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Outcomes after critical illness
1 Plays6 months ago
Originally posted in April of 2023, we are sharing this episode of Critical Matters again as Dr. Sergio Zanotti's discussion about the long journey to healing and recovery for those who've survived critical illness in the ICU remains pertinent and important. This conversation features Dr. Margaret Herridge, Professor of Medicine, Senior Scientist in Critical Care and Respiratory Medicine at the University of Toronto. Dr. Herridge is also Director of Critical Care Research. Director of the RECOVER Program, and Clinical Director of the Grace RECOVER Program for Chronic Critical Illness, in the University Health Network, Toronto, Canada.
Additional Resources:
Outcomes after Critical Illness. M. Herridge and E. Azoulay: https://pubmed.ncbi.nlm.nih.gov/36884324/
Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Hopkins RO, et al: https://pubmed.ncbi.nlm.nih.gov/10390379/
One-year outcomes in survivors of the acute respiratory distress syndrome. Herridge m, et al: https://pubmed.ncbi.nlm.nih.gov/12594312/
Long-term cognitive impairment after critical illness. Pandharipande PP, et al: https://pubmed.ncbi.nlm.nih.gov/24088092/
The RECOVER Program: disability risk groups and 1-year outcome after 7 or more days of mechanical ventilation. Herridge M, et al: https://pubmed.ncbi.nlm.nih.gov/26974173/
Determinants of long-term outcome in ICU survivors: results from the FROG-ICU study. Gayat E, et al: https://pubmed.ncbi.nlm.nih.gov/29347987/
Symptoms of anxiety and depression in family members of intensive care unit patients. Pochard F, et al: https://pubmed.ncbi.nlm.nih.gov/11588447/
Books Mentioned in this Episode:
Bel Canto. By Ann Patchett: bit.ly/3nWs7Vp
Commonwealth. By Ann Patchett: bit.ly/43pWSCt
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Advances and Challenges in Critical Care Medicine
00:00:32
Speaker
We have made great advances in the field of critical care medicine.
00:00:36
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Without doubt, we have improved our ability to care for the sickest patients.
00:00:40
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To support patients who are critically ill with multi-organ failure is something we continue to improve at.
00:00:46
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Yet, we have much to learn in the journey survivors of the ICU have ahead of them as they leave the ICU and try to heal and return to their families and society.
00:00:55
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In today's episode of the podcast, we will discuss outcomes after critical illness.
ICU Survival and Recovery with Dr. Herridge
00:01:00
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Our guest is Dr. Margaret Herridge, professor of medicine and senior scientist in critical care and respiratory medicine at the University of Toronto.
00:01:08
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Dr. Herridge is also director of critical care research, director of the RECOVER program,
00:01:13
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and Clinical Director of the Grace Recover Program for Chronic Critical Illness at the University Health Network in Toronto, Canada.
00:01:21
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It is a true honor to have her on the podcast to discuss such an important topic for our practices.
00:01:26
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Margaret, welcome to Critical Matters.
00:01:29
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Thank you so much, Sergio.
00:01:30
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It's a pleasure to be here.
00:01:32
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As we were discussing before we started recording, ICUs all over North America and the world probably are very focused on helping patients survive from critical illness.
00:01:43
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And often when somebody leaves after a couple of weeks, the ICU, there seems to be this sense of victory and triumph.
00:01:52
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And what we're learning these days is that there's still a very long road ahead of our patients.
00:01:58
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And there's a lot of challenges and probably there's a lot that we can do and a lot that we have to learn to make that journey a better one for our patients.
00:02:08
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So I felt this was an extremely important topic and I'm so happy that you, with all your expertise, are willing to share that with our audience.
Multi-Dimensional Morbidities Post-ICU
00:02:17
Speaker
Margaret, maybe we could start with a little bit of a historical perspective.
00:02:21
Speaker
I know a lot of our field kind of starts with ARDS, the original description, and slowly it seems that over decades we evolved our understanding of what it really means to be an ICU survivor.
00:02:36
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Yeah, I mean, that's right, Sergio.
00:02:39
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I think that that's right.
00:02:43
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I think there were studies before ARDS where people were beginning to think a little bit about this, but I think that was really the genesis of a lot of the outcomes work.
00:02:55
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And it's interesting that...
00:02:59
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You know, the outcomes work really began as being very single system focused, worrying about or at least reflecting on what the pulmonary function outcomes could look like and really progressing then to more generic health related quality of life outcomes.
00:03:18
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And then really in the last year,
00:03:21
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15 to 20 years really drilling down on different domains of disability and you know the seminal papers there that we mentioned in our review and I like to mention the names of people because we have a lot of important people who've contributed very seminal observations so the neurocognitive aspect of things really contributed by Mona Hopkins in her group
00:03:47
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And the PTSD challenges really brought to the community through the work of Gustav Schelling and others.
00:03:59
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And gradually more and more people contributing
00:04:04
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very important observations and really with the culmination of understanding that there are really multi-dimensional morbidities and ever-growing morbidity counts really as we become more aware of this and more deliberately catalog all of the challenges that patients have and their families have and um
00:04:31
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I think one thing that Ellie and I were trying to emphasize in our review as well is that it's just really bringing children
Long COVID and Post-ICU Outcomes
00:04:39
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in.
00:04:39
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And, of course, the health care team, that an episode of critical illness really is the starting point for a cascade of many events for lots and lots of people involved.
00:04:52
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And there's a really durable impact of this that may extend for years or decades after these events.
00:05:03
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So, yeah, we have we've done a lot of great work.
00:05:06
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There's no question our specialty has really done a lot of great work.
00:05:09
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But I think this may be one of the really important.
00:05:13
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important challenges in the next decades to come to really understand how we can mitigate this in real time in the unit and what might be modifiable or non-modifiable morbidities afterwards and how to really care for
00:05:35
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patients and families and children longitudinally, but frankly also our healthcare team.
00:05:41
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And I think the post-COVID observations have really heightened the urgency of, you know, many of these issues.
00:05:51
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And you mentioned challenges and you mentioned COVID.
00:05:54
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And I think that none of our listeners obviously is alien to what 2020, 2021, and part of 22 meant for critical care all over the world.
00:06:04
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I mean, we talked a lot about COVID, but an emerging concern and challenges, long COVID, which may be something different or may be just part of the same discussion we're having.
00:06:16
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I want to hear your opinion.
00:06:18
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But
00:06:18
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Could you just mention what that really means?
00:06:21
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I guess one way of thinking about it is that we have the largest cohort of critical illness survivors at one time worldwide, and now we've got to figure out what to do with them, right?
00:06:32
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Yeah, no question.
00:06:33
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I mean, we really kind of deliberately landed on this statement because โ
00:06:41
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I think it takes the outcomes work, which has really been sort of percolating in the literature for decades, to another level and to really the level of a public health, public policy, urgency, emergency.
