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Intensive Care Unit Patients
Including a chapter on the psychiatric care of patients in the intensive care unit (ICU) runs the risk of suggesting that the evaluation and treatment of patients differ depending on patients' location in the general hospital. Such a risk evokes the unfortunate misnomer “ICU psychosis,” with its erroneous suggestion that a psychotic condition can be induced by a patient's mere residence in an ICU and the absurd corollary that transfer out of that environment can be curative. While we maintain that patients and their needs transcend geography, we also recognize that the critical nature of illnesses treated in ICUs creates a unique environment for patients, staff, and consultation psychiatrists alike. In this chapter, the serial presentation of a typical ICU psychiatric consultation highlights the distinguishing characteristics of this distinctive setting, the common reasons for consultation requests in the ICU, and the clinical approach to consultative practice in the ICU.
The Intensive Care Unit Setting
The chief difference between the ICU and other hospital units is the severity of the morbidity treated there. Patients are admitted to ICUs when they require life support for organ system failure, close monitoring or treatment for potentially life-threatening complications, or careful observation and treatment that cannot be safely provided elsewhere in the hospital. Some of the conditions commonly treated in the ICU include stroke, myocardial infarction (MI), arrhythmias, severe pneumonia, sepsis, multisystem organ failure, trauma, and burns.
Commensurate with this degree of morbidity, the intensity of the treatment arrayed against these life-imperiling conditions contributes significantly to the ICU ambiance. The numerous “lines”—wires, catheters, and tubes—wending their way to and from critically ill patients attest to the high-technology care rendered in the modern ICU. Patients routinely require mechanical ventilation, which entails endotracheal intubation and sedation, and sometimes pharmacologic paralysis; use of vasopressors, cardiac monitors, pacemakers, parenteral nutrition, and several intravenous (IV) antibiotics is common. In more severe situations, renal replacement therapies, intra-aortic balloon pumps, left ventricular assist devices, and heart–lung machines become necessary.
The flashing lights, sounding alarms, and constant whirrings of machines in action create an almost surreal, de-humanized (and de-humanizing) atmosphere that is difficult for patients, families, and staff to tolerate. It seems odd that human lives hang in the balance in such a mechanized setting, the nature and purpose of which has been indicted for engendering delirium, anxiety, and depression in patients; tension and stress that can progress to fatigue and burnout in ICU staff; and feelings of hopelessness, helplessness, frustration, despair, and anger in family members, as well as in patients and staff. The acuity of illness and potential for rapid changes in clinical status create a tremendous pressure for the staff to stay ahead of the curve and a powerful stimulus for families to remain on high alert. When a patient succumbs to an illness that ultimately proves a foe mightier than the awesome therapeutic forces arrayed against it, the staff confronts death and their own personal feelings of weakness, imperfection, insecurity, and impotence that may be stimulated by the loss of a patient. Amid their own struggles, they must somehow comfort bereaved family and friends.
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