity and the spirituality of his critically ill patients.
It is the deep connections that Dr. Ely forges with his patients that could inspire nurses and physicians who read his book to take a closer look at the fragile human beings in our care. “Every day, I intentionally try to cultivate compassion and love within the minute-to-minute practice of medicine. This deliberate focus keeps the drift toward burnout at bay.” (p. 225)
The final chapter goes into the challenges and more innovative approaches that Dr. Ely advocates for end-of-life care. Perhaps the author could have started another, equally useful, book from this chapter. He reflects:
“One in five deaths in the United States occurs in a critical care bed – and when it becomes clear to the medical team that we cannot save a patient’s life, our thoughts and actions must turn from cure to comfort. It becomes time to focus not on what’s the matter with the patient to what matters to the patient. I have found this switch of the preposition serves extremely well for patients and families to open a gateway of communication and sharing … We can’t address patients’ wishes about dying unless we first ask what those wishes are. What’s more, we can’t ask them their preferences if they are heavily sedated or profoundly delirious.” (pp. 210)
How many of us and our colleagues never get to have this conversation with our patients because we cannot even acknowledge that we can no longer save a patient’s life. Too many of us view this occurrence as a sign of our own personal defeat or failing.
I vividly recall making daily rounds on the two burn patients that I cared for during my month-long rotation through the Burn ICU at St. Agnes Hospital in South Philadelphia. In a month taking care of those two ladies, not once were they conscious, speaking or having any visitors. Our attending and resident staff thought we were doing what was best, but for whom?
COVID and ICU care
The book’s epilogue reaches into the COVID-19 era that likely began after Dr. Ely finished the first draft of this book. He describes the unparalleled upheaval in society and the medical community to treat the highly contagious and ferocious disease. He writes, “Unfortunately, in our rush to respond, we set aside twenty-five years of progress in critical care … Though we knew better, our ICUs became delirium factories all over again. Launching an enduring public health crisis for a new wave of survivors.” (pp. 235)
Dr. Ely writes of his hope of getting back to the basics of getting families back to the bedsides as vaccines, more PPE and knowledge become available. The book closes with an invaluable chapter of definitions, tips and resources for both health care professionals, patients and their families.
Dr. Ely’s mission to re-focus care on who the human patients are before, during and after their critical care unit stays will take an entire village. To participate in the village of care, more doctors, nurses, social workers and patients and their families would be well-served by reading this book.