00:06:57
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I might even use the word emergency because there are just so many people.
00:07:03
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affected and the cascade of events that we just sort of chatted about, about patients and families and children.
00:07:13
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Yeah, I mean, I think that...
00:07:16
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I think it's a long discussion about what long COVID really means, you know, because I think long COVID looks very different across this spectrum of severity of illness.
00:07:30
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And we're looking at that a bit in our Canadian National Study, CANCOVE, and I'm leading with my colleague here in Canada, Dr. Angela Chung.
00:07:40
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So Angela and I talk about this a lot, and lots of people in our community talk about this a lot, I think.
00:07:46
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the long COVID in the ICU folks is different.
00:07:50
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I think there's an enormous overlap with what we already know in the post-ICU outcomes literature.
00:08:01
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And this sort of overlapping construct of post-ARDS, post-sepsis, post-chronic critical illness and the post-intensive care syndrome nomenclature put forward by Dale Needham.
00:08:18
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And others.
00:08:19
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But, you know, I think there definitely is a unique contribution from COVID as well.
00:08:27
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And I think it's going to take a while to really sort that out.
00:08:30
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I mean, there is a very specific brain injury with COVID and renal injury and pulmonary injury that cardiac injury, you know, sort of multi-system injuries related to the ACE2 receptor sort of ubiquitous expression that I think is a bit different.
00:08:47
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But I think we are seeing so much overlap that it may be how we manage the morbidities in the longer term may look pretty similar to what we're trying to put together for post-ICU patients and families.
Post-ICU Recovery and Multidisciplinary Models
00:09:07
Speaker
And that in turn probably looks a lot like these historic events
00:09:12
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multidisciplinary, interprofessional models of rehab that most of us who do this work have adapted or adopted that really began in the kind of pulmonary rehab, cardiac rehab literature.
00:09:26
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So just to kind of reference that history too, because it's really what people need and longitudinal care needs.
00:09:35
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a sense of connectedness, you know, whether that's through a navigator role in nursing or other navigator role, but just continuity and education and advocacy, you know, sort of as basic principles for trying to address not only what long COVID will look like, but just, you know, sort of the more generic construct of post-critical illness outcomes.
00:10:02
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Absolutely.
00:10:03
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And I think that, as you mentioned, there might be some specific, unique aspects.
00:10:08
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But today we're going to focus on what's common to surviving critical illness and the journey post that.
00:10:15
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So maybe we could start or we could continue by diving into a little bit of...
00:10:20
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patient outcomes after critical illness, specifically thinking of three buckets of physical sequela, cognitive impairment, and mood and psychological impact.
00:10:31
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I think that's a good construct that we can use as a framework today.
00:10:36
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And why don't we start with some physical sequela that are common to many patients who survive the ICU that a lot of intensivists might not be thinking of as their patients leave the ICU?
00:10:49
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Yeah, sure, Sergio.
00:10:50
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I think...
00:10:53
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You know, I would always sort of put at the top of the list ICU acquired weakness and with that acquired or exacerbated frailty.
00:11:05
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So for your listeners who are maybe less familiar with ICU acquired weakness, this is a construct that's really emerged a lot in the last 15 to 20 years.
00:11:18
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But there are historic reports of this dating back to the early 80s.
00:11:23
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And actually by some Canadian colleagues of mine, I'm really noticing a flaccid quadriparesis in the ICU.
00:11:33
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So what is this?
00:11:35
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It really is an injury to the muscle and to the nerve.
00:11:38
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And it's not just from immobility.
00:11:40
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I think it's an important issue.
00:11:43
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Clarification here that there is a certain degree of muscle injury that relates to mechanical unloading through immobility because we're sedating, we're paralyzing our patients.
00:11:56
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But these are discrete injuries to the muscle, characterized as a myosin depletion myopathy, and an injury to the nerve, characterized as an axinopathy.
00:12:10
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And these can occur separately, very commonly occur together.
00:12:18
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they really create an enormous burden of disability.
00:12:24
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And we know that ICU-acquired weakness increases time on the ventilator because it affects the diaphragm.
00:12:33
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And the diaphragm may be specifically vulnerable to these sorts of injuries because the diaphragm teleologically is a muscle that was never programmed to rest.
00:12:48
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It's our only muscle that never rests.
00:12:50
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We use it 24 hours a day, seven days a week.
00:12:55
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So, you know, and many weeks a year.
00:12:58
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So the ICU acquired weakness will prolong mechanical ventilation.
00:13:05
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So ventilator time, ICU length of stay, hospital length of stay.
00:13:12
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It's associated with an increase in ICU mortality, hospital mortality, one-year mortality,
00:13:23
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And maybe may result in durable disability for five to eight to more years and may not be wholly reversible.
00:13:35
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So it's quite a devastating complication.
00:13:38
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And I think there is.
00:13:40
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an assumption that with rehab, this will all get better.
00:13:43
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And I think it's very important for me to clarify that with your listeners, that certainly rehabilitation and early mobility can help.
00:13:54
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However, there can be a point of no return for every patient after they've been in the unit for weeks or months.
00:14:03
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Because, and this is some nice work from Samir Jaber,
00:14:07
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and others.
00:14:08
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Over time, the sarcomeres of the muscle may become fixed, and you actually will have an irreversible injury to the muscle, and the contractile force will be lost.
Physical Consequences and Overlooked Problems Post-ICU
00:14:23
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Muscles may not necessarily regenerate or don't regenerate with the same degree of muscle bulk or contractile force.
00:14:31
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This is also work published by Jane Bade and Claudia DeSantos who work here at the University of Toronto.
00:14:41
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in their own group collaboratively with our recover group.
00:14:45
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And there are lots of muscle groups around the world.
00:14:47
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There's a large muscle group in the UK.
00:14:50
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This is the, pardon me, the group who published the JAMA paper led by Zudin Puthachiri, Nick Hart, Steve Herridge.
00:15:05
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and others which showed this sort of relentless muscle loss during the first week of ICU.
00:15:11
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They were looking at quadriceps muscle.
00:15:14
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And Sandy Levine in his New England Journal paper in 2008 looking at the injury to the diaphragm.
00:15:20
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So I'm just referencing some and naming some individuals who've made some seminal observations here.
00:15:26
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And just to highlight, this can be a devastating, long-term, and sometimes irreversible situation
00:15:32
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disability, and it is linked to age.
00:15:36
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It's linked to ICU length of stay.
00:15:38
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It's linked to severity of illness.
00:15:40
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And there's a beautiful review on ICU acquired weakness led by
00:15:48
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led by Jesse Hall and JP Kress in the New England Journal.
00:15:54
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And so I refer your listeners to that excellent review.
00:15:59
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And we'll definitely link that in the show notes.
00:16:02
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Absolutely.
00:16:02
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Yeah.
