What is the status and treatment of a patient in the Intensive Care Unit (ICU)?

From the Guidelines

The primary goal in managing a patient in the Intensive Care Unit (ICU) should be to provide end-of-life (EoL) and palliative care that prioritizes alleviating symptoms, meeting emotional, psychological, and spiritual needs, and supporting the patient and their family, as outlined in the European Society of Intensive Care Medicine guidelines 1.

Patient Care Approach

The treatment plan for ICU patients should shift from curative intent to EoL and palliative care when warranted by patient preferences or non-beneficial treatments. This involves withdrawing or withholding life-supporting treatments (LSTs) in a manner that is sensitive to the patient's and family's needs, and is guided by ethical principles, legal frameworks, and cultural norms 1.

Key Components of Care

• Symptom Management: Focus on alleviating symptoms to improve the patient's quality of life.
• Communication: Effective communication with the patient and their family is crucial, providing them with continuous emotional support and frequent opportunities to voice their wishes and concerns 1.
• Interdisciplinary Care: An interdisciplinary approach helps in providing holistic care, addressing the physical, emotional, and spiritual needs of the patient and their family.
• Conflict Management: Conflicts should be managed sensitively, with attention to the well-being of both the patient's family and the clinical team 1.

Decision-Making Process

Decision-making in the ICU, especially regarding the limitation of life-supporting treatments, should be tailored to the individual patient's situation, considering their autonomy, best interests, and the clinical judgment of the healthcare team 1. The process should involve sharing decisions with patients and families when possible, and should be guided by the principles of empathy, understanding, and trust.

Implementation of Guidelines

The European Society of Intensive Care Medicine guidelines on EoL and palliative care in the ICU aim to improve the quality of dying and death, minimize adverse effects on families, support the well-being of healthcare professionals, and serve as a resource for hospital administrators and policymakers 1. These guidelines are based on data from the last two decades, including the COVID-19 pandemic, and expert opinions where evidence was inadequate.

Ongoing Care and Support

Ongoing care should include continuous monitoring of the patient's status, with a focus on comfort and symptom management. This may involve the use of medications for pain and symptom control, as well as psychological and spiritual support for the patient and their family. The goal is to provide care that respects the patient's dignity and supports their quality of life, even in the face of a life-limiting illness.

From the Research

Status of Patients in the ICU

• The status of patients in the Intensive Care Unit (ICU) can vary greatly, with some patients requiring intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency 2.
• Patients with septic shock may require the concomitant administration of vasopressors such as norepinephrine and vasopressin to raise blood pressure 3, 4.
• The level of care provided in an ICU can be stratified into different levels, with level 1 ICUs providing oxygen, noninvasive monitoring, and more intensive nursing care, level 2 ICUs providing invasive monitoring and basic life support, and level 3 ICUs providing a full spectrum of monitoring and life support technologies 2.

Treatment of Patients in the ICU

• The treatment of patients in the ICU may involve the use of vasopressors such as norepinephrine and vasopressin to manage septic shock 3, 4.
• The use of low caloric intake has been shown to reduce mortality rates and length of stay in the hospital for critically ill patients in the ICU 5.
• The management of pain, anxiety, agitation/sedation, delirium, immobility, and sleep disruption is also an important aspect of care in the ICU, with guidelines recommending the use of dexmedetomidine over propofol for sedation, enhanced mobilization/rehabilitation, and the administration of melatonin 6.
• The discontinuation of vasopressors in patients with septic shock may be done in a specific order, with some studies suggesting that discontinuing vasopressin first may lead to a higher incidence of hypotension 4.