00:16:03
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Yeah.
00:16:03
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Really drills down on that a hundred percent.
00:16:05
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And,
00:16:06
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And frailty too, you know, as sort of a slightly different construct, but frailty as something that's a very important negative prognosticator for outcomes in people who come to the ICU with this, and often it's exacerbated or acquired in the ICU, also an independent risk factor for all of these negative long-term outcomes that I've mentioned with ICU acquired weakness.
00:16:31
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Absolutely.
00:16:32
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So that's a good place to start.
00:16:36
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Did you want me to focus on some other things or yeah, go ahead.
00:16:39
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No, and I was going to say that with ICU acquired weakness, it's almost like the tip of the iceberg, right?
00:16:46
Speaker
We started talking about this earlier, but then we started adding more and more layers, not only of understanding of that specific topic, but other problems.
00:16:55
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that our ICU survivors develop post the ICU stay.
00:17:00
Speaker
Are there any others that you want to mention in the physical consequences that might be of relevance before we dive into the cognitive area?
00:17:09
Speaker
Yeah, for sure.
00:17:10
Speaker
Again, you know, many people have published on these, so your readers can look at those for sure.
00:17:20
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And we articulated a few of these in our sort of original sort of one-year ARDS outcomes paper, actually, shockingly, 20 years ago now.
00:17:31
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But
00:17:33
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Things I like to highlight because they sometimes don't get quite as much attention.
00:17:39
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So with immobility, though, there's a lot of morbidity from contractures.
00:17:46
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In particular, frozen shoulders are very morbid.
00:17:51
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Some patients can develop heterotopic ossification, which is sort of an extraarticular bony deposition, again leading to a decrease in joint movement and disability.
00:18:04
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A lot of patients will have peripheral neuropathies, again related to
00:18:10
Speaker
nerve injury, but these can be pretty devastating and also lead to gait disturbances and disability.
00:18:20
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Some things that I really might highlight that often don't get to prime time are pressure injuries, which I think many of us in ICU might think just get better over time.
00:18:34
Speaker
These can be extremely morbid and can take a year or longer to heal, especially because they're often colonized with really pernicious, multiply drug-resistant organisms.
00:18:50
Speaker
And actually, the severity of pressure injuries and their duration, they are associated with one-year mortality.
00:18:59
Speaker
And this is a very seminal observation in the decubitus paper that was published recently.
00:19:05
Speaker
The other thing I might like to emphasize in addition to pressure injuries that people don't talk about enough, I think, is oral health.
00:19:14
Speaker
I mean, I've always been struck in our follow-up over the years by how much tooth loss and dental morbidity our patients have.
00:19:24
Speaker
And they don't talk about it.
00:19:27
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And maybe people think this is just normal.
00:19:30
Speaker
I think we can do a much better job with oral hygiene, tooth brushing.
00:19:35
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There's enormous dental loss and complex gingival disease, need for root canals.
00:19:41
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And depending on what country you live in and your own income issues, this can be an extraordinary burden and extremely expensive.
00:19:51
Speaker
And it really can go on for years as well.
00:19:54
Speaker
And I think it would be good to really highlight this.
00:19:59
Speaker
There's also vocal cord injury.
00:20:01
Speaker
I would just make the comment in our COVID cohort,
00:20:04
Speaker
And I think this may be due to proning.
00:20:07
Speaker
I've never seen so many tracheal injuries.
00:20:10
Speaker
We have a lot of people with tracheal stenosis, which has been documented by our group and other groups historically.
00:20:17
Speaker
But I think this may be a new and emerging, you know, getting back to my comment that we have this ever-increasing list of things to keep an eye on, may be related to a lot of recurrent and chronic proning that we may be creating in
00:20:34
Speaker
airway injuries that manifest you know months later as a tracheal stenosis and may go undiagnosed so a long list of a lot of things and and we tried to really detail and enumerate these ellie and i did in our paper so i might refer to your listeners to that as well for a more complete list
00:20:57
Speaker
Absolutely.
00:20:58
Speaker
And I think that what you mentioned about the tracheal injury is very interesting because it also makes me think immediately, Margaret, are there unique aspects of COVID as a disease or are there particular aspects of how we care for those patients that actually now are causing an increase in us diagnosing certain problems?
00:21:21
Speaker
Yeah, well, I mean...
00:21:25
Speaker
you know, for sure.
00:21:28
Speaker
I don't know.
00:21:28
Speaker
No, it's a question, a rhetorical question, I guess.
00:21:30
Speaker
It was a rhetorical question.
00:21:32
Speaker
Yeah, yeah.
00:21:32
Speaker
So I, yeah, like 100%.
00:21:33
Speaker
And I think I might just quickly say that the de-adoption of so many of our great
00:21:43
Speaker
principles that we've spent so many or standards of care that we spent so much time studying.
00:21:49
Speaker
I think we really need to have a hard and honest look at what the ramifications of those were for our patients, for sure, and families.
00:21:59
Speaker
Absolutely.
Cognitive Dysfunction in ICU Survivors
00:22:00
Speaker
So the other bucket we mentioned is cognitive impairment.
00:22:04
Speaker
And my understanding is that this is something that we have learned more recently, or at least after we were understanding about the...
00:22:16
Speaker
ICU acquired weakness, but it might have devastating effects on our patients.
00:22:21
Speaker
And especially if we don't talk to them about it, they don't realize that it's going on or that they can actually talk about it or try to seek help for it.
00:22:31
Speaker
Could you talk a little bit about this area?
00:22:34
Speaker
Yeah, for sure.
00:22:36
Speaker
Well, at the beginning, I mentioned Mona Hopkins, who's really a very important figure in all of this and really put this whole issue on the map.
00:22:48
Speaker
So I really would want to publicly acknowledge Mona and her important work.
00:22:54
Speaker
She is the leader in this and everyone has followed.
00:22:58
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She was the one who, in 1999, published a Blue Journal paper on cognitive outcomes in ARDS patients and really helped us to understand that these patients at one year, and now it's clear for many years, will have problems with ARDS.
00:23:19
Speaker
memory concentration, processing speed, and I have a lot of challenges with executive function, really the ability to multitask.
00:23:35
Speaker
And these can be really very devastating complications.
00:23:41
Speaker
I think this is one of the very invisible morbidities initially.
00:23:47
Speaker
Because in the ICU, you know, everyone is very excited that a patient can obey commands.
00:23:54
Speaker
And...
00:23:56
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I mean, while that can be very reassuring in the short term, it's really not going to disclose any of these higher cognitive or more integrative processes that really may be very compromised in our post-ICU patients.
00:24:13
Speaker
And in Mona's experience, and she's written a lot about this, and in her own experience and seeing ICU patients for a long time, often these cognitive problems, these cognitive sequelae don't really become evident until people try to resume their life again.
00:24:32
Speaker
And most usually try to go back to work and find that it is hard to, you know, their memory is not the same.
00:24:39
Speaker
It's hard to concentrate, hard to focus.
00:24:43
Speaker
They process at a more slower, you know, they process more slowly.
00:24:49
Speaker
And they really are having problems with,
00:24:53
Speaker
managing multiple tasks.
00:24:55
Speaker
And many of us have jobs that require very, very intact and high-level executive functioning.
00:25:06
Speaker
I would say as an intensivist, we're really taxed in that way enormously.
00:25:12
Speaker
And this can be a big barrier to return to work, as I mentioned, and can be very devastating for patients.
00:25:26
Speaker
I think that in my experience, this is just an anecdotal comment, that the higher functioning patients often...
00:25:32
Speaker
because they're really working at the limits of their cognition.
00:25:37
Speaker
Notice even a minor decrement in these abilities.
00:25:41
Speaker
And it can be extraordinarily distressing.
00:25:43
Speaker
And depending on the job, it really will work.
00:25:47
Speaker
it really will be a barrier.
00:25:49
Speaker
It's interesting in Mona's initial paper, a long time ago now, that the cognitive dysfunction was linked to hypoxemia.
00:26:00
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And...
00:26:03
Speaker
And others now have really helped to create, you know, a list of risk factors that are also associated with cognitive dysfunction and things like being in deep coma, where we really have problems.
00:26:23
Speaker
an injury not just to the cortex, but probably the white matter and a pruning effect related to a real change in external exposure to external stimuli, you know, and all the various sedation and narcotic and anesthetic drugs.
00:26:43
Speaker
Just to your point earlier, Sergio, that we were running continuously for days and in many cases weeks.
00:26:52
Speaker
in some of our sickest COVID patients and just, you know, I mean, meeting all of the high-risk factors, the documented risk factors that we know are associated with long-term cognitive dysfunction.
00:27:07
Speaker
And a seminal observation from the Brain ICU group, the Vanderbilt group, that particular New England Journal paper published in 2013 led by Pradeck-Pendrup-Pondi and Wes Ely,
00:27:22
Speaker
You know, so many others, so many other leaders, Jim Jacks and others, who've, Tim Gerard, who've done a lot of important work, you know, showing not just delirium, but duration of delirium is an extremely potent determinant of long-term cognitive dysfunction.
00:27:42
Speaker
And we know in the COVID patients that they had a lot of very complex delirium.
00:27:48
Speaker
Another reason we needed to,
00:27:52
Speaker
resort to polypharmacy often with sedation and narcotics, etc.
00:27:59
Speaker
to be able to vent them, to be able to manage them on ECLS and other things.
00:28:06
Speaker
Lots of robust literature that would make you expect or, you know, I mean, foreshadow what we're finding in the post-COVID people, that we were doing all the things that we know hurt the brain.
Cognitive Impairment and Reintegration Challenges
00:28:20
Speaker
And these are the consequences.
00:28:22
Speaker
Absolutely.
00:28:23
Speaker
And I'm always struck when we talk about cognitive impairment by just one case of a family friend who was older, but extremely functional, recovered from the ICU.
00:28:38
Speaker
Everybody was elated and it seemed he was fine, went back to run his business and six months later was bankrupt.
00:28:45
Speaker
And now connecting the dots, obviously, there probably was significant functional issues that were not recognized, were not addressed.
00:28:56
Speaker
Right.
00:28:56
Speaker
And this is not, I think, an uncommon story, unfortunately.
00:29:01
Speaker
Yeah, absolutely.
00:29:04
Speaker
And.
00:29:06
Speaker
And I think the other just along the, I'm so sorry to hear about your family friend.
00:29:10
Speaker
I, yeah, lots of stories like that, that so many of us in the outcomes world have heard in our clinics and indirectly.
00:29:16
Speaker
But I think there's just such a key issue that people should be really counseled not to try to return to work too early.
00:29:26
Speaker
And to really try to understand where they're at so that we can try to mitigate some of these disastrous consequences.
00:29:36
Speaker
Many people will have some, you know, improvement over time.
00:29:43
Speaker
There's no clear intervention at this moment, although, you know, Jim Jackson's working very hard on this in the brain ICU group in particular at Vanderbilt.
00:29:51
Speaker
But, you know, just even just trying to protect patients from themselves, you know, trying to get back to normal, trying to rush back to work, trying to put this horrible life event behind them.
00:30:03
Speaker
I see this a lot.
00:30:04
Speaker
And, you know,
00:30:05
Speaker
I really try to caution people and try to protect them from going back to work too early.
00:30:12
Speaker
One, because...
00:30:16
Speaker
I don't think it's good for their colleagues to see that maybe they're not functioning at the same level.
00:30:21
Speaker
And that creates its own problems at work, problems with discrimination, or they're trying to take on too much responsibility and truly are not able to with sometimes disastrous consequences as you've just outlined.
00:30:36
Speaker
So I think this is an important role for the follow-up clinic or longitudinal follow-up care.
00:30:43
Speaker
to or educating primary care physicians because these clinics are not disseminated around the world to educate people about how to advise patients and families after this and maybe advocate for disability or rationale for being you know needing more recovery time I think if you've never
00:31:06
Speaker
known someone who's been in ICU or you don't understand what it looks like, I think people, when they come home, everyone around them figures they'll be fine in a couple of weeks.
00:31:16
Speaker
And of course, this is never the case.
00:31:17
Speaker
It's more like a year.
00:31:20
Speaker
And I've spent a lot of time writing letters advocating for disability with insurance companies, disability issues.
00:31:31
Speaker
And it's really tough.
00:31:34
Speaker
There's not a lot of understanding about this.
00:31:36
Speaker
And that translates into not a lot of work accommodation, unfortunately.
00:31:43
Speaker
Absolutely.
Psychological Impact on ICU Survivors and Healthcare Workers
00:31:44
Speaker
And the third bucket I wanted to comment before we move on
00:31:47
Speaker
which obviously also is extremely important, is the mood disorders, psychological impact, or mental health disorders that are very common in the ICU in general for people who have worked in the ICU at COVID, but also for our patients.
00:32:03
Speaker
Could you just comment some of those aspects, Margaret?
00:32:06
Speaker
Yeah, for sure, Sergio.
00:32:09
Speaker
Maybe I'll just start with the patients and then maybe just comment briefly on the healthcare workers because I think that's important too.
00:32:19
Speaker
So as I started off by saying that Gustav Schelling in his paper in 1998 said,
00:32:26
Speaker
I'm just highlighting the authors and the papers because these papers are a long time ago.
00:32:32
Speaker
And still, I think, Sergio, it may be some of your listeners or certainly many of our colleagues are really unaware of this robust literature that's decades old that Ellie and I were really trying to give a historic perspective on just to underline, like, we know this and we all should know this.
00:32:54
Speaker
So he really put PTSD on the map, and I think people at the time were shocked by it.
00:32:59
Speaker
Maybe in disbelief, but it's a very robust finding.
00:33:04
Speaker
As are anxiety, anxiety,
00:33:08
Speaker
as is, pardon me, depressive symptoms.
00:33:12
Speaker
We've learned over the years that the depressive symptoms, and many people have published on this, many different groups.
00:33:22
Speaker
The Vanderbilt group has Mona's group.
00:33:24
Speaker
Our group in Toronto has Dale Needham's group.
00:33:29
Speaker
Hopkins has...
00:33:32
Speaker
Dimitri Davido, Joe Benvenu, who work at the Hopkins Group or have moved to other places now, Dimitri has published a lot on this topic, Jim Jackson recently, too.
00:33:48
Speaker
Really prevalent depressive symptoms, major episodes of depression.
00:33:54
Speaker
There's an emerging literature on suicidality,
00:33:59
Speaker
Shannon Fernando, a Canadian colleague in a recent JAMA paper published on suicidality.
00:34:04
Speaker
We know that there are challenges with substance misuse.
00:34:09
Speaker
So these are really big deals.
00:34:12
Speaker
And unfortunately, for a lot of the patients,
00:34:18
Speaker
They're ashamed of this.
00:34:20
Speaker
They're ashamed to talk about it.
00:34:23
Speaker
They've had the PTSD has been linked to restraint use in the ICU.
00:34:29
Speaker
Getting back to some of your earlier comments, things we can do.
00:34:33
Speaker
We should not be tying people down.
00:34:37
Speaker
There's some suggestion, although it's inconsistent, that polypharmacy and running these continuous sedation infusions or drug infusions may be associated with that, but it's equivocal.
00:34:48
Speaker
Some studies have shown that.
00:34:50
Speaker
The Brain ICU New England Journal paper did not demonstrate that, at least with cognition and mood disorders.
00:34:58
Speaker
But these are ways we can mitigate that, but they're devastating.
00:35:02
Speaker
The delusions that patients have as part of delirium in the ICU are very disturbing.
00:35:10
Speaker
Many of us who do follow-up have had patients talk a lot with us once they know and trust us that they have...
00:35:18
Speaker
they are convinced, tragically, that they've been sexually assaulted in the ICU.
00:35:23
Speaker
So many stimuli in the ICU are distorted and misperceived in the context of delirium in a very kind of persecutory way.
00:35:36
Speaker
So the difficult to insert femoral vascaf
00:35:41
Speaker
Maybe construed as sexual assault or the insertion of rectal tubes similarly.
00:35:47
Speaker
Being tied down, absolutely.
00:35:50
Speaker
It's not hard to imagine how people feel they've been, they are being tortured and held in places against their will.
00:36:00
Speaker
So I think we have a lot of work to do in that, and it's always very disturbing and continues to be very disturbing for those of us who do follow up to listen to these stories.
00:36:09
Speaker
They are not one-off stories.
00:36:11
Speaker
They are robust stories.
00:36:13
Speaker
I've been listening to stories like this for decades in our own work here in Toronto.
00:36:18
Speaker
So very important to emphasize that and to think about ways we can improve it.
00:36:24
Speaker
I might just finish by just saying the healthcare workers we know now get really sick.
00:36:30
Speaker
And I think that this kind of, if I can be candid, and it's okay here.
00:36:37
Speaker
Absolutely.
00:36:37
Speaker
You might disagree with me, but I think this kind of hero archetype, the intensivist as the hero archetype, only does our profession a disservice.
00:36:48
Speaker
We are people.
00:36:50
Speaker
And after COVID, we all have our own devastating stories and experiences.
00:36:58
Speaker
Many people have been challenged by their own mood disorders, mental health issues.
00:37:05
Speaker
I think, and we sort of tried to highlight this in the paper too, that
00:37:10
Speaker
it has its own effect on those of us who do this work.
00:37:13
Speaker
And we need to look after ourselves and our community as well and acknowledge, I think, I hope, that what we do changes us too.
00:37:26
Speaker
And we need to...
00:37:30
Speaker
kind of acknowledge that and be honest about how difficult this work is.
00:37:34
Speaker
As rewarding as it is and how much, you know, we all love doing it and making a difference, we pay a price for doing it.
00:37:41
Speaker
And I think it's important to be able to talk openly and honestly about that.
Risk Factors for Post-ICU Disabilities
00:37:47
Speaker
I couldn't agree more.
00:37:47
Speaker
And I always say that we don't need another hero.
00:37:50
Speaker
We need great teams and a system that works, right?
00:37:54
Speaker
And that's what should be, I think, valued, praised, as opposed to somebody who's been on for 48 hours.
00:38:00
Speaker
That is not really what we need, like you said.
00:38:04
Speaker
So those are all great points.
00:38:06
Speaker
And quite humbling.
00:38:07
Speaker
And I would hope that our listeners think about these issues with a lot more compassion and empathy towards our patients as we care for them in the ICU.
00:38:19
Speaker
We talked a little bit about age and length of ICU stay as obviously important risk factors.
00:38:27
Speaker
Could you just give us a brief summary in terms of what are some of the risk factors that we know today, modifiable and non-modifiable, for all these post-ICU disabilities?
00:38:39
Speaker
Wow.
00:38:40
Speaker
Well, that could be his own podcast, Sergio.
00:38:45
Speaker
So maybe we just hit on the most important ones.
00:38:48
Speaker
Yeah.
00:38:48
Speaker
Let me just give you, I can give you sort of the highlights or things that I always try to teach when I'm attending myself and I try to highlight for our group.
00:38:57
Speaker
Yeah.
00:38:59
Speaker
I think what I always say to people when I'm working with the team is it's so important that, and I guess we tried to emphasize this too, that we really do embrace the continuum because everyone had a really important history before they came to the ICU.
00:39:18
Speaker
And the history may be that they were young and entirely healthy, but that's extremely relevant because that person has tons of reserve when they come.
00:39:27
Speaker
And that changes how you...
00:39:32
Speaker
I think your attitudes about how extensive your, I don't want to use the name of extensive, but the sort of extreme levels of care that you may wish to expose that patient to.
00:39:46
Speaker
How about I express it that way?
00:39:49
Speaker
But things that I really think are important to emphasize maybe for the listeners here,
00:39:54
Speaker
and this is some very nice work done by Lauren Ferrante and others, you know, the trajectory that someone's on before they come to the ICU is extremely important.
00:40:04
Speaker
And we often don't take a careful enough history because there's a lot of richness there in terms of prognostication.
00:40:12
Speaker
Not just older patients, but patients who are in declining health,
00:40:17
Speaker
patients who have acquired important frailty, patients who've had multiple hospital admissions leading up to kind of a final decompensation and they're in the ICU.
00:40:31
Speaker
You know, patients who are very comorbid, you know, they come to you with very limited reserve, whether that's neurocognitive reserve, they're beginning to show early signs of dementia, or, you know, they've got some underlying pulmonary or cardiac or renal disease, you know,
00:40:52
Speaker
or you know they're they're bed bound at home literally or in an institution the pre-icu trajectory is extremely key there's no doubt
00:41:04
Speaker
I would say the other issue too is that people get very upset when you talk about age, that it seems discriminatory, but it's not.
00:41:14
Speaker
The reason why age is in every prognostic model is for a good reason, because we all lose organ reserve with age.
00:41:22
Speaker
And it's part of normal aging, normal senescence that we lose organ reserve.
00:41:28
Speaker
And that is why age does matter.
00:41:31
Speaker
I mean, you know, I don't have the same reserve I had when I was, even though I am fortunate to be in good health, that I had 20 or 30 years ago.
00:41:42
Speaker
This is normal.
00:41:43
Speaker
And I think that this is important to keep in mind.
00:41:50
Speaker
I mentioned age, trajectory.
00:41:52
Speaker
I mentioned frailty is enormously important.
00:41:58
Speaker
And those are factors coming into the ICU for sure.
00:42:03
Speaker
In the ICU, I think that there's a robust literature from many groups.
00:42:11
Speaker
I like to highlight the French group, the frog ICU group, our own recover groups contributed to this.
00:42:17
Speaker
Those who've published a lot on chronic critical illness, Judy Nelson, Shannon Carson, Terry Huff,
00:42:27
Speaker
Chris Cox, there are many, many leaders in this area have really helped to highlight, and in this Provence study that was led by Terry Huff, that the longer you spend in the ICU, the more trouble you're in.
00:42:41
Speaker
So I think that's an important piece for your listeners, that no one...
00:42:46
Speaker
No one is getting better weeks into the ICU.
00:42:49
Speaker
They might survive the unit, but what they definitely are accruing over time is disability.
00:42:56
Speaker
They're accruing physical disability, you know, the neuropsychological disabilities that we've already talked about in this podcast.
00:43:04
Speaker
And there's a huge cost to this.
00:43:06
Speaker
And we know from all of these studies that I've mentioned that each decade of age,
00:43:14
Speaker
Each week you spend in the unit, after about two weeks, you are going to have more and more disability.
00:43:22
Speaker
And it's not just that.
00:43:25
Speaker
It's that at one year, you're going to have an increase in your one-year mortality.
00:43:30
Speaker
So I really, one thing we were advocating for in the paper, and maybe, you know, it's controversial for some, but that it's literature-based, is that really after a couple of weeks, you know when someone's in trouble as an experienced intensivist.
00:43:48
Speaker
And I think it's really important to begin to have weekly discussions about
00:43:54
Speaker
about goals of care and just educating patients and families about disability about accruing mortality risk and really about all of the challenges that people may face that's not to say that people won't want to take that on but i think it's very important to be very transparent about what's happening
00:44:19
Speaker
and that people have declared themselves as having very complex chronic critical illness.
00:44:25
Speaker
And there's a lot of morbidity and mortality and change in disposition that's associated with that and wanting to be really honest about living a life that looks like that.
00:44:42
Speaker
And depending on the health care system you're in, you know, dealing with an enormous cost.
00:44:50
Speaker
for the ICU care.
00:44:51
Speaker
This would not be the case in Canada, but in many countries.
00:44:56
Speaker
And then being disabled and unable to work on the back end of that with an enormous medical debt.
00:45:03
Speaker
So I think just having an honest discussion about that is something that I think we need to have a bit of a change in focus even during the acute ICU stay.
00:45:18
Speaker
I agree.
00:45:19
Speaker
And perhaps step number one in any new challenge or problem is awareness and understanding.
00:45:26
Speaker
But perhaps right after that, step number two for clinicians is to be familiar with the data and what really happens to patients and to share that information.
00:45:37
Speaker
in a way that families and patients can really understand what we're talking about weeks and weeks after ICU care.
00:45:44
Speaker
I think that's a great point.
00:45:46
Speaker
We talked a lot about patients, Margaret, but there are also co-survivors.
00:45:52
Speaker
There are family members and caregivers that also have significant impact post-ICU care.
00:45:59
Speaker
Could you just comment very briefly, and I know we're coming up on time, on some of the caregiver outcomes or family outcomes, and then we can maybe talk about some interventions and a call to action.
00:46:11
Speaker
For sure.
00:46:13
Speaker
Yeah, so I'm here representing both my colleague, Dr. Ellie Azoulay, and Ellie is really one of, if not the international expert in this area.
00:46:29
Speaker
So I would really want to couch my comments in that.
00:46:33
Speaker
We do some work too, and many others do, but Ellie is really the authority.
00:46:39
Speaker
I think it's important, and I love that you use the term co-survivors, Sergio.
Family as ICU Co-Survivors
00:46:46
Speaker
I think that's a really wonderful way to think about it.
00:46:49
Speaker
And I think it really is increasingly important to report and study dyads that we really acknowledge that patients have families like the pediatricians always have, but we're sort of a little bit behind in catching up in.
00:47:06
Speaker
The families suffer a lot.
00:47:09
Speaker
And I think, again, just getting back to your earlier comment on COVID, having the families away from the bedside was devastating.
00:47:19
Speaker
And Ellie and his colleague in Paris, who's also a leader in this area, Nancy Kentish-Barnes, have published a lot on COVID recently about the isolation, especially how devastating that has been at the end of life.
00:47:35
Speaker
and the loss of sort of those final treasured moments at the end of someone's life, a family member.
00:47:43
Speaker
The families become mentally ill.
00:47:46
Speaker
And I think people find that hard to, people, I mean colleagues, find that really hard to accept.
00:47:55
Speaker
I would just say that from my own experience.
00:47:58
Speaker
I think historically we have really characterized families as
00:48:04
Speaker
Difficult.
00:48:07
Speaker
I'm sorry to use these words, but we've all heard them.
00:48:09
Speaker
Difficult, crazy, insane, you know, losing it.
00:48:14
Speaker
They can't cope with it.
00:48:15
Speaker
They don't get it.
00:48:16
Speaker
Like very hurtful, pejorative, critical comments of the family.
00:48:22
Speaker
And I think in my own practice as an intensivist and as a teacher, when I'm at the bedside, I...
00:48:32
Speaker
I mean, I'm not here to be self-righteous.
00:48:34
Speaker
I'm really here to be teaching or messaging that we need to show more compassion for the families.
00:48:44
Speaker
Sorry, they're going through the worst experience of their life.
00:48:47
Speaker
Most would characterize it as such.
00:48:49
Speaker
And not everyone is built for this kind of unremitting, high-level stress and uncertainty.
00:48:58
Speaker
And, you know, they just can't sublimate it in the same way.
00:49:03
Speaker
And we just expect people to behave themselves, to, you know, just agree with what we're saying and be calm and accepting.
00:49:14
Speaker
I mean, this is just not realistic.
00:49:16
Speaker
And it's really not fair.
00:49:18
Speaker
And I really, I think we can, one thing I hope our community can work on is being,
00:49:27
Speaker
less judgmental and more compassionate and definitely not endorsing of these sorts of pejorative, really harsh and cruel things that we say about the families all the time when you really listen for them.
00:49:45
Speaker
I think that's a great point.
00:49:46
Speaker
You've got to really stop that.
00:49:47
Speaker
You've got to really stop that.
00:49:49
Speaker
Yeah, one of the things, Margaret, that I have worked on as I've developed more white hair and reflected more on my career is when somebody talks to me or they sign out to me or the nurse talks about a...
00:50:03
Speaker
difficult family, I would kind of re-challenge them and say, maybe it's not a difficult family, but a family in a difficult position.
00:50:11
Speaker
Or this is not a, maybe it's not a crazy family.
00:50:15
Speaker
It's a family in a crazy situation, right?
00:50:18
Speaker
I mean, if you, and we all have seen this, when we become the family or we become the patient, we're no different, right?
00:50:25
Speaker
And it just has to do with everything that's going on.
00:50:28
Speaker
And like you said, being more compassionate and understanding
00:50:32
Speaker
I believe is extremely important.
00:50:36
Speaker
So I think that's a very, very valuable point.
00:50:38
Speaker
And as we move towards the closing, like you said, this is a topic that we're just scratching the surface, but there's a lot to learn, a lot to discuss.
00:50:47
Speaker
But what are some things, Marga, that we could do today to move the needle for our ICU survivors and their families?
00:50:57
Speaker
Well, I think...
00:51:01
Speaker
First of all, let me just say, Sergio, I really loved how you just said that you reframe this discussion about the families with your colleagues.
00:51:10
Speaker
I think it's a very wonderful way of reframing that's not judgmental also of their behavior.
00:51:16
Speaker
I just wanted to say I loved how you just phrased that.
00:51:19
Speaker
That was just great.
Improving ICU Survivor Outcomes
00:51:20
Speaker
Yeah.
00:51:22
Speaker
Well, I think one way to begin is what you're doing and others are doing is to try to disseminate and educate and to demystify what's going on and to not make it seem like it's an indictment of our specialty because it isn't.
00:51:41
Speaker
We're learning.
00:51:42
Speaker
You're right.
00:51:43
Speaker
We have a lot to learn and we have a lot to learn about ways that we can mitigate all of this.
00:51:48
Speaker
So,
00:51:49
Speaker
I think beginning with education and honesty and humility about what we're doing and, you know, really moving beyond saving a life.
00:51:59
Speaker
It has got to, we've got to, you know, examine this much more deeply and much more longitudinally.
00:52:11
Speaker
and maybe multidimensionally, maybe I would say that.
00:52:14
Speaker
I think outside of education, which is a great place to start, is...
00:52:21
Speaker
I do think we need some way to create pathways for these patients and families.
00:52:28
Speaker
And not every system is even amenable to that.
00:52:32
Speaker
Depending on the health care system you work in, it is really so compartmentalized and politically so, structurally so, that it may be very difficult to create continuity and to create pathways for these patients.
00:52:49
Speaker
In those systems in which it's possible, I think we really should move towards mandating that.
00:52:56
Speaker
This is possible in Canada.
00:52:59
Speaker
I think it's possible in single-payer systems because they, you know, I think that the health policy people can see the merits in this.
00:53:09
Speaker
And these won't necessarily be high-cost endeavours.
00:53:15
Speaker
Lots of people are working on interventional studies.
00:53:19
Speaker
Within the ICU, the whole early mobility movement is trying to understand how that can, you know, mitigate disability.
00:53:30
Speaker
The results are a bit equivocal.
00:53:32
Speaker
The most recent important teams, a study led by Carol Hodgson, unfortunately did not show
00:53:40
Speaker
There may be reasons for that methodologically, but it is a bit of an equivocal literature, getting back to what I was saying earlier on, that a lot of these injuries may not be wholly remediable or reversible.
00:53:55
Speaker
But understanding things already, you know, if you look to the A to F bundle, which some people are critical of, but I think it's a reasonable touchstone and kind of reminder of things that really we should try to do.
00:54:11
Speaker
And we de-adopted in COVID and we've seen the deleterious consequences of that.
00:54:18
Speaker
Things as simple as
00:54:21
Speaker
Also, monitoring or observing good glycemic control.
00:54:26
Speaker
We know, and this is work from Greet Vandenberg, not just her historic paper on tight glycemic control, but JAMA publication looking at tight glycemic control in children and how that mitigates cognitive dysfunction.
00:54:40
Speaker
I think...
00:54:41
Speaker
And triglycemic control can really mitigate some of these peripheral nerve and central nervous system issues.
00:54:50
Speaker
Hypoxemia, I mentioned in from Mona's work, you know, trying to mitigate delirium, again, a potent risk factor for cognitive dysfunction.
00:55:05
Speaker
Mood disorders, you know, not having people on polypharmacy, trying to have people awake so that we can reorient them and keep them connected in some way so they don't have these really injurious delusions.
00:55:24
Speaker
Don't tie people down.
00:55:27
Speaker
You know, I mean, these are things we can do now.
00:55:32
Speaker
In the longer term, the post-ICU, well, that's its own maybe chapter in discussion, but I think still working on understanding how much of the brain injury in the longer term can be mitigated, how much of the muscle injury can be mitigated.
00:55:50
Speaker
I think the benefit of the long-term follow-up right now is education, advocacy, continuity, helping in return to work, these sorts of things.
00:56:02
Speaker
And I think one of the most powerful aspects of suffering post-ICU, especially the psychological aspect of the cognitive, might be the isolation that people who suffer it, where it's a patient or a family member feel.
00:56:19
Speaker
in terms that this is only happening to them, which is a common theme in mental illness, right?
00:56:24
Speaker
And by educating, explaining that these things might occur, where to maybe seek some help, and realizing that these are common events that happen to a lot of people, and normalizing them as problems that need to be discussed, I think is also something where there's, from my perspective, plenty of opportunity in the ICU practice.
00:56:48
Speaker
Yeah, it's a great point.
00:56:50
Speaker
I think one thing that we really can mitigate in the longer term are the mood disorders.
00:56:56
Speaker
And I would really emphasize that, that the patients need us to advocate for access to mental health care after they leave the ICU.
00:57:06
Speaker
And you're right, normalize it so people don't feel so stigmatized and they'll be open to
00:57:13
Speaker
sorry, receiving this and pursuing it.
00:57:16
Speaker
Totally agree.
00:57:17
Speaker
And it's a great point, Sergio.
00:57:19
Speaker
Thank you.
00:57:21
Speaker
So I would like to close the podcast, Margaret, with questions that we ask our guests just to tap into their wisdom that are not related to the topic that we just discussed.
Dr. Herridge's Personal Insights and Conclusion
00:57:32
Speaker
Would that be okay?
00:57:34
Speaker
course sure no problem so the first question relates to books and I just want to know are there any books that have influenced you significantly or books that you have gifted often to other people oh um well I don't know it might um
00:57:59
Speaker
It might sound a bit weird.
00:58:03
Speaker
I mean, maybe I'll speak more personally that I am somebody who tends to read a lot of fiction.
00:58:13
Speaker
I read fiction that is about
00:58:19
Speaker
human relationships because I think a lot about relationships in the ICU as an intensivist and we're exposed a lot to and exposed isn't the word I want to use we are enormously privileged to be welcomed into the or be allowed to have a look at someone's life
00:58:46
Speaker
at a moment when people are so exquisitely vulnerable.
00:58:51
Speaker
And so I read a lot about relationships and people and what people are going through.
00:58:55
Speaker
So I'll tell you one of my favorite authors in this way is Anne Patchett.
00:59:00
Speaker
She's an American author.
00:59:02
Speaker
And she writes a lot about complex people and complex relationships.
00:59:07
Speaker
And I guess I'm drawn to that because that's sort of the nature of the work that we do.
00:59:13
Speaker
Absolutely.
00:59:14
Speaker
And so that's what I do.
00:59:15
Speaker
That's what I read, actually.
00:59:17
Speaker
Love it.
00:59:17
Speaker
I'm a nonfiction reader, but I do read fiction because I do believe that in terms of enhancing our empathy, great fiction writers really understand human connection, human emotions and human behavior.
00:59:33
Speaker
And I agree 100% with what you said, Margaret.
00:59:36
Speaker
To be at somebody's bedside when they're dying and their family is around them is a privilege.
00:59:42
Speaker
And it's something that I think we should never lose sight of.
00:59:47
Speaker
And we should always look in awe because it's one of the things that we don't fully understand.
00:59:52
Speaker
But you're right.
00:59:53
Speaker
I mean, it's all about that very intense human connection at a very vulnerable point.
00:59:59
Speaker
And we can make it a lot worse.
01:00:03
Speaker
We can make it a little bit better.
01:00:04
Speaker
And I think that we would all agree that we want to make it a little bit better.
01:00:07
Speaker
So definitely we'll add some Ann Patchett books and I'll definitely look to read one of them, see how I enjoy them.
01:00:14
Speaker
I'll let you know.
01:00:16
Speaker
The second question is, is there something you believe that most people don't believe or don't behave like they believe can be in medicine or just in life in general?
01:00:28
Speaker
Wow.
01:00:39
Speaker
Well, I don't know.
01:00:46
Speaker
That's a very, very deep and interesting question.
01:00:50
Speaker
I'm not even sure how to answer it.
01:00:56
Speaker
This is what, I mean, I'm not sure this is like a perfect answer to this question, but something maybe I've learned over the years.
01:01:05
Speaker
But some of the, I believe that people really are capable of a lot of,
01:01:21
Speaker
like really a lot of kindness and that the kindness that you can see can be very unexpected and you see it in unexpected places and that you can learn a lot about kindness.
01:01:36
Speaker
I think about this all the time when I'm in the unit.
01:01:39
Speaker
I think a lot about kindness in ways that people don't really acknowledge very frequently.
01:01:47
Speaker
So I look, I'm often so struck by this, like we have these patient attendants here in our ICU.
01:01:56
Speaker
Or, you know, I look at the kindness and how they carefully move patients who are often in such bad shape, you know, with these injuries and they're cachectic, et cetera, and show so much compassion and kindness as the nurses are washing them.
01:02:10
Speaker
And people don't even acknowledge this.
01:02:12
Speaker
But they're caring.
01:02:15
Speaker
And I see so much kindness in the people who clean our ICU.
01:02:21
Speaker
Most people don't even know their names.
01:02:23
Speaker
But they know the families.
01:02:25
Speaker
And they are there every day talking with the families and showing support.
01:02:31
Speaker
And I'm always so struck by a lot of our nurses who will say to me, well, Mark, I'm just going to give this person a spa night tonight.
01:02:41
Speaker
And they bring in toiletries.
01:02:46
Speaker
and they wash hair or put lotion on, and how patients in follow-up
01:02:54
Speaker
I'm highlighting these groups because patients in follow-up tell me this, you know, how much it meant for someone to move them so gently when they were in so much pain or the cleaning staff became friends with their family member or the night that the nurse just spent the night, like they were kind of weaning, kind of stable more, and there weren't acute issues, but the nurse just kind of comforted them and showed them so much kindness and
01:03:23
Speaker
I mean, I think a lot about that.
01:03:25
Speaker
So I don't think that's a unique observation, but I think that so many people are capable of so much kindness that maybe what I think people don't understand, to get back to the original question, is the lifelong impact, some of these extraordinarily kind actions, which some people might think are mundane, how profound the impact of these actions are on people,
01:03:52
Speaker
in this most vulnerable state of critical illness and how meaningful they are.
01:04:00
Speaker
I think that's the perfect answer, Margaret, and especially
01:04:07
Speaker
The negativity that is fed to us through new cycles, through what's out there, I think makes us believe that there's so much wrong with the world.
01:04:19
Speaker
Yet your observation that human beings not only have an enormous capacity for being kind, but we can find it.
01:04:28
Speaker
right around the corner where we work, right?
01:04:30
Speaker
We just have to look for it and find it.
01:04:33
Speaker
And the impact that a simple act of kindness can have on our human being is enormous.
01:04:41
Speaker
And we should, I think, not only value and embrace that, but look for it and try to replicate that.
01:04:48
Speaker
So I think that's the perfect answer, the perfect place to stop.
01:04:53
Speaker
I want to thank you for all your amazing work, for a beautiful review article that will link with other, obviously, literature that you mentioned.
01:05:02
Speaker
And more importantly, thank you for giving us your time today, Margaret.
01:05:06
Speaker
I hope to have you back.
01:05:08
Speaker
And there's a lot of topics that we can dive deeper and talk about as we learn.
01:05:12
Speaker
And once again, thank you so much.
01:05:16
Speaker
Thanks so much for really nice to meet you, Sergio.
01:05:18
Speaker
Nice to chat with you.
01:05:19
Speaker
Thanks for your comments.
01:05:21
Speaker
And, you know, thanks for the opportunity to share some of these thoughts with your listeners.
01:05:28
Speaker
Thank you.
01:05:30
Speaker
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01:05:34
Speaker
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01:05:40
Speaker
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01:05:44
Speaker
